Factors influencing recruitment, retention, and turnover of the dental practitioner workforce in Australian rural areas

Dental practitioners provide important primary health care services through the provision of preventive and restorative dental services. Despite an increase in dental practitioner numbers in Australia and a current workforce oversupply, there is a mal-distribution between urban and rural areas, with the majority of dental practitioners working in major cities. Rural populations experience poorer oral health outcomes than their metropolitan counterparts. One reason for this is that people in rural areas experience difficulties with access to dental health care compared with people in metropolitan areas. Health workforce shortages have negative health effects on rural populations. The successful recruitment and retention of health practitioners is a common problem faced in rural areas across the Western world. Turnover is higher in rural than in urban areas because dental practitioners often leave rural areas and move to more urban areas for a range of social and professional reasons. These reasons include geographical isolation, and difficulties for their families to access services, which are less often issues in larger metropolitan areas. This turnover creates a 'churn' of more experienced dental practitioners moving away from rural to urban areas creating a skills shortage in rural areas that can result in poorer oral health outcomes for rural populations. These workforce shortages are having negative effects on already disadvantaged rural populations and should be addressed. While some dental practitioners choose to work in rural areas, we need to better understand the reasons why they do and why many others chose not to do so. This information is critical when developing strategies to encourage more practitioner to practice in rural areas. This thesis aimed to (1) identify the attitudes of Australian dental practitioners towards living and working in Australian rural areas, (2) identify the factors that influence the rural recruitment and retention of Australian dental practitioners, (3) investigate whether dental practitioners who themselves have a rural background were more likely to practice in rural areas, than those who do not have a rural background and if so, investigate whether this rural background effect differs between female and male dental practitioners. A conceptual framework and a systematic literature review were developed to guide the study. The study employed a mixed methods design with semi‚ÄövÑv™structured interviews and a self‚ÄövÑv™administered online survey of dental practitioners Australia-wide as data collection methods. Through collaboration and advertisements with the four major Australian dental professional associations, semi-structured interviews were conducted with 50 dental practitioners and 631 online surveys were completed using LimeSurvey software. The interview data were analysed using content and thematic analysis with the use of NVivo 10.0. The survey data were analysed using Poisson regression with robust standard errors and ordinal log multinomial regression with SPSS 22 and STATA 14. Four key themes were identified from the analyses of the interviews and surveys as being important for rural recruitment, retention, and turnover of dental practitioners in Australia: (i) Business Case: The dental practitioners expressed concerns about perceived difficulties in achieving a sustainable income when operating a dental practice in a rural area. These concerns were due to smaller population sizes, average lower incomes of clients in rural areas, and their tendency not to seek regular dental treatment. The most important factor influencing rural practice recruitment decisions was whether or not operating private dental practice in a rural area would provide financial security. Financial issues were associated with rural practice decisions for men, in particular. (ii) Differences in Clinical Practices: There are differences in clinical practices between urban and rural areas that can influence rural practice decisions. Rural dental practitioners more often treat patients seeking emergency pain relief, whereas routine preventative treatment is a feature of urban practice. Rural practitioners were less concerned about these differences than urban practitioners. Women practicing in rural areas were additionally less concerned with work structures and workplace relations than women in urban practice. (iii) Community: The community plays an important role in facilitating recruitment and retention of dental practitioners in rural practice. Perceptions of dental practitioners about what it would be like to live in rural areas shape their willingness to practice in rural areas. Those who chose to do so professed having a sense of belonging to their community, a belief that they are valued by members of their community and have an affection for their community. There are heightened social expectations of dental practitioners who live and work in rural areas that may discourage some from doing so. For women who practice in rural areas, affordability of housing and lack of community was of lesser concern than those in urban practice. (iv) Individual Factors: Participants described their personal backgrounds and how they felt it had shaped their practice location decision. Individual factors such as where they grew up, their family needs, and expectations of quality of life played an important role in dental practitioners' decisions about working in rural areas. In particular dental practitioners with rural backgrounds were more than twice as likely to work in rural practice as their urban background counterparts. Lifestyle preferences, stage of life, and family structure and circumstances influence recruitment and retention. Particularly for women, rural practitioners were less concerned about being close to extended family than their urban practice counterparts. This thesis provides important recommendations for the provision of rural dental care services to address the factors influencing work location for rural dental practitioners. Due to the high fixed costs of operating a dental practice, many rural and remote communities have population sizes that are too small for a privately operated dental practice to be financially viable. Private dental practitioners could be encouraged to treat public patients in rural areas, and this could be funded by the public sector. In very isolated and remote areas, where a fixed private dental practice is not financially viable due to the low population; physicians, nurses, Aboriginal health workers and pharmacists could be trained to provide dental screening. They could also be taught to understand which oral conditions require urgent dentist or dental specialist referral, and which can be treated by antibiotics or minimally invasive dental techniques. Australian dental schools, both located in urban and rural areas could be encouraged to increase their proportion of students with a rural background. A particular target could be women with a rural background, because evidence in this thesis indicates that they are more likely than their male rural background counterparts to practice in rural areas. Exposure to rural clinical work prior to entering the workforce could be provided to promote rural workforce choices by dental practitioners because those with a rural background and understanding of rural practice were more likely to practice in rural areas. Increased promotion and exposure to rural practice during undergraduate training through rural work experience and community integration could also be encouraged for all undergraduate students in all dental schools. In addition, effective and efficient referral pathways and communication pathways between dentists, GPs, and all health care service providers in rural areas could be promoted. Rural professional support networks could be improved to provide mentoring and supervision for newer graduates. The professional dental associations and CPD providers have an important role to play in building these networks. Using methods such as phone help services, online help, tele-dental and e-dental services, and electronic network communities. In summary, this study makes an important contribution to the body of knowledge about the influences on rural practice decisions of Australian dental practitioners. The key findings are important because they provide guidance to policy makers responsible for designing strategies to ensure the correct number of dental practitioners are working in rural areas and to stabilise workforce turnover in the rural dental workforce that best meets the needs and demand for dental care.