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What Needs to Change?

Dr Cosgrave’s research has revealed that health professionals’ decisions to accept a rural health position, and their subsequent decision to stay or leave, are complex and influenced by ‘a myriad of highly interactive dimensions within personal, organisational, social and spatial domains’.

These influences can be broadly categorised into three domains:

  • organisational (or workplace);
  • role (including profession and career development opportunities); and
  • personal (including individual characteristics, spousal and family support, social aspects, and lifestyle interests.

Until recently research and human resource strategies have mostly focussed on strengthening understanding and improving organisational and role conditions. Much less focus has been given to the inter- and intra-personal determinants, despite the fact that psychosocial and personal factors are increasingly being found to significantly influence both recruitment and retention.

In addition, the need for active community participation in settling new recruits into community has been identified as an ‘essential’ strategic element for the recruitment and retention of the ‘right’ professionals needed to achieve a ‘sustainable’, ‘fit-for-purpose’ rural health workforce.

So, there are significant influences on recruitment and retention that are currently not being addressed either by government or rural health services. Namely these factors are:

There is an urgent need for a ‘fundamental reframing’ of the rural health recruitment and retention problem. This change is not about rejecting the old – in fact there is much merit in governments’ pursuit of a rural pipeline strategy given its positive influence on the rural practice intentions of medical graduates.

The reframing required, is to move from a narrow economic understanding of the maldistributed health workforce problem towards a more person-centred and holistic approach. The development of the Whole-of-Person Retention Improvement Framework is Dr Cosgrave’s response to this call.

The whole-of-person retention improvement framework

A framework addressing the need for a person-centred, holistic, approach to successfully attract and retain health professionals to rural places

Following nearly ten years of research and hundreds of interviews with rural health staff, Dr Cosgrave has distilled these learnings into a person-centred and holistic approach aimed at tackling the long-standing health workforce shortage problem facing many rural communities. She calls it the ‘Whole-of-Person Retention Improvement Framework’.


Whole-of-Person Retention Improvement Framework

Figure 1: Whole-of-Person Retention Improvement Framework

The Framework has three domains: Workplace / Organisation, Role / Career and Community / Place (Figure 1). The Framework recognises and embraces the need for a whole-of-community response to address challenges experienced at the individual, workforce and community levels. It has been described as a ‘valuable resource’ for rural health services and communities to use both independently and jointly to address their long-standing health workforce problems.

Each domain identifies the necessary pre-conditions for improving rural retention through strengthening health professionals’ job and personal satisfaction (see table 1).

Types of SatisfactionWoP-RIF domainsMajor influences on job/personal satisfaction
Job satisfactionWorkplace High quality workplace relationships with line manager and team
Organisational Organisation managed efficiently and strategically
Role Opportunities to engage with other discipline-specific health professionals and governing bodies
CareerOpportunities for career development/advancement
Personal satisfactionPlaceExperience a sense of connection leading to belonging
CommunityCommunity involved in the planning and implementation of recruitment and retention strategies

Table 1: Pre-conditions for improving rural retention by WoP-RiF Domain

A distinguishing aspect of the Whole-of-Person Retention Improvement Framework, compared to earlier health workforce retention frameworks/models, is the equal weighting given to the ‘Community and Place’ domain as given to the Workplace/Organisational and Role/Career influences.

While the ‘Community and Place’ domain has relevance for all health professionals, it is of particular importance for supporting health professionals (and their families) who have relocated and need support to settle-in and encourage social connection.

Dr Cosgrave’s research identifies if ‘newcomers’ did not develop strong social bonds within the first 12-months of relocating, then turnover is likely.

The importance of social connection and a sense of belonging for retention, also highlights the value of rural communities and health services investing in ‘grow-your-own’ workforce strategies.

While supporting social connection of newcomer health professionals (and their families) is known to be important for retention there is very little research available to guide rural communities on what are effective strategies.

To address this knowledge gap, in 2018 Dr Cosgrave was awarded a Churchill Fellowship to travel to Canada to investigate community-led strategies to support newcomer health professionals’ resettlement and to support social connection and a sense of belonging.

While in Canada, she came across the highly successful Health Workforce Recruiter Connector model operating in the town of Marathon in the Province of Ontario. The position was created in 2009 and since then has been funded by local businesses and managed by community members.

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