Retention: An unresolved workforce issue affecting rural occupational therapy services

Australian Occupational Therapy Journal

(2002)

49

, 170–181

Blackwell Science, Ltd

F e a t u r e A r t i c l e

Retention: An unresolved workforce issue affecting rural occupational therapy services

Anna

Mi l ls and Jeannine

Mi l ls teed

School of Occupational Therapy, Curtin University of Technology, Perth, Western Australia, Australia

Failure to retain health professionals in rural areas contributes to the poor health status of these communities through an inability to deliver reliable and consistent services. Considerable attention has been focused on factors affecting recruitment of health professionals. Far less is known about factors affecting the retention of occupational therapists. This was the focus of this study. Ethnographic interviews were used to explore the experiences of 10 occupational therapists who had left rural practice. Six themes emerged from the participants’ experiences, from when they first considered rural practice to reflections following their departure from it. These themes were initial appeal, facing the challenge, rural practice issues, the social sphere, reasons for leaving and the value of rural experience. These factors gave rise to a proposed Model of Retention Equilibrium, which suggests that retention can be improved by addressing the imbalance between incentives to leave and incentives to stay. The model provides a useful framework for occupational therapists contemplating rural practice, as well as for health services managers responsible for service delivery in rural areas.

K E Y W O R D S

health,

occupational therapists,

retention,

rural,

workforce.

INTRODUCTION

The poor health status of rural Australians has beendocumented in recent years and indicates that they havegreater morbidity and mortality rates than metropolitanpeople in almost all categories (Australian Institute ofHealth and Welfare, 1998; Humphreys & Rolley, 1991;Mathers, 1994). A lack of access to health professionalsacross disciplines in many rural and remote communitiescontributes to this poor health status (Comer & Mueller,1995).

Direct and indirect costs associated with staffing ruraland remote health positions are substantial. These includeadvertising costs, costs of unfilled vacancies, costs associatedwith hiring, termination costs, orientation and training

costs, and the costs of decreased productivity of newpersonnel (Friesen & Conahan, 1980).

A range of disciplines including nursing, medicine,psychology, physiotherapy and occupational therapy havereported difficulties with rural recruitment and retention(Beggs & Noh, 1991; Elliot-Schmidt & Strong, 1995;Hageman & Fuchs, 1993; Muus, Stratton, Dunkin & Juhl,1993; Wolfenden, 1996). Although a variety of factorsaffect recruitment and retention, research has largelyfocused on those affecting recruitment rather than reten-tion. It is often assumed that recruitment to a rural areawill automatically lead to retention (Cejka, 1998). There isgrowing evidence that factors that lead health profession-als to commence rural practice do, however, differ fromthose that influence them to remain (Wolfenden, Blanchard

Anna Mills

BSc(OT)(Hons); Occupational Therapist.

Jeannine Millsteed

BAppSc(OT), BAppSc(Psych), MEd, GradDipSocResEval; Senior Lecturer.Correspondence: Ms Anna Mills, Therapy Focus, Level 2, 161 Gt Eastern Highway, Belmont, WA 6104, Australia.

Accepted for publication August 2001.

AOT_293.fm Page 170 Friday, October 25, 2002 10:55 AM

Retention: An unresolved workforce issue

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& Probst, 1996). In order to address the inequity in accessto, and provision of, health services between urban andrural areas, attention must be paid to factors affectingboth recruitment and retention.

L i terature review

In Australia there is little consensus within the literatureon the definitions of ‘rural’ and ‘remote’ (Humphreys,1998; Lee, 1991). This is partly due to the differing uses forsuch a definition by organisations representing differentinterests such as health, agriculture, mining or transportindustries (MacLeod, Browne & Leipert, 1998). In thepresent study, the term ‘rural’ is used to incorporate bothremote and rural areas, and refers to areas of Australiahaving the characteristics of distance from a metropolitanarea, isolation, and small and dispersed populations(Humphreys, 1990).

Difficulty with recruitment of health professionals torural areas has been recognised as a chronic problem(Alexander, 1997; Humphreys & Rolley, 1991). The likeli-hood of health professionals taking up a rural position isinfluenced by a number of factors that include the influ-ence of a rural upbringing or previous rural experience(Rhodes & Day, 1989), having a partner with a ruralbackground (Huntley, 1995), the perceived appeal of arural life (Hageman & Fuchs, 1993; Mitchell, 1996) andthe desire for autonomy and opportunity to develop clin-ical skills (Wolfenden

et al.

, 1996; Woodcock & Kamien,1997). These factors affect the likelihood of commencing,rather than remaining in, rural practice. The high turnoverof professionals in rural areas suggests that the realitiesof practice may not match expectations, or that other un-anticipated factors may cause disillusionment (Hays, Veitch,Cheers & Crossland, 1997a). In a study of rural doctors,Pathman, Konrad and Rickettset (1992) concluded thatthe factors influencing recruitment differ fundamentallyfrom those affecting retention.

There is little agreement about the particular factorsaffecting retention. Wolfenden (1996) maintains that it islifestyle and personal opportunities that are fundamentalto the retention of health professionals in rural areas.Kamien and Buttfield (1990) describe a loss of socialanonymity in rural communities for health professionalsand their families. In small rural communities healthprofessionals are more likely to come into contact withcolleagues and clients during non-work hours, thus there

is less distinction between professional and personallife (Wills & Case-Smith, 1996). For some this is welcomedas valuable community involvement (Elliot-Schmidt &Strong, 1995) while for others it may represent anunwanted intrusion into personal life (Hays, Veitch,Cheers & Crossland, 1997b).

Other research suggests that professional reasons, suchas workload, professional support, professional relationships,organisational structure, opportunities for advancementand access to professional development have greater impacton retention (Dunkin, Juhl & Stratton, 1996; MacLeod

et al.

,1998; Muus

et al.

, 1993; Pooyan, Eberhardt & Szigeter, 1990;Ruah, 1991; Seybolt, 1986; Smith, 1990; Welch, McKenna& Bock, 1992). Woodcock and Kamien (1997) found thatamong doctors who had remained in rural practice, thethree most commonly cited reasons for staying werework related: the ability to utilise all professional skills,the variety of work and autonomy of practice. In contrast,among those who had left rural practice, the three mainreasons given were personal rather than professional, andincluded lack of educational opportunities for children,feelings of burnout and desire of partner to relocate.

To remedy difficulties in retaining rural health staff anumber of suggestions have been made related to education,professional development, work role design, orientationand mentorship. Alexander (1997) identifies the needfor education on rural practice issues within undergraduateprogrammes. The recruitment of professionals with ruralexperience to teaching facilities can provide relevantinformation on the particular requirements of ruralpractice, as well as serving as role models (Turner &Gunn, 1991). Kennedy and Griffiths (1996) suggest theactive recruitment of students from rural areas, as they aremore likely to return to, and remain in, rural employment.

Suggestions to improve opportunities for professionaldevelopment include the use of external enrolmentoptions (Underwood, Gamble & Jones, 1997), subsidisedcontinuing professional education (Australian Associationof Occupational Therapists, 1996) and maximising the useof technology to deliver training (McDonald, Hannaford& Cockfield, 1996; van Willigan, 1993). A need for funda-mental changes in work structure and organisation to retainhealth professionals in rural areas has been identified(Booth & Johns, 1993; Hodgson, 1994; Turner & Gunn, 1991).Retention may be improved by the provision of orientationto the rural position and community (Cejka, 1998; Friesan& Conahan, 1980; Hinshaw, Smeltzer & Atwood, 1987;


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A. Mills and J. Millsteed

Hodgson & Berry, 1993; Wolfenden, 1996), and the use ofmentorship schemes (Hoyal, 1995; Welch

et al.

, 1992).

Summary

Emphasis in the literature has largely been on issuesrelated to recruitment rather than those related to reten-tion. Low retention rates amongst health professionalsimpacts on the health of rural communities by creatingdifficulties in providing a consistent and reliable service(Huntley, 1995; Kohler & Mayberry, 1993). Studies inmedicine and nursing suggest there are differencesbetween factors affecting recruitment and those that affectretention. It is likely that retention of health professionalsis due to a complex interplay of personal, environmentaland work related factors (Hays

et al.

, 1997b; Hoyal, 1995).Both recruitment and retention need to be addressed inorder to reduce the ongoing costs of recruitment andmake a positive contribution to the health status of ruralcommunities. The picture for occupational therapy isunclear, as little research has been completed on theparticular factors associated with either recruitment orretention of occupational therapists in rural areas.

Purpose

The purpose of this study was to identify the factorsthat affect retention of occupational therapists in ruralpractice, including what is considered valuable in ruraloccupational therapy practice, strategies devised byrural occupational therapists to succeed in their positions,and reasons for leaving rural practice.

The information may provide insight into the waysin which rural employers can improve retention of theiroccupational therapy staff and promote a continuity ofservice in rural communities. Ultimately the significanceof increased retention is the improvement of serviceprovision, which can contribute to enhancing the healthstatus of rural communities.

METHODS

Research paradigm

The qualitative approach was used to develop an under-standing of the beliefs, practices and experiences of occu-pational therapists who had worked in rural practice

(Hunt, 1991; Morse & Field, 1995). Qualitative researchis characterised by three features. These are its holisticnature, an emic perspective and an inductive approach toinquiry (DePoy & Gitlin, 1994; Grbich, 1999; Morse, 1992).

Each of the three features of qualitative research wasvaluable for the study. The holistic nature of qualitativeinquiry allowed for the exploration of participant back-ground and beliefs, which may have influenced the expecta-tions and experience of rural practice. Adopting an emicperspective enabled the participants’ experience andoutlook to guide the research and determine outcomes.The inductive approach meant that the researcher did notbegin with a proposition or preconceived framework ofrural experience and retention, but instead involved theresearcher gaining meanings and insights from the inter-views and participants themselves as the study progressed(Seaman, 1987).

Part ic ipants

Participants in the study were 10 occupational therapistswho had worked in rural occupational therapy positions inWestern Australia, and had returned to the metropolitanarea within the previous 24 months. Nine of the parti-cipants were women. Five participants had entered ruralpractice within a year of graduating. The remaining fivecommenced rural practice between 3 and 6 years followinggraduation. All had been based in rural hospitals. Thelength of stay in the rural area ranged from 3 months to5 years, with a median length of stay of 2 years. Six parti-cipants had lived in a rural area prior to studying occupa-tional therapy and four had undertaken rural placementsas occupational therapy students.

Sampl ing

Purposive sampling was utilised and participants wereidentified by rural and metropolitan occupational ther-apists. Participants also identified others meeting the selec-tion criteria; that is, a snowball sampling approach wasused as it is an effective means of identifying an otherwiseinvisible group (Grbich, 1999).

Data col lect ion

A semi-structured interview protocol was developedbased on the issues raised in the literature review (DePoy



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& Gitlin, 1994). Ethnographic interviews were used as ameans to gain insight into the culture of rural areas, inparticular of occupational therapists within this context.Each interview covered the same general themes, but wasflexible enough to encourage participants to raise mattersthat were of particular concern to them. Such areas couldthen be incorporated into the interview and explored withsubsequent participants. This kind of interview producesrich and detailed data, and allows for a thorough explora-tion of the issues being investigated (McCracken, 1988;Minichiello, Aroni, Timewell & Alexander, 1990). Theinterviews were audiotaped and transcribed verbatim.

Eth ical considerat ions

The ethics of this study were approved and monitoredby the Human Research Ethics Committee at CurtinUniversity of Technology.

Data analys is

An inductive approach to analysis was used. Manualcontent analysis and the QSR NUD*IST 4 computerprogramme were used for this analysis (Richards, 1998).Analysis involved a rigorous inspection of spoken andwritten accounts to identify themes as well as more subtlemeanings and interpretations. These themes were thenconstructed into more cohesive and identifiable categor-ies. Data analysis was concluded when categories weredeveloped that reflected the views and experiences ofthe participants, the relationships between categories wereidentified, and a framework regarding rural occupationaltherapy practice was established and confirmed in thedata.

Trustworthiness of data

The concepts of validity and reliability as applied toscientific research methodology do not fit easily within thequalitative approach. However, adoption of triangulationconcepts ensures the process is rigorous and the trust-worthiness of the data (Lincoln & Guba, 1985). In this studyseveral techniques were used to triangulate data. First, anaudit trail was developed consisting of tape recordings,transcripts and field notes. Second, sections of the tran-scripts were analysed by other researchers experienced inqualitative methods to ensure consistency of the emergent

themes. Last, two additional therapists with extensiveexperience in rural practice were interviewed. The informa-tion obtained from the 10 participants was comparedwith that from these two therapists, to determine if theparticipants’ views and experiences were an accuratereflection of rural occupational therapy practice. Theinformation from the participants was in this way valid-ated against a second, expert, source. The triangulationtechniques ensured that the data were accurate and ableto be applied in the context of any emergent model ofretention (Minichiello

et al.

, 1990; Kumar, 1996; Miles &Huberman, 1994).

RESULTS

Six major themes that reflected the participants’ experi-ences of rural practice and factors that caused them toleave emerged from the data. These lie along a temporalcontinuum from the initial consideration of rural practiceto reflections following departure. The themes were initialappeal, facing the challenge, rural practice issues, thesocial sphere, reasons for leaving and reflection on thevalue of rural experience.

In i t ia l appeal

The participants sought work in a rural area for a varietyof reasons. Five were for partner-related reasons, fouractively sought out a country position for its perceivedmerits of lifestyle and to gain experience in a variety ofareas, and one participant to pursue the professionalopportunity of a combined caseload that she felt wouldnot be available in the city.

Facing the chal lenge

The early days of rural experience presented the parti-cipants, especially new graduates, with many challenges infulfilling the responsibilities of their positions. There wasan initial period of feeling overwhelmed and uncertainabout what was expected of them.

I was trying to say to myself, ‘Oh you’re so lucky to havegot this,’ but I was very overwhelmed, probably becausereally I’d never lived out of home, and I was really closeto my family, I was crying from homesickness at night(R03).


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Four participants went to a new position or a positionthat had been vacant for some time and they had to create,or re-create, the occupational therapist’s role. As onetherapist said, ‘I was blown away, didn’t really knowwhere to start’ (R05). In spite of these uncertainties theparticipants concurrently appreciated the benefits ofautonomy and clinical diversity and felt keen to ‘rise tothe challenge’ (R07) of rural practice.

A lack of adequate orientation to both the positionand community was a common experience. Three ther-apists received minimal orientation to the hospital, butnot to their specific position. Two participants receivedwhat they identified as adequate orientation. Five of the10 therapists received no orientation.

When I rocked up to [town] the department had beenclosed, and no one even knew … where the keys were toopen up the department, and when I did get in there … Iwaited in there for someone to come and say hello to meor something, and no one did (R03).

The lack of orientation meant that initially the job wasoften stressful with the participants having to work outthe parameters of the position and establish such thingsas policy and procedures, referral agencies and relevantcontacts in the town. This was time consuming and meantthat, ‘every job … in the first 3 months took five times aslong as in the second 3 months’ (R07).

All participants described the scope of rural practice asbeing wider than in the metropolitan area. All were eithersole practitioners or one of two therapists and hadprevious experience in city-based practice. There was nopossibility of sharing a caseload or referring a client toanother therapist, so the scope was ‘everything that camein the door, and you had to deal with everything’ (R01).They were required to know ‘a little bit about an awfullot of areas of practice’ (R08). Therapists had frequentcontact with health service managers, were involved inresearch, networking, volunteer community work, estab-lishing programmes and informing a range of people andagencies about the contribution occupational therapycould make. The potential volume of work seemedlimitless, and the number of people who could benefitfrom services always exceeded the therapist’s workloadcapacity. The extensive scope and volume were seen as apart of the challenge of rural work, and part of its reward.‘I got exposure to every area of OT … in terms of clinicalexperience it was invaluable to me’ (R07).

The participants identified a number of skills necessaryto succeed in rural practice. These included a broad rangeof clinical skills because of the generalist nature of theposition and because therapists were often working alone.Other skills considered valuable in the rural settingincluded communication skills, resourcefulness, creativityand management skills.

Rural pract ice issues

Participants described their rural practice as fundamentallydifferent to that which they had experienced in themetropolitan area. The isolation, lack of support andworkload gave rise to a range of professional issues. Thesetherapists also described a range of strategies devisedto ease their working life, and better meet the needs ofrural individuals and communities. These creative andadaptive solutions allowed the therapists to work success-fully, and reflect a positive response to a sometimes tryingsituation.

Formal supervision was minimal or nonexistent forthe participants and a lack of direct support from anotheroccupational therapist was identified as an ongoing con-cern. The therapists described a variety of ways in whichthey achieved alternative means of support. The mostfrequently mentioned source of professional and socialsupport was from other allied health professionals. Thera-pists also forged links with the occupational therapistsgeographically closest to them. This may have been dis-tances of hundreds of kilometres, yet these therapistsshared common experiences and were a source of bothprofessional and emotional support.

Rural therapists also made contact with metropolitantherapists working in a variety of settings. This contactwas mostly of a practical nature, for example telephoninga paediatric practitioner in the city to discuss the results ofan assessment and confirm the implications for treatment.The ability to receive guidance or confirmation of thevalidity of their treatment was identified as valuable forparticipants.

Locum cover was rarely available which resulted indepartments being closed when annual leave was taken. Amassive backlog awaited the therapists’ return to work.

Ideally, it would have been great to have relief, but noneof us did, so you just deal with it. You come back [fromannual leave], I remember there were 32 messages on myanswering machine, and the tape had run out (R02).



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Opportunities for professional advancement variedwidely between therapists. For many there was little or noopportunity, and any upgrade had to be fought for, whileothers experienced rapid progression through to a seniorposition. The seven therapists in sole positions believedthat they were performing senior responsibilities withoutthe commensurate pay and conditions. Several sole therapistsattempted to have their base grade positions upgraded.This entailed a lengthy process of negotiation, often with-out success. The four participants who had opportunitiesfor professional advancement stayed the longest in ruralpractice, with length of stay ranging from 2 to 5 years.Participants felt strongly about advancement and for thoseto whom it was available, advancement was highly prized.These therapists saw the country position as providingthem with opportunities that would not be available in thecity. The therapists who did not have these opportunitiesfelt strongly that this was unacceptable, and a source ofongoing frustration.

There’s no doubt that the responsibility is massive, andyou should be paid for it because you’re doing a reallyresponsible job, and most of them work extremely hard,and are very dedicated people and they deserve every bitof it [a higher classification] (R02).

Generally it was expensive for therapists to take up theircountry position, with travelling and relocation costs metby the practitioners themselves. Financial incentives to remainin the position were similarly lacking. For those therapistsworking in mining towns, the inequity between the payand conditions of mining and health staff was marked.Mining staff frequently received quality accommodation,flights to the city and other advantages, in addition toreceiving high incomes. These incentives to stay were instark contrast to the experiences of the occupationaltherapists, none of whom received these benefits.

Lack of professional development was cited as areason for therapists leaving their positions. The therapistsdid, however, devise means of achieving less formalprofessional development. These strategies included regu-lar meetings with a co-therapist, or therapist in a nearbytown, regional occupational therapy group meetings, anduse of the Internet and teleconferencing. By these meansthe therapists were able to test out their ideas, learn fromthe experiences of others and gain valued support.

Participants described rural occupational therapists asinnovators. Therapists typically had little direction but

also few limitations. They recounted being able to guidethe development of the occupational therapy service in away that would be impossible in the metropolitan setting.Although this was a monumental task, it was both a sourceof frustration and excitement for therapists.

You’ve really got to sit down and say ‘Well what is OT?What should I be doing on a day to day basis?’ … Yes, soit’s incredibly exciting (R09).

Social sphere

Participants had varying experiences of the social aspectsof living in a rural community. In this way the socialexperience was both an incentive to stay and to leave. Thesocial issues identified by participants included homesick-ness, friendships and lifestyle, community acceptance,privacy and children’s education. The lifestyle offered bythe rural setting was described as wholly different to thatof the metropolitan area and was generally regardedpositively. On the negative side, there were fewer choicesin leisure activities, restaurants, pubs and cultural eventsthan a metropolitan area offers. In contrast the therapistsalso described a rural lifestyle boasting beaches, boating,exploring beautiful scenery, barbecues, involvement incommunity groups and extensive socialising.

Your lifestyle, your options are a lot more limited, butthen you had the opportunity to go out on boats andspend nights out on islands, it was just totally different.It’s so beautiful there (R07).

Although most therapists established social networksin the country, this was not without its difficulties. Manyexperienced an initial reluctance on the part of long-termresidents to trust or befriend the therapist. Privacy wasidentified as a rare commodity; however, generally anydisadvantage this posed was countered by accompanyingadvantages. A less anonymous existence offered socialcontact and involvement that fostered a sense of belongingto the community.

Participants felt that the country area could notoffer their children the academic opportunities thatwould be available to them in the metropolitan area. Thetwo participants with children each stated that they feltconfident of the quality of rural primary school education.However, they believed that had they remained in thecountry, a return to the city would have been necessaryonce their children reached high school age. This was


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also mentioned as a barrier to returning to a countryarea.

Reasons for leaving

The therapists described a combination of personal andprofessional reasons for leaving their rural positions. Foreach participant there was an identifiable personal orprofessional trigger that primarily led to departure.However, all therapists described other factors which mighthave caused them to leave, had the particular trigger notdone so. Six participants left for largely personal reasonsand four departed for essentially professional reasons. Ofthe six who left for personal reasons, three moved withpartners transferred to the metropolitan area. The otherthree personal reasons for leaving were due to travelplans, a general reluctance to settle down and the desire toreunite with family.

The four professional reasons cited for leaving centredaround wanting greater support and career opportunities.Therapists were keen to experience more professionaldevelopment, the support of an occupational therapydepartment and formal supervision. One participant feltthat she had achieved what she had hoped for in the ruralposition and it was time to move on. The decision to leavewas not an easy one for many of the therapists. Onetherapist left due to personal reasons, but experiencedthis as a loss to which she was still adjusting 12 monthslater. Others described it as a difficult decision, and asad time.

Reflect ion on the value of rural experience

The participants described a range of benefits to workingin a rural area. Most commonly mentioned were theopportunities and skills gained by working in a largelyautonomous position, and the friendships formed. Onetherapist had a position on the hospital board at 23 yearsof age, something few therapists ever achieve in themetropolitan area. Another therapist had opportunities tonetwork at a political level to gain funding for projectsand to employ additional allied health staff. Other oppor-tunities included working with remote Aboriginal com-munities, flying with the Royal Flying Doctors Service tooutlying towns and the ability to develop the direction ofthe occupational therapy service for the area.

Two of the participants experienced promotionalopportunities that they felt would be unavailable in themetropolitan area. These therapists were able to move tosenior positions relatively early in their careers. For othertherapists the rural experience also provided professionalopportunities in the metropolitan area. The broad experi-ence gained in the country meant it was possible to workin a variety of settings on returning to the city. One of thetherapists chose to move to a country area partly becauseshe wanted to diversify, and as a specialist therapist in thecity felt unable to do so. This therapist was able to work asa generalist in the country, and on her return to the city2 years later was able to choose the area in which sheworked.

Therapists described the friendships that they forgedin the rural area as satisfying and long lasting. Thesefriendships both with allied health staff and other membersof the community were identified as one of the mostvaluable aspects of the rural experience. The lifestyle inwhich these friendships were formed and played out wasalso remembered fondly by participants.

All the participants indicated that they would considerreturning to a rural position.

Therapists generally reported feeling valued by therural community, with those in smaller towns tending toexperience greater recognition and appreciation. Therapistsdescribed being the occupational therapist for the town,whereas in the city they are an occupational therapist, oneof many serving the metropolitan area.

Seven of the participants felt that rural practice wasundervalued by metropolitan occupational therapists. Thiswas felt to be largely because city practitioners had littleidea or appreciation of the breadth and volume of workcovered by rural therapists.

Participants also identified an accompanying lack ofconfidence in rural practitioners themselves. Practitionersleaving the rural area for metropolitan practice describeda fear that their skills would not be adequate in thissetting. Once working in the metropolitan area, however,all found their clinical skills to be of a high standard,reinforcing the breadth and depth of knowledge andexperience gained in the country. For many of the ther-apists it took the move back to the city to realise the valueof rural practice.

Now having spent time in the city, I’m very proud of thework I did in the country, and I think that most ofthe country therapists are working extremely hard and



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making sure they know an awful lot about a lot of clinicalareas, and maintaining their professional skills in reallyquite difficult circumstances (R08).

DISCUSSION

Participants had all returned from rural practice andthus had physical and temporal distance from their ruralexperience. This may have influenced participants’memories and descriptions of rural practice, and thislimitation of the study is acknowledged.

The findings of the study indicate that retentionmeasures must be wide ranging as retention is fosteredby a combination of satisfaction in both professional andpersonal realms. Further indications are that these effortswould be most successful if implemented prior to arrival,early in the position and on an ongoing basis.

From the emergent themes, a Model of RetentionEquilibrium is proposed that reflects the interplay betweenprofessional and personal factors affecting the retention ofoccupational therapists in rural practice (Table 1). The modelidentifies the incentives and disincentives to occupationaltherapists remaining in rural practice. The documenteddifficulties in retaining occupational therapists in ruralareas (Australian Association of Occupational Therapist,1996) indicate that currently the incentives to leave areoutweighing incentives to stay. The model is supportedby the findings of Hays

et al.

(1997b) who in their study ofrural doctors described the friction between influences tostay and leave rural practice. Although the specific factorsmay differ for occupational therapists, the premise remainsthe same, that an imbalance exists between incentives anddisincentives to stay in rural practice that contributes tothe low retention of health professionals.

Recommendations are drawn from the model thatboth consolidate and promote incentives to remain in

rural practice as well as address the incentives to leave.The suggestions discussed here are not intended to beexhaustive, rather they offer some potential ways to tipthe balance in favour of retention. These fall under theheadings of orientation, professional packages, andprofessional development and support.

Or ientat ion

The provision of discipline specific orientation or a handoverperiod is often difficult in rural practice due to the pre-dominance of small departments or sole positions. Effortscan be made, however, to ensure that at least a basicorientation is available. Health service managers can ensurethat all staff receive a generic orientation to the hospitalor clinical setting, to the responsibilities of the position, anda general introduction to the community. This communityinformation could be through the provision of a packageabout community facilities and local attractions, ideallyprovided prior to, as well as following, the commencementof the position.

The provision of orientation, especially to new graduates,gives therapists an idea of the structure and dimensions ofthe position, providing them with a sense of what is expectedand how to proceed with the position (Hodgson & Berry,1993). Similarly, therapists can seek out information priorto and on commencement of the position to orientatethemselves to both the community and the position.

Professional packages

All participants expressed dissatisfaction with professionalissues including pay and conditions and work organisation.Addressing all of the professional concerns of rural occu-pational therapists would be beyond the means of healthservices. Professions such as teaching and medicine haveattempted to encourage retention by the provision of

Table 1. Model of retention equilibrium

Incentives to leave Incentives to remain

Professional factors Lack of professional development Development of professional skillsLittle professional support or recognition Autonomy and independencePay and conditions Good working relationships

Personal factors Family-related factors FriendshipsHomesickness Lifestyle


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professional packages to those in rural practice. These aimto address the range of concerns experienced by thoseworking in rural areas, providing additional benefits thelonger a professional stays. A similar professional packagecould meet the needs of rural occupational therapists,and provide incentives to stay. There are currently noprofessional benefits to staying long-term in a ruraloccupational therapy position.

Components of a package could include: bonusescommensurate with the length of time a therapist remainsin the rural position, such as an additional trip to a city forprofessional development purposes or additional annualleave entitlements; and an identified career path withopportunities to progress through to a senior position, whichwould lead to greater satisfaction, provide recognition,reasonable remuneration and the ability to apply for jobsat the same level if the therapist should return to the city.

Professional development and support

Participants identified the lack of access to professionaldevelopment as an ongoing frustration, and a significantfactor in the decision to leave rural practice. Rural accesscould be improved, and the importance of participationby rural therapists acknowledged, by more professionaldevelopment activities occurring in rural settings. Therapistsvalued the contribution of city-based services that travelledto rural areas to provide professional development. Althoughit was recognised by therapists that these travelling servicescan only occur infrequently, their existence is a symbol thatthe needs and contributions of rural occupational therapistsare valued. Access to professional development couldbe further enhanced by reduced workshop costs for countrytherapists, in recognition of the increased costs ofattending courses in the metropolitan area.

Therapists outlined many benefits of rural practice andalso described steps they had taken to make the positionmore manageable. In addressing retention it is essentialto maximise existing benefits and to recognise and supportthe solutions that rural therapists have devised. Participantsdescribed gaining support from networks with ruraltherapists in neighbouring areas, other allied health staff,metropolitan occupational therapists and management.The formal allocation of work time so therapists receivethis support can provide a buttress against the daily andcumulative stresses of a rural position. It can also reinforcethe therapist’s sense of belonging to their profession.

The provision of professional support by metropolitantherapists could be similarly formalised. Participantsdescribed receiving support from metropolitan occupa-tional therapists, particularly from those in teachinghospitals or large clinical centres. This was identified tobe of immense value to rural therapists, unable to holdspecialist knowledge in all areas of practice. Entrenchingthis support in the job descriptions of senior city-basedtherapists would help to forge connections betweenmetropolitan and rural therapists.

The participants identified that valuable aspects oftheir rural practice were the range of opportunities avail-able and skills acquired. Conversely, participants alsoexpressed concern that their experiences and skills gainedin rural practice were not recognised nor appreciated bymetropolitan practitioners. Therapists felt that their dailypractice was undervalued, and that remaining in the ruralarea might limit their employment prospects should theyreturn to the metropolitan area. Increasing awarenessand appreciation of rural occupational therapy can ensurethat the valuable skills gained in the country are regardedwith the respect they deserve. This enables rural skills tobe transferable into the metropolitan environment, withemployers recognising the asset to the workplace thatrural practitioners represent. Without the concern that theywill be considered second rate practitioners, occupationaltherapists are less likely to feel a compulsion to leave ruralpractice. Efforts to improve recognition of the contributionof rural occupational therapists can be made at the educa-tional, professional association and individual levels. Acomponent of recognising the skills of rural therapists is toacknowledge that they have much to teach metropolitantherapists, and to contribute to the body of knowledge inoccupational therapy. Making conferences and workshopsmore accessible to rural therapists means that all therapistshave the opportunity to learn of the exciting and innovativedevelopments occurring in rural areas, which are otherwiserarely seen by city therapists. In this way the contributionsof rural therapists can come to be recognised as valuable.

Rural therapists, or those with recent rural experience,have an important contribution to make to schools ofoccupational therapy. Learning opportunities devoted torural practice issues can promote the option of rural prac-tice as well as equipping students with some of the skillsimportant in rural occupational therapy. For those stu-dents who never enter rural practice this informationwould still be valuable, both in providing generic skills



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useful in any situation, and in fostering greater awarenessof the contribution of rural occupational therapists. Thiscan contribute to a shift in thinking away from seeing ruralpractice as second best, to viewing it as a challenging,vibrant and rewarding option.

CONCLUSION AND RECOMMENDATIONS

Low retention of health professionals in rural areascontributes to the poor health status of these communities.Through the use of ethnographic interviews, this studyexplored the particular factors which influenced a group of10 occupational therapists to leave rural practice. Thesetherapists described a range of both personal and pro-fessional factors leading to departure. They also identifiedmany positive factors contributing to their experience ofrural practice. Exploration of these positive and negativefactors gave rise to a Model of Retention Equilibrium,and a number of suggestions that may positively influenceretention rates in rural areas. We recommend that thesuggestions arising from the Model of RetentionEquilibrium now be tested to determine if the proposedeffects on retention are borne out in reality.

A commitment to rural health necessitates continuedresearch into retention issues. The retention of healthprofessionals in rural Australia promotes continuity andaccessibility of services and has as its ultimate end theimprovement of the health status of rural communities.

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Documents

Retention: An unresolved workforce issue affecting rural occupational therapy services