A study published last month reveals astoundingly high levels of staff turnover in the primary health care clinics of 53 remote Northern Territory communities.
The revolving door of nurses and Aboriginal Health Practitioners poses problems of access and continuity for remote-living people, and is almost certainly affecting the bottom line of health outcomes.
In the post below, two of the study’s authors, Dr Deborah Russell and Professor John Wakerman, discuss the significance of their findings and pose some strategies for achieving much needed stability.
Dr Deborah Russell and Professor John Wakerman write:
The Northern Territory (NT) is geographically vast, covering 18% of Australia’s land mass, sparsely populated and home to some of Australia’s most disadvantaged populations. Aboriginal and Torres Strait Islanders living in remote NT communities experience very high rates of death and morbidity attributable in large part to a range of chronic diseases including diabetes, ischaemic heart disease and chronic kidney disease.
The challenge of continuity in primary care
With appropriate access to primary health care, remote-living people with chronic diseases can receive effective management, resulting better health outcomes and decreased rates of hospitalisation.
An important feature of effective primary care is interpersonal continuity of care – seeing the same person on each visit – which helps build trust and create strong therapeutic relationships. Low continuity of care has been demonstrated to result in higher mortality in vulnerable populations. Building these trusting relationships is especially important in cross-cultural settings characterised by language and other cultural differences.
At the same time, remote primary health care services in NT and elsewhere are under-resourced. Geographical isolation, population dispersion, high population health needs and salary costs associated with maintaining an adequate supply of appropriately skilled health professionals in remote areas all contribute to the higher costs of delivering remote primary care services.
A workforce in flux
Recent workforce research with the NT Department of Health provides an insight into the extraordinarily high turnover rates of community-based remote health care workers. Remote area nurses in NT Government clinics exhibit a turnover rate of 148% per annum. In other Australian health care settings nurse turnover levels of over 20% – whereby one in five of the workforce leave each year – are considered too high.
Aboriginal Health Practitioners (AHP) have a relatively lower turnover level – about 80% per annum. In remote NT, half of the nursing and AHP workforce have left a remote clinic within a mere 4 months of having started work at that clinic and on average only one fifth remain at the end of 12 months.
A costly exercise
These extremely high levels of nurse and Aboriginal health practitioner turnover and short retention are costly. Short-term agency nurses are expensive – costing twice as much as permanent staff, on average. Repeated recruitment of permanent staff is also expensive and time consuming. Importantly, substantial costs are also incurred in terms of decreased effectiveness of primary health care, as trusting relationships between community members and primary health care staff are frequently disrupted.
One consequence may be that remote community members are more likely to disengage from primary health care, present later and more acutely unwell, with an increased likelihood of hospitalisation which could otherwise have been avoided if primary health care had been more effective.
For the permanent staff who stick it out, high turnover results in increased workload and stress due to the constant need to orient, train and support short-term staff. Time invested in orienting and training new and short-term staff is time no longer available to provide clinical care for patients.
In order to address these concerns, this study is part of a larger collaborative project involving Flinders, Monash, Adelaide, Melbourne, Macquarie and Sydney Universities, and the NT DOH. The research will describe and quantify the impact of short-term health staff in remote areas on the cost and effectiveness of primary health care services.
Towards a stable workforce
What then can we do about stabilising the remote workforce and strengthening primary health care in remote Australia? Of course we need to make sure short term staff are appropriately prepared to provide culturally safe services, but in the face of such high turnover, we need to develop robust health service models that are adequately funded, competently managed and clinical protocol driven.
Remote health workforce policy needs to take a systemic, not piecemeal approach in order to ensure a well-prepared, culturally safe workforce with vastly improved retention.
More robust workforce models could include shared remote nursing positions, with one to three months working in a particular remote community alternating with time away; higher utilisation of remote nurse practitioners (NP); and providing enhanced support for local Indigenous people into AHP or nursing training (for example scholarships, the ability to study close to home, remote housing for employees), as well as into non-clinical community-based positions such as administration and transport.
We can also apply lessons learnt from successful efforts to redress medical workforce misdistribution through the development of an integrated remote training pipeline for non-medical staff. This could entail preferential selection into health professional training for students from remote communities; training in and for the context in which the students will work; support into post-graduate study and specialisation, such as remote NP training; and provision of flexible retention incentives.
*Dr Deborah Russell is a Research fellow, School of Rural Health, Monash University. Professor John Wakerman is Associate Dean, Flinders University, Northern Territory