John Wakerman

Systematic review of effective retention incentives for health workers in rural and remote areas: Towards evidence‐based policy

BACKGROUND Poor retention of health workers is a significant problem in rural and remote areas, with negative consequences for both health services and patient care. OBJECTIVE This review aimed to synthesise the available evidence regarding the effectiveness of retention strategies for health workers in rural and remote areas, with a focus on those studies relevant to Australia. DESIGN A systematic review method was adopted. Six program evaluation articles, eight review articles and one grey literature report were identified that met study inclusion/exclusion criteria. RESULTS While a wide range of retention strategies have been introduced in various settings to reduce unnecessary staff turnover and increase length of stay, few have been rigorously evaluated. Little evidence demonstrating the effectiveness of any specific strategy is currently available, with the possible exception of health worker obligation. Multiple factors influence length of employment, indicating that a flexible, multifaceted response to improving workforce retention is required. CONCLUSIONS This paper proposes a comprehensive rural and remote health workforce retention framework to address factors known to contribute to avoidable turnover. The six components of the framework relate to staffing, infrastructure, remuneration, workplace organisation, professional environment, and social, family and community support. In order to ensure their effectiveness, retention strategies should be rigorously evaluated using appropriate pre- and post-intervention comparisons.

Potential primary health care savings for chronic disease care associated with Australian Aboriginal involvement in land management.

RATIONALE To identify the possible savings in the cost of primary health care of chronic disease associated with the participation by Aboriginal people in land management. In so-doing we investigate the connection of health of Aboriginal people and the extent of their involvement in land management in remote-very remote Australia. METHODS Possible savings in primary care costs for hypertension, renal disease and diabetes were estimated using multivariate regression to examine associations between Aboriginal involvement in land management and Northern Territory Government-defined chronic disease outcomes, controlling for socio-demographics and health behaviours. Participants were 298 Aboriginal adults aged 15-54 from a remote Aboriginal community, classified by their chronic disease status and a previously validated measure of self-reported participation in land management activities. RESULTS Land management participants were significantly less likely to have diabetes, renal disease or hypertension. Using the sampled mean value of engagement in land management, we found the expected net annual savings for the community from involvement in land management of

Psychosocial safety climate as an antecedent of work characteristics and psychological strain: A multilevel model

268,000. This equates to a net present value of primary health care savings in chronic disease care for the sampled community over 25 years of

The turmoil of aboriginal enumeration: mobility and service population analysis in a central Australian community.

4.08 million. This estimate does not include further savings in other primary health conditions nor costs anticipated in referred and hospital-based health care for chronic disease. CONCLUSION While the association between involvement in land management and better health requires further clarification, our findings indicate that significant and substantial primary health care cost savings may be associated with greater participation in land management activities. These estimated savings are in addition to the market and non-market economic benefits of a healthier population and environmental benefits.

Levels of occupational stress in the remote area nursing workforce

Abstract Psychosocial safety climate (PSC) refers to a specific organizational climate for the psychological health of workers. It is largely determined by management and at low levels is proposed as a latent pathogen for psychosocial risk factors and psychological strain. Using an extended Job Demands-Control-Support framework, we predicted the (24 month) cross-level effects of PSC on psychological strain via work conditions. We used a novel design whereby data from two unrelated samples of nurses working in remote areas were used across time (N=202, Time 1; N=163, Time 2), matched at the work unit level (N= 48). Using hierarchical linear modelling we found that unit PSC assessed by nurses predicted work conditions (workload, control, supervisor support) and psychological strain in different nurses in the same work unit 24 months later. There was evidence that the between-group relationship between unit PSC and psychological strain was mediated via Time 2 work conditions (workload, job control) as well as Time 1 emotional demands. The results support a multilevel work stress model with PSC as a plausible primary cause, or “cause of the causes”, of work-related strain. The study adds to the literature that identifies organizational contextual factors as origins of the work stress process.

Rural and remote public health in Australia: building on our strengths.

This paper documents Aboriginal population change and mobility over time in a remote community in central Australia. The movement of population has implications for service delivery and resource allocation. Aboriginal population in the region is characterised by high mobility. We conducted four population surveys in a selected remote community over a 12 month period and categorised individuals into four mutually exclusive groups: residents, dual residents, visitors and absent residents. Based on these categories we developed two population classifications: actual and potential service populations. The potential service population was consistently higher than the Australian Bureau of Statistics (ABS) census figure. We question the use of ABS census estimates as appropriate population figures for determining resource allocation to remote communities. We quantify inter– and intra–community mobility. When the potential population is used as denominator, 35% of the population of this community was classified as inter–community mobile. Given this level of mobility we argue that: (1) Resources should be allocated to compensate health services for the additional time and resource requirements to deal with the high level of population mobility. (2) Health programs such as STD control, trachoma, scabies and other communicable diseases common in Central Australia should be coordinated and delivered as regional programs often crossing State/Territory borders.

Helping policy‐makers address rural health access problems

OBJECTIVE   To identify key workplace demands and resources for nurses working in very remote Australia and measure levels of occupational stress in this population. METHODS   The study used a cross-sectional design, utilising a structured questionnaire. SETTING   Health centres in very remote Australia. RESULTS   Nurses working in very remote Australia experience significantly higher levels of psychological distress and emotional exhaustion, compared with other professional populations. Paradoxically, results also highlight higher than average levels of work engagement. Nurses working in very remote regions in Australia further report moderate levels of job satisfaction. Most significant job demands identified were emotional demands, staffing issues, workload, responsibilities and expectations, and social issues. Key job resources included supervision, opportunities for professional development, and skill development and application. CONCLUSION   In a context of high stress, high levels of work engagement and moderate levels of job satisfaction do not obviate high workforce turnover for this population. There is a need to reduce job demands and increase job resources in order to foster long-term work engagement and reduced emotional exhaustion. This might subsequently decrease remote area nursing workforce turnover.

‘Making evidence count’: A framework to monitor the impact of health services research

The governments of Australia have agreed that ‘People in rural, regional and remote Australia will be as healthy as other Australians . . .’ To eliminate current health inequalities between metropolitan and rural Australia, we need to enhance disease prevention and health promotion efforts based on a better understanding of the nature of rural–urban inequalities. We also need to recognise that a deficit view of the bush is neither helpful nor justified. Future effort should acknowledge rural and remote area advantages and build on the strength of rural and remote public health infrastructure, ingenuity and practice.

Tactics at the interface: Australian Aboriginal and Torres Strait Islander health managers

This paper provides a comprehensive review of the key dimensions of access and their significance for the provision of primary health care and a framework that assists policy-makers to evaluate how well policy targets the dimensions of access. Access to health care can be conceptualised as the potential ease with which consumers can obtain health care at times of need. Disaggregation of the concept of access into the dimensions of availability, geography, affordability, accommodation, timeliness, acceptability and awareness allows policy-makers to identify key questions which must be addressed to ensure reasonable primary health care access for rural and remote Australians. Evaluating how well national primary health care policies target these dimensions of access helps identify policy gaps and potential inequities in ensuring access to primary health care. Effective policies must incorporate the multiple dimensions of access if they are to comprehensively and effectively address unacceptable inequities in health status and access to basic health services experienced by rural and remote Australians.

Impact of community participation in primary health care: what is the evidence?

OBJECTIVES The objective of this study is to develop a framework to measure the impact of primary health care research, describe how it could be used and propose a method for its validation. DESIGN Literature review and critical appraisal of existing models of research impact, and integration of three into a comprehensive impact framework. SETTING Centre of Research Excellence focusing on access to primary health care services in Australia. PARTICIPANTS Not applicable. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The Health Services Research Impact Framework, integrating the strengths of three existing models of research impact. CONCLUSION In order to ensure relevance to policy and practice and to provide accountability for funding, it is essential that the impact of health services research is measured and monitored over time. Our framework draws upon previously published literature regarding specific measures of research impact. We organise this information according to the main area of impact (i.e. research related, policy, service and societal) and whether the impact originated with the researcher (i.e. producer push) or the end-user (i.e. user pull). We propose to test the utility of the framework by recording and monitoring the impact of our own research and that of other groups of primary health care researchers.