Abstract
There is a known global shortage of nurses and midwives within the workforce. Developing capacity and capability within these professions is of paramount importance to the health and wellbeing of rural communities. It is essential that nurse and midwife leaders who are uniquely positioned, not only set the direction but also drive the agenda to ensure a skilled workforce is available to care for rural and remote communities in the years to come. Those organisations that demonstrate nursing and midwifery leadership by investing in nurses and midwives do so by investing in career pathways. The experience here in Australia suggests that those organisations have higher success in attracting and retaining staff. Nurses and midwives hold significant leadership roles, and have an appreciable presence and respect in their communities globally. They are the predominate workforce within our healthcare systems that are best placed to influence and advocate for the health of these communities by acting to address the sustainable development goals to shift the outcomes for current and future populations. They are powerful influencers in the rural setting through the direct nature of the provision of acute and primary healthcare delivery that they provide daily. Universal healthcare coverage can only – and will only – be achieved through successful attraction and recruitment of nurses and midwives.
For the purpose of this article, rural and remote practice is not necessarily described only by geographical location or boundary. The health settings are diverse. They may be in country or island settings that have small hospitals, multi-purpose centres, public health and primary care clinics. They deliver acute, chronic, aged care and midwifery support based on the needs of the community in which they work. The Australian CRANAplus rural nursing network expresses that.
The Rural Nursing context is determined by aspects such as:
Small communities with variable access to amenities – i.e. housing, shopping, schools, leisure activities; The social, cultural and economic characteristics of the community; The availability and access to other health care capability - i.e. medical, allied and relief staff, equipment, medical evacuation; and The communities’ expectations on their local rural nurses – i.e. first-line emergency response (CRANAplus, 2020).
As rural locales influence health needs and service responses in specific ways, rural health is much more than simply the practice of health in another location (Wakerman and Humphreys, 2002). Grobler et al. (2015; p3) state ‘All countries have areas that are relatively underserved by health professionals; mostly among rural communities and the urban poor. This problem is seen across the world but is particularly serious in low- and middle-income countries’. Contemporary nursing and midwifery leaders are integral to successful workforce planning. International rural workforce literature raises awareness and identifies an increasing workforce shortage of skilled professionals attracted to and remaining in rural locations. The phenomenon is experienced across the globe (Dumont et al., 2008; Kulig et al., 2015).
Factors influencing this phenomenon are:
An ageing workforce and subsequent difficulties of knowledge transferred and retained in the community; The gap between academic knowledge and skills gained in universities' degrees versus the practical experience and ability required to work in the health service; Discrepancies between educational opportunities, financial incentives and enhanced infrastructure requirements; and The lack of awareness of rural health services as a career path for future health workers.
Recruitment and retention are simply about the right person being in the right place, with the right qualifications, at the right time, and then ensuring that the person wants to remain working in that place. As with any retention and recruitment strategy, there is a need for political and local leadership that drives the administration, communication, education, clinical-practice experience, supervision, research and audit capabilities. Nursing and midwifery leaders are professionally responsible for one of the largest components of the healthcare team that lives, contributes and works within their community. They are invited into people’s homes and lives to provide care on a 24-hour, 7-day basis. Each and every day nurses and midwives can shift the inequity within societies that revolves around universal health coverage. Those nursing and midwifery leaders hold the future of our workforce in their hands by advocating, influencing and, most of all, being active in positive attraction and recruitment initiatives that ensure success.
Essentially, workforce attraction and retention are underpinned by workforce planning whereby education and professional development plans support the nurse and midwife to enable the delivery of a sustainable workforce that meets the current and future health needs of the communities it services. Some commentaries point to a move towards a community development approach that works with local people, acknowledging differing health literacy and cultural factors, but providing a multifactorial approach that creates a synergy between community, practitioners, universities and hospitals and health services. This strategy builds on the strength and value of communities, their relationships, networks and uniqueness to develop and sustain the rural and remote workforce (Bushy and Leipert, 2005; Trepanier et al., 2013; World Health Organization, 2010). Examples from North Dakota, (Austin et al., 2019), mid-northern Canada (Zimmer et al, 2014) and Queensland, Australia, (State of Queensland (Queensland Health), 2018) point to the increasing success of such collaborative interprofessional approaches. Practitioner benefits include cross-cultural exposure that leads to life-changing interest, shared experiences, clinical practice and cultural competence. Community benefits include an opportunity to explore workplace experiences and potential sustainable community opportunities.
In gathering evidence from Queensland, Australia to inform workforce policy development for Far North Queensland in 2019, nurses working in Torres and Cape Hospital and Health Service were asked for their perspective on what attracts and retains them in remote nursing practice. Different perspectives were shared from the workforce themselves. What was revealed was that, from a professional perspective, nurses valued the diversity of clinical care, high accountability within their scope of practice and engagement, along with trust that they experienced with colleagues and the local community. Professional collaboration was significant, as too was respect for each individual’s contribution and capability to the healthcare teams. Nurses who had transitioned into remote practice from rural or regional services stated that their professional satisfaction in delivering nurse-led models of care was more appealing than in other roles they had previously undertaken in their career. Nurses also valued professional development, collegial support and recognition of their contribution to health care. Further to this, it was revealed that both support from peer networks and mentorship were vital for autonomous professional practice, as well as formal education opportunities to maintain clinical knowledge and progress career opportunities.
Consultation themes echoed the findings of Onnis and Pryce (2016), who systematically reviewed the literature regarding health professionals working in remote Australia and examined factors common to workforce and practice support. They also found that intrinsic incentives of work satisfaction, autonomy of practice and personal/professional development rated higher in importance among health professionals than extrinsic incentives (location incentives, subsidies and leave) across multiple studies. The experience shared by nurses of Far North Queensland in the Torres and Cape concluded that implementing effective education and experiential learning was a foundation to build professional capability. The Office of the Chief Nursing and Midwifery Officer, Queensland (2020; p 5) espouses that The Framework for Lifelong Learning for Nurses and Midwives – Queensland Health provides a scaffold for all teaching and learning considerations that ‘value add’ to achieving a sustainable, professional, capable, person-focused nursing and midwifery workforce that is respected for competence and quality.
The NMEP is a Queensland statewide programme. The programme makes provision for both nurses and midwives to undertake an experiential work placement in which they are supported to explore and develop practice skills in new practice environments as an active work-experience exchange between rural, regional and metropolitan work places. The programme is underpinned within a supportive mentoring framework. Essentially the participants, being nurses and midwives, are championed as a future workforce to strengthen the capacity of rural and remote health services. They are actively supported to develop clinical skill sets suitable to the rural generalist nurse. This is achieved by increasing both knowledge and skill of those Queensland nurses and midwives in the clinical practice setting in which the exchange occurs, therefore, by immersion in the rural setting, attracting and retaining new nurses and midwives. As a result, it is envisaged that the exchange of novice and expert nurses and midwives will provide an avenue for services to actively recruit staff through the transition of additional nursing and midwifery graduates, essential to sustaining these workforces into the future.
The second programme is Queensland SWIM Program. This programme is based on a theory of clinical immersion whereby accelerated learning occurs. It is designed to lift the capacity of the nursing and midwifery workforce by supporting early- to mid-career nurses and midwives to develop skills in a select ‘specialty practice area’ that will then support their attraction and/or retention within the rural workforce. Early career nurses and midwives are afforded participation in a structured education programme that effectively transitions them safely within a clinical specialty. It bolsters their skill and knowledge along with confidence to work in a rural isolated practice setting.
The specialty areas are:
aged care; critical care; mental health; midwifery; perioperative services; community nursing practice; neonatal; paediatrics; gastroenterology; and rural generalist.
The aim is to strengthen the early career nursing workforce to be adequately clinically skilled to take up vacancies in rural Queensland. Research infers that clinical immersion assists learning when accompanied with structured learning, clinical skill demonstrations, direct clinical exposure, and preceptor/mentor programmes (Baumann et al., 2019: 1). To date this initiative has proven successful in Queensland Australia to attract and retain nurses and midwives to rural service areas.
In conclusion, policy makers who demonstrated leadership in this area have combined organisational mechanisms supporting career development, workforce planning and professional development. These policy makers utilised these approaches to forge unique education pathways and modalities for rural and remote practice. They fostered responsive workplace environments that engaged nurses in professional networks of active collaboration so that the expertise of remote practice nurses was valued and sustained into the future. It is evident that nurse and midwife leaders who invested in these initiatives saw it as essential to positively influence nurses and midwives to be attracted to work in rural settings and to remain in the communities that they provide care for. Organisations that attract and retain their nurses and midwives are those that invest in nursing and midwifery leadership, professional development, and support practice autonomy and a broad scope of practice that not only improves the satisfaction of the nurse and midwife but also the patient experience. Responding to the health needs of rural and remote communities in diverse settings requires these investments to achieve sustainable universal health coverage.