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					                Report to:

   Department of Human Services




   Recruitment & Retention
   of Allied Health
   Professionals in Victoria
   – A Literature Review




Human Capital
    Human capital specialists

      June 2005
Recruitment & retention of allied health professionals in Victoria – a literature review



Acknowledgements
Human Capital Alliance would like to acknowledge the generous support of the
Reference Group for this project including Department of Human Service’s officers
Emma Sartori and Tamara McKenzie, and the Australian Physiotherapy Association’s
Kerren Clark.
They supported the consultancy through a range of actions, including providing a
store of important collected literature, numerous editing suggestions and arranging
contact with key stakeholders.




                   About Human Capital Alliance

Human Capital Alliance (International) Pty. Ltd. (HCA) is a management and research
consultancy firm that specialises in workforce planning, competency-based
management and program design and evaluation. Comprised of a small core group of
human resource management experts and experienced researchers, HCA boasts of
an extensive network of associates and alliances across Australia and overseas who
are thought to be leaders in their respective areas of expertise. This enables HCA to
take on a strategic, multi-disciplinary, dynamic, innovative but practical, no non-sense
approach to its consultancies. Since its establishment in 1989, HCA has successfully
worked with the public, non-government and private sectors, spanning a wide diversity
of content and contexts. It has gained a reputation for its ability to listen to and
collaborate with clients towards finding innovative solutions that do work.




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Recruitment & retention of allied health professionals in Victoria – a literature review



Contents
1.       EXECUTIVE SUMMARY .............................................................................................................6
2.       METHODOLOGY ..........................................................................................................................8
     REVIEW SCOPE........................................................................................................................................8
     METHODOLOGY ......................................................................................................................................8
     LIMITATION OF ‘DATA’ .........................................................................................................................10
     LIMITATIONS OF THE LITERATURE ........................................................................................................10
3.       THE AUSTRALIAN LABOUR MARKET.................................................................................12
4.       OVERALL CONCEPTUAL FRAMEWORK ............................................................................15
     WORKFORCE SHORTAGES .....................................................................................................................15
     LABOUR MARKETS ................................................................................................................................17
     FACTORS THAT INFLUENCE RECRUITMENT AND RETENTION DECISIONS ................................................18
       All workers.......................................................................................................................................18
       Health workers.................................................................................................................................21
       Allied health workers.......................................................................................................................23
       Summary ..........................................................................................................................................25
     RECRUITMENT AND RETENTION DIFFICULTIES ......................................................................................26
5.       NOTES ON THE DEFINITION OF ALLIED HEALTH..........................................................29
     THE VALUE OF THE ALLIED HEALTH CONSTRUCT ..................................................................................31
     ALLIED HEALTH LABOUR SUPPLY .........................................................................................................31
6.       PODIATRIST ................................................................................................................................33
     RECRUITMENT AND RETENTION ISSUES .................................................................................................33
     STRATEGIES TO RECRUIT & RETAIN ......................................................................................................34
       A more balanced labour market ......................................................................................................34
       Recruitment to unattractive employment opportunities ...................................................................35
       Retention approaches ......................................................................................................................36
7.       PHARMACISTS............................................................................................................................37
     RECRUITMENT AND RETENTION ISSUES .................................................................................................37
     STRATEGIES TO RECRUIT & RETAIN ......................................................................................................40
       A more balanced labour market ......................................................................................................40
       Recruitment to unattractive employment opportunities ...................................................................41
       Retention approaches ......................................................................................................................43
     OTHER STRATEGIES IN PRACTICE ..........................................................................................................45
8.       PHYSIOTHERAPISTS.................................................................................................................46
     RECRUITMENT AND RETENTION ISSUES .................................................................................................46
     STRATEGIES TO RECRUIT & RETAIN ......................................................................................................47
       A more balanced labour market ......................................................................................................47
       Recruitment to unattractive employment opportunities ...................................................................49
       Retention approaches ......................................................................................................................50
9.       CLINICAL PSYCHOLOGISTS ..................................................................................................52
     RECRUITMENT AND RETENTION ISSUES .................................................................................................52
     STRATEGIES TO RECRUIT & RETAIN ......................................................................................................52
       A more balanced labour market ......................................................................................................52
10.           RADIOGRAPHERS ................................................................................................................55
     RECRUITMENT AND RETENTION ISSUES ................................................................................................55
       Incentives (perceived key drivers / attractors / enablers / motivators)............................................55
       Disincentives (perceived barriers / deterring factors).....................................................................55
       Recruitment Factors ........................................................................................................................56
     STRATEGIES TO RECRUIT & RETAIN ......................................................................................................56



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Recruitment & retention of allied health professionals in Victoria – a literature review

       In practice - Australia......................................................................................................................56
       In practice – U.K. National radiography recruitment and retention strategy .................................57
       Proposed – U.K. ..............................................................................................................................58
       Proposed – Diagnostic radiography/sonography............................................................................58
       Proposed – Radiation therapy .........................................................................................................58
       Shortage of supply ...........................................................................................................................59
11.         SOCIAL WORKERS...............................................................................................................60
   RECRUITMENT AND RETENTION ISSUES .................................................................................................60
     Incentives (perceived key drivers / attractors / enablers / motivators)............................................60
     Disincentives (perceived barriers / deterring factors).....................................................................60
   STRATEGIES TO RECRUIT & RETAIN ......................................................................................................60
12.         SPEECH PATHOLOGIST .....................................................................................................61
   RECRUITMENT AND RETENTION ISSUES .................................................................................................61
   STRATEGIES TO RECRUIT & RETAIN ......................................................................................................61
13.         DIETITIANS ............................................................................................................................63
   RECRUITMENT AND RETENTION ISSUES .................................................................................................63
   STRATEGIES TO RECRUIT & RETAIN ......................................................................................................63
14.         OCCUPATIONAL THERAPISTS.........................................................................................64
   RECRUITMENT AND RETENTION ISSUES .................................................................................................64
   STRATEGIES TO RECRUIT & RETAIN ......................................................................................................65
15.         ANALYSIS OF PROFESSIONS ............................................................................................66
   COMMONALITIES ..................................................................................................................................66
   DIFFERENCES ........................................................................................................................................67
   SUMMARY OF STRATEGIES ....................................................................................................................67
16.         BROAD STRATEGIES...........................................................................................................71
   THE NEED FOR FOCUS............................................................................................................................71
   FOCUS ON RECRUITMENT AND RETENTION FACTORS .............................................................................72
   INDUSTRY STRATEGIES .........................................................................................................................74
     Personal issues ................................................................................................................................74
     Remuneration issues ........................................................................................................................75
     Locum services.................................................................................................................................76
   ORGANISATIONAL CHANGE STRATEGIES ...............................................................................................76
     The worth of organisational change ................................................................................................76
     Employer of choice ..........................................................................................................................79
     Practical issues................................................................................................................................80
   ORGANISATIONAL DEVELOPMENT STRATEGIES .....................................................................................81
   CONCLUSION ........................................................................................................................................83
17.         GLOSSARY..............................................................................................................................84
18.         REFERENCES.........................................................................................................................85

Tables
Table 1 Literature content and volume by profession ............................................................................ 10
Table 2 Projected female labour force participation rates, 1998-2048 ................................................. 13
Table 3 Male and fulltime share characteristics of the fastest growing Australian industries............... 13
Table 4 Incidence of skill shortages for selected professions in the past 10 and 25 years..................... 16
Table 5 Factors influencing decision making on recruitment and retention .......................................... 18
Table 6 Most popular “attractors” for employees in various industries................................................ 19
Table 7 Most popular “retainers” for employees in various industries................................................. 19
Table 8 Optimising workforce recruitment for members of three generations: Baby Boomers, and
Generation X’ers and Y’s.* .................................................................................................................... 21
Table 9 Optimising workforce retention for members of three generations: Baby Boomers, and
Generation X’ers and Y’s.* .................................................................................................................... 21



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Recruitment & retention of allied health professionals in Victoria – a literature review

Table 10 Recruitment factors: Top 10 categories grouping ................................................................... 24
Table 11 Retention factors: Top 10 categories grouping ....................................................................... 24
Table 12 Top triggers to leave................................................................................................................ 25
Table 13 Allied health professions identified within stakeholders definitions........................................ 30
Table 14 Proportion (%) of students identifying different aspects of rural pharmacy practice potentially
attractive (n=153) .................................................................................................................................. 37
Table 15 Proportion (%) of practising rural pharmacists identifying aspects that attracted them to rural
pharmacy practice (n=335).................................................................................................................... 38
Table 16 Proportion (%) of students identifying possible incentives to rural pharmacy practice (n = 153)
................................................................................................................................................................ 38
Table 17 Why respondents currently working in pharmacy intend to continue pharmacy work (n = 338)
................................................................................................................................................................ 39
Table 18 Proportion (%) of rural pharmacists intending to leave identifying aspects that would influence
their decision to leave rural pharmacy practice (n = 148) .................................................................... 40
Table 19 Factors influencing recruitment to rural areas: Major factor groupings by professions
(Figures are % of persons surveyed in respective profession) ............................................................... 66
Table 20 Selected recruitment and retention strategies by profession ................................................... 69
Table 21 Average annual investment level ($’s) in different RPIP initiatives ........................................ 71
Table 22 Initiatives identified by rural pharmacists as an important influence on their decision to remain
in rural practice...................................................................................................................................... 72

Figures
Figure 1 Nursing Turnover Risk vs. Social cohesion in the workplace .................................................. 22
Figure 2 A multidimensional interactive allied health workforce recruitment and retention conceptual
model ...................................................................................................................................................... 73
Figure 3 The relationship between organisational culture and propensity to leave the organisation ... 77




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Recruitment & retention of allied health professionals in Victoria – a literature review



1. Executive summary
This report describes the results of a review of literature into recruitment and retention
issues, focussing upon factors that most strongly appear to influence behaviour of
allied health professionals.
Project time constraints precluded undertaking what might be termed an exhaustive
literature search and review. However a fairly significant volume of literature was able
to be collected. The volume of literature gathered was misleading since there remain a
number of significant ‘holes’ that prohibit a comprehensive picture being formed. The
most problematic information gaps are:
   Literature specific to the individual allied health professions, particularly the smaller
   disciplines;
   Literature on what initially attracts persons to various allied health profession
   options;
   Poor quality and out of date information on specific allied health labour markets,
   making it difficult to prioritise strategy options;
   A focus on difficulties in recruitment and retention with little examination of the
   conditions underpinning ‘normal’ decision making and behaviour.
Even the more voluminous literature on difficult allied health recruitment and retention
was very skewed towards difficulties in rural locations, to the almost total exclusion of
literature related to other areas of disadvantage (outer metropolitan, inner city) or
unattractive areas of practice (eg aged care).
The review adopts a broad labour market framework and attempts to place
recruitment and retention of allied health workers in the context of both their own
narrow labour markets and that of the broader historical Australian labour market of
the last 20-30 years. Using this framework we view labour turnover as a natural
process, the normal workings of supply being cleared to satisfy labour demand. In
labour markets with a supply shortage, less attractive employment circumstances (eg
rural locations, less glamorous areas of practice) that are normally cleared are at risk
not being cleared at all (or only temporarily). This generates recruitment ‘difficulties’.
The general labour market literature was explored to develop an understanding of the
key factors influencing worker decision making; to join, stay with, or leave an
employer. The findings suggest the following factors are the most important for all
workers, including allied health professionals:
Recruitment
   Personal factors, particularly associated with choice of place to live;
   Job satisfaction / interesting and challenging work;
   Career prospects, especially the potential to ‘fast track’ progression;
   Income earning capacity, including salary, benefits, security;
   Balance between work / life (style) / family.
Retention
   Relationship with work colleagues;
   Job satisfaction / interesting and challenging work;



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Recruitment & retention of allied health professionals in Victoria – a literature review

   Personal factors, particularly associated with choice of place to live;
   Work environment, including a supportive culture;
   Balance between work / life (style) / family.
Continuing this theme, workers from different allied health professions appear to make
very similar recruitment and retention decisions, for the same reasons. Some small
differences arise from workforce composition, workforce distribution (public / private
sector) and work conditions (awards, OHS issues), however a more powerful
influence on behaviour than allied health discipline is likely to be age / stage of career.
No attempt has been made to develop recommendations for future recruitment and
retention strategies; not only is this beyond the scope of the review but the evidence
to support a particular direction is insufficient. However, it was possible to develop
some ‘best bet’ future investment options to discuss, negotiate and possibly explore in
practical ways. These directions are:
   Reduce the number of recruitment and retention strategies for investment. The
   literature is replete with long lists of possible strategy approaches, and several
   programs have been funded in the last decade to pursue multiple strategies in the
   aim of being ‘comprehensive’. It would be better perhaps to invest adequately in a
   few strategies with good prospects than under-invest in a raft of strategies;
   Commit resources and investment at appropriate levels and in ways that equate to
   real levels of influence. Influence can be at an industry level, organisational level,
   community or individual level;
   Accept that the most important influence on recruitment and especially retention
   outcomes are the employing organisations. The personnel management processes
   organisations employ and the cultures they create profoundly impact on their
   attractiveness as an employer and hence their staff turnover. This should be the
   focus of effort, in ways that are again appropriate to the level and type of influence
   that can be brought to bear;
   Supportive infrastructure development (capacity building in the lexicon of public
   health) might be more important than a range of short term funded ‘programs’,
   even if the latter are easier to organise, fund and promote.




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Recruitment & retention of allied health professionals in Victoria – a literature review



2. Methodology
Review Scope
The allied health professions included in this review were:

    1. audiologists,
    2. clinical psychologists,
    3. dieticians,
    4. occupational therapists,
    5. orthoptists,
    6. pharmacists,
    7. physiotherapists,
    8. podiatrists,
    9. prosthetists/orthotists,
    10. radiographers,
    11. social workers, and
    12. speech pathologists.

Methodology
This project was essentially a review of the literature. In addition though, relevant
quantitative and qualitative data on recruitment and retention of the allied health
workforce were collected primarily via the Department of Human Services,
professional associations, identified academics and key Australian research institutes
(including the Australian Bureau of Statistics (ABS) and Australian Institute of Health
and Welfare (AIHW).
The table below outlines the search criteria employed with respect to the literature
search and review.


Areas to review          Key words                              Source of literature
Conceptual framework
-   Australian labour    First level:                           ABS; AIHW; DEWR; DIMEA
    market
                         Labour supply; recruitment;
                         retention; shortage; vacancies.
                         Second level:
                         Ageing workforce; feminisation;
                         diversity
                         First level:                           ABS; AIHW; DEWR;
Professional issues
                                                                journals/newsletters &
                         Incentives; disincentives; barriers,
                                                                submissions of professional
                         retention, attrition
                                                                associations via contact
                         Second level:                          persons & websites; Medline;
                                                                Productivity Commission
                         Training; career development;
                         mentoring; network; expectations;
                         autonomy; remuneration;
                         professional development; burn
                         out; attractions
Each identified allied health profession



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Recruitment & retention of allied health professionals in Victoria – a literature review


Areas to review           Key words                            Source of literature
First level:
    1. audiologist
    2. clinical psychologists
    3. dieticians
    4. occupational therapists
    5. orthoptists
    6. pharmacists
    7. physiotherapists
    8. podiatrists
    9. prosthetists/orthotists
    10. radiographers
    11. social workers
    12. speech pathologists
                          Second level:                        ABS; AIHW; DEWR; DIMEA;
Workforce profile /
                                                               AHWAC; Health Professions
Distribution              Location (rural, remote, outer
                                                               Council of Australia; State
                          urban); setting / sector; practice
                                                               Allied Health Alliance;
                          area
                                                               journals/newsletters &
                          Third level:                         submissions of professional
                                                               associations via contact
                          gender; age; diversity; working      persons & websites
                          hours; vacancies; attrition
                          Second level:                        ABS; AIHW; DEWR;
Workforce
                                                               AHWAC; Health Professions
expectations              Location (rural, remote, outer
                                                               Council of Australia; State
                          urban); setting / sector; practice
                                                               Allied Health Alliance;
                          area
                                                               journals/newsletters &
                          Third level:                         submissions of professional
                                                               associations via contact
                          Incentives; attractions; barriers;   persons & websites
                          disincentives; perceptions;
                          motivations; expectations;
                          autonomy; mentoring; network;
                          remuneration; re-entry;
                          participation
Strategies (proven & proposed) to resolve identified issues
                          First level:                         IPPR; OECD, allied health
International practices
                                                               organisations; international
                          U.K.; Canada; U.S.A.
                                                               private sector organisations;
                          Second level:                        governments
                          Allied health; recruitment
                          strategies; retention strategies.
                          First level:                         AHRI; selected employer
HR practices
                                                               websites; journals/newsletters
                          Recruitment strategies; retention
                                                               & submissions of professional
                          strategies.
                                                               associations via contact
                          Second level:                        persons & websites
                          Employer of choice (EOC); best
                          practice HR




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Recruitment & retention of allied health professionals in Victoria – a literature review


Limitation of ‘data’
First, time proved to be the major constraint in the search for relevant literature.
Identified literature that could not be readily accessed had to be abandoned in order to
meet project timeframes.

Second, where mandatory registration or licensing of allied health practice is not
required, membership of a professional association is also not compulsory. Caution is
therefore required in reading and interpreting data collected by professional
associations as it may not reflect the workforce in its entirety.
Third, the majority of quantitative data quoted in this review are directly or indirectly
derived from the Australian 2001 Census by the Australian Bureau of Statistics (ABS),
in nearly all cases the most recent source of complete labour force data. The ABS
Quarterly Labour Force survey data is also quoted; however this data source can be
unreliable for smaller workforces as a result of sampling errors.
Finally, graphs shown for individual professionals (if available) were obtained from the
Australian Job Search website in which it declared that:
    “ … the data underpinning the graphs are drawn from the most recent
   Australian Bureau of Statistics (ABS) Labour Force Survey in most instances.
   Other sources are the 2001 Census of Population of Housing, also conducted by
   the ABS, and ABS labour force supplementary surveys such as Employee
   Earnings, Benefits and Trade Union Membership, Annual averages of the
   quarterly, or trend data, have been used to smooth the somewhat volatile data.”

Limitations of the literature
In conducting this literature review of allied health recruitment and retention issues it
became apparent that an examination of the reviewed literature alone was insufficient
to develop comprehensive, sound and evidence supported policy which could
determine specific investment strategies. A related review by Leggat (2003) found
similar problems. The reason for this limitation is shown in the following table,
summarising the focus of the literature found by major area of interest.

Table 1 Literature content and volume by profession


                                 Content areas & volume of literature uncovered
   Allied health
                             Attraction  Broad labour     Difficult     Occupational
   profession
                                 to          market     recruitment       wastage
                             profession     issues /   and retention
                                          assessment       areas
   audiologists
   clinical psychologists
   dieticians
   occupational therapists
   orthoptists
   pharmacists
   physiotherapists
   podiatrists
   prosthetists/orthotists
   radiographers
   social workers
   speech pathologists
   Allied health workforce



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Recruitment & retention of allied health professionals in Victoria – a literature review



The limitations of the literature do not reflect the volume per se, but rather:
    the skewed emphasis on particular areas of problem employment, particularly
    recruitment and retention in rural and remote locations1;
    the disproportionate volume of information on certain health professions and almost
    absence of literature on others;
    the tendency to aggregate distinct workforce categories into a single ‘allied health’
    category and treat them in an undifferentiated manner;
    the descriptive nature of the available information. Where evaluative studies in the
    literature do exist, few use randomised or controlled methodologies for assessing
    the relative value of different approaches.
    the propensity to create ‘shopping lists’ of factors that influence recruitment and
    retention, but little evidence-based weighting of different factors. When strategies
    are directly derived from these factors and result in recommended approaches, the
    problems are compounded.
Leggat (2003) also notes that the nature of rural practice means that there are
relatively few positions available and this results in small study populations, which
limits the ability to generalise the results to other populations. On a number of
occasions in this report we attempt to generalise (or at least extrapolate) results from
rural studies (since there are often no alternatives) to other situations with recruitment
and retention problems. Clearly this poses risks, of which the reader should be
mindful.
Despite these limitations, we have endeavoured to review the literature in a way
helpful to policy makers and those investing in strategies that would alleviate
recruitment and retention difficulties. A key element of our efforts was to distil from the
‘shopping list’ of options a small number of approaches that appear more likely to yield
a good return on investment.




1
  There is a paucity of literature for instance on recruitment problems in other unattractive
locations such as outer metropolitan or poor inner city areas, and too on unattractive areas of
practice such as aged care or adult disability services.


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Recruitment & retention of allied health professionals in Victoria – a literature review



3. The Australian labour market
There has been a quiet revolution in the Australian labour market over the last 20-30
years. It has been characterised by:
   A comparatively dramatic ‘feminisation’ of the workforce;
   Lowered real workforce participation even as unemployment returned to historically
   low levels);
   Increased level of skill of the workforce; and
   Increased level of casual employment (or ‘flexible’ employment) within the
   workforce.
One of the most remarkable aspects has been the change in gender participation in
the workforce and unemployment rates. In 1991 the traditional place of male
unemployment rate as below that of females was reversed for the first time, and for a
period of time in the mid 1990s the female unemployment rate stood at 9% compared
to 11% for male workers (Hancock & Safari 2001). In subsequent years, the gap has
narrowed as the unemployment rate has dropped to the lowest levels in 20 years.
The unemployment rate is certainly a controversial statistic, particularly given that
employment is defined as having worked for at least an hour in the previous week. It is
made more controversial by the growing levels of non fulltime work being performed;
between 1980 and 2000 the proportion of the workforce employed full time has
dropped from 93% to 88% (Hancock & Safari 2001).
Indeed, the falling level of fulltime employment has undercut otherwise impressive
gains in workforce participation; that is, the proportion of working age persons actually
engaged in the workforce – either employed or seeking work.
In terms of numbers, the participation rate has increased in recent years to 60%.
However, in real terms of full time equivalent (FTE) units of labour, participation has
actually fallen from 51% to 48% (Hancock and Safari, 2001). Most commentators are
unwilling to say whether the reduced FTE employment rates are more a result of
employer demand or employee supply factors – obviously, both contribute. Most
believe though there is a latent degree of under-employment in Australia, i.e. a surplus
of labour who desire to work more hours if they could (e.g. Wooden, 1996). This
suggests reduced FTE employment rates are largely a product of employer demand.
Both in terms of participation and hours of work, the trends for male and female
workers have been at odds as described by Debelle and Swann (1998):
   “The rise in aggregate participation rate has masked offsetting trends in the
   participation rate for males, which has declined from around 84% to around
   73%, and females, which has risen from around 37% to around 54%.”
In FTE contribution also between 1980 and 2000 female participation rose from 32%
to 37%, while male participation dropped from 70% to 63% (Hancock & Safari 2001).
The trend in female employment rates are predicted to continue by most observers,
with male employment behaviour less predictable.
In regard to female workforce participation rates, McDonald and Kippen (1999) offer
the following projected the future trends:




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Recruitment & retention of allied health professionals in Victoria – a literature review


Table 2 Projected female labour force participation rates, 1998-2048

    Age group               1998 Participation rate           2018-48 Projected
                                                              participation rate
    15-19                             55.0                             55.0
    20-24                             77.0                             80.0
    25-34                             69.0                             75.0
    35-44                             71.0                             75.0
    45-54                             70.0                             75.0
    55-59                             43.0                             60.0
These statistical trends draw into stark relief the clearly converging labour market
behaviour of males and females, and bring into question long held views that focused
on wasted skills formation and high occupation wastage rates in respect to female
dominated occupational and industry labour markets. Indeed, labour market analysts
and others are increasingly looking to greater female workforce participation (fuelled
further by falling fertility rates) to provide a ‘soft landing’ to the so called crisis
supposedly likely to accompany the ageing of the Australian population (Treasurer of
the Commonwealth of Australia 2002).
Several of Australia’s fastest growing industries in terms of employment are female
dominated (see table below), while even some of those that are not are rapidly
becoming feminised (e.g. property and business services).
Table 3 Male and fulltime share characteristics of the fastest growing Australian
industries

   Industry                           Males’ share of total    Full time share of total
                                         employment                  employment
   Property & business services                57                         77
   Accommodation, cafes, etc.                  45                         55
   Cultural & recreational services            55                         61
   Personal & other services                   50                         71
   Health & community services                 22                         62
   Retail services                             49                         57
   Construction                                86                         86
   Education                                   34                         70
                                                                Source: Debelle and Swann, 1998

This quiet revolution in female workforce participation has been achieved without any
appreciable change in female wages (female / male earning relativity has improved
since 1984 from 81.4% to just 84.0% in 2000, Hancock and Safari, 2001). Nor have
the conditions of child care been a major factor, despite the continued focus on this
issue through repeated survey outcomes:
   “Non-employed mothers do not cite child care as the barrier preventing them
   from working and many two-earner families appear to be able to adjust their
   schedules so as to avoid paying child care costs at all.” (Cobb-Clark, Liu &
   Mitchell 2000)
As well as the increased participation of women, Australia’s employment growth in the
last 20 years has been characterised by higher levels of skill. Between 1980 and 2000


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Recruitment & retention of allied health professionals in Victoria – a literature review

the average annual growth rate of persons employed with post-school qualifications
had been 3.2%, whereas the growth rate for persons without post-school qualifications
has been only 0.6% per annum. In absolute employment terms, this means the
numbers employed with a post-school qualification has grown from just over 2 million
to 4 million, while the growth of those with no post-school qualification has been from
3.5 million also to 4 million in the same time period.
Finally, a word can be offered on the ‘casualisation’ of the Australian workforce. Using
the standard ABS definition for ‘casual’ employment, Australia has seen a quantum
move in the levels of casual employment from 1982 to 2000 of 13.3% to 27.3%
(Campbell & Burgess 2001). Casual employment is generally associated with higher
levels of employment uncertainty, although the extended length of many casual
employment arrangements in today’s labour market has begun to challenge this
perception. Campbell and Burgess (2001) thus canvass an alternative notion of the
‘precariousness’ of employment which draws a relationship between the type of
employment (whether part or full time, temporary or permanent) and the rights of the
contract:
   “What we can see here is the overriding salience of the casual contract of
   employment and the general shortfall in rights, benefits and forms of protection
   that this contract defines.”
Some observers are not sure that the level of casualisation of the workforce has
progressed as far as the ABS statistics would suggest (Murtough & Waite 2001).
These authors question the validity in the current labour market of the ABS definition
of ‘casual’, and prefer instead to use self-report (self-perception) data to make their
estimate; which produces a significantly lower estimate. It is not just the definition they
attack, they also confront the issue of precariousness and argue for many ‘casuals’
that form of employment is a deliberate and rational choice in order to optimise
participation in the labour market.
The controversy over definition is but one element of an increasingly confused
situation with casual labour (a segment of the labour market which plays an important,
maybe critical role in the health industry). Significant industrial relations issues are
emerging, amidst which Owen highlights a lack of agreed common law standards,
resulting in judgements that currently go one way or the other (Owen 2001). Courts
have even introduced the oxymoron ‘permanent casual’, which might especially arise
through long term relationships with labour hire companies. These relationships are
potentially open to challenge in court.




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Recruitment & retention of allied health professionals in Victoria – a literature review



4. Overall conceptual framework
Workforce shortages
The concept of a skills or workforce shortage is complex (Barnow, Trutco & Lerman
1998). In their comprehensive study on skills shortages, Shah and Burke (2003)
propose a definition for ‘shortage’ as the condition where:
   “The demand for workers for a particular occupation is greater than the supply of
   workers who are qualified, available and willing to work under existing market
   conditions.” (p. v).
In these circumstances of genuine shortage, one would expect to see evidence of
recruitment difficulty emerge as well as retention problems; as these are related but
separate phenomena, discussed later.
Richardson (2005) builds on the above definition of shortage, adds detail regarding
conditions, and allows for a typology of four possible levels of shortage as follows:
   Level 1 shortage:
   i. There are few people who have the essential technical skills who are not
      already using them; and
   ii. There is a long training time to develop the skills; and/or
   iii. There are limits to the capacity of training organisations
   Level 2 shortage
   i. There are few people who have the essential technical skills who are not
      already using them; but
   ii. There is a short training time to develop the skills; and
   iii. The capacity of training organisations can be readily expanded
   Level 3 shortage: Skills mismatch
   There are sufficient people who have the essential technical skills who are not
   already using them, but they are not willing to apply for the vacancies under
   current conditions.
   Level 4 shortage: Quality gap
   There are sufficient people with the essential technical skills, not already using
   them, who are willing to apply for the vacancies, but who lack some qualities
   that employers think are important.
Most commentators now agree that majority of the medical and the registered nurse
workforces are experiencing ‘level 1’ shortages. These shortages have become
chronic (see the table below) in the case of some medical practice areas including
general practice (AMWAC 1998), and especially the nursing practice workforce
(Ridoutt & Cook 2001). There are increasing fears that allied health professions, at
least selected disciplines, may end up in the same situation. Department of




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Recruitment & retention of allied health professionals in Victoria – a literature review

Employment and Workplace Relations (DEWR) assessments2 certainly suggests
several of the allied health labour forces in most Australian jurisdictions have been in
conditions of overall undersupply for many years.
Table 4 Incidence of skill shortages for selected professions in the past 10 and 25 years

                                                                   No. of years profession has been
    Occupational Title                                               in national shortage in past
                                                                       25 years                10 years
    Nurses
    Nurse Managers                                                          0                       0
    Nurse Educators and Researchers                                         0                       0
    Registered Nurses                                                      19                      10
    Registered Midwives                                                    16                       9
    Registered Mental Health Nurses                                        17                      10
    Registered Developmental Disability Nurses                              0                       0
    Allied Health Professionals
    Pharmacists                                                             7                       7
    Occupational Therapists                                                11                       4
    Optometrists                                                            0                       0
    Physiotherapists                                                       17                       9
    Speech Pathologists                                                     7                       2
    Chiropractors and Osteopaths                                            0                       0
    Podiatrists                                                             1                       1
    Medical Imaging Professionals                                          18                      10
    Dieticians                                                              0                       0
    Audiologists, Orthoptists and Orthotists                                0                       0
    Social Welfare
    Social Workers                                                          2                       2
    Welfare and Community Workers                                           0                       0
    Counsellors                                                             0                       0
    Psychologists                                                           0                       0
Source: March 1980 to 1984-85: Summary Characteristics of Principal Skilled Occupations, Department of
Employment and Industrial Relations; 1985-86 to 1989-90: Meeting Australia's Skill Needs - report on the
Occupational Share System for Skilled Migration, Reports 2 to 6. Department of Employment and Industrial Relations
(Department of Employment, Education and Training from 1987 onwards); 1990-91 to 1997-98: National Skills
Shortage Lists, Department of Employment, Education, Training and Youth Affairs; Dec 1998 to Feb 2001: National
Skill Shortages Lists, Department of Employment, Workplace Relations and Small Business; Feb 2002 to March 2004:
National Skill Shortages Lists, Department of Employment and Workplace Relations




2
  DEWR assesses skill shortages by a number of means including contact with employers,
industry, employer and employee organisations and education and training providers. The
core of the research methodology is a survey of employers who have recently advertised
vacancies for selected skilled occupations and examining whether employers were able to find
suitable workers for their positions.


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Recruitment & retention of allied health professionals in Victoria – a literature review

Of the allied health professions noted in the above table, the most persistent
workforce shortages appear to be associated with those professions with a strong
public sector services presence (eg occupational therapists, radiographers, speech
pathologists) although several professions with more equally distributed workforces
(eg physiotherapy) and more private sector participation (pharmacy) have also
exhibited significant shortages in supply. The labour market conditions of each of the
allied health professions will be discussed in later chapters.

Labour markets
Labour markets act to clear the demand for labour under available conditions of
supply. The clearing process operates (at equivalent price of supply across
geographic locations) to satisfy demand first in attractive locations; that is, labour will
seek out employment first in positions that appear attractive because of location, type
of employer, qualities of the job, career prospects, etc.
If there is total insufficient supply to meet total demand (a ‘level 1’ shortage), less
attractive locations will not have their demand for labour satisfied3. Employers seeking
labour for these less attractive employment opportunities will experience recruitment
problems primarily in the form of lengthy periods of unfilled vacancies. Alternatively,
they may fill their vacancies with persons who represent a skills gap (Level 4
shortage), for instance a new graduate in a position that requires significant
experience or a form of substitute skills (e.g. welfare work qualification for a social
work qualification requirement). Even under conditions of a balance between demand
and supply, a ‘Level 3’ shortage can manifest if some employment opportunities are
sufficiently unattractive and price conditions (that is the financial arrangements for
employment) cannot be manipulated to make the opportunity more attractive. It has
long been hypothesised, for instance, that many allied health professions (especially
those dominated by female workforce participation) would prefer un- or
underemployment to work in unattractive locations or practice areas (see for instance
Ridoutt, 1987)4.
Labour markets are certainly dynamic; a phenomenon that many workforce
commentators fail to take into account. In the case of sustained shortages, those in
control of the factors of demand (health consumers, health service managers) act to
reduce dependence on a particular form of supply by looking to alternative service
options (say chiropractor vs. physiotherapy services), by redesigning the way services
are delivered, or by changing consumer preferences (e.g. shifting to alternative
medicine options). Similarly, labour responds to changes in the ‘price’ employers are
willing to pay (through wages and other non wage financial or pseudo financial
benefits) and to other circumstances (e.g. an increase in general unemployment or



3
  ‘Less attractive locations’ are generally taken to imply rural and remote service regions.
Difficulty in attracting and retaining all forms of health professionals to rural areas have been
widely reported (e.g. Huntley, 1991). In more recent times outer metropolitan areas of the
larger cities (including Melbourne) have become almost as common reporters of difficulty, as
have specific areas of practice that are not perceived by professionals as particularly attractive.
For many therapists for instance aged care or intellectual disability practice is not perceived as
a good career choice.
4
  What little evidence exists does not support this hypothesis. A study of allied health
recruitment and retention difficulties undertaken by Gadiel and Ridoutt (1993) in rural NSW
occurred at a rare time when several therapy workforces had been oversupplied by a sudden
increase in new graduate supplies. The study found that there were no recruitment difficulties
(at least in so far as filling vacancies), offering evidence that indeed supply was willing to
accept unattractive employment opportunities in preference to unemployment.


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Recruitment & retention of allied health professionals in Victoria – a literature review

interest rates) to increase supply. Recruitment and retention issues need to be
considered in this dynamic context.
Trying to influence the way labour behaves in response to an adverse labour market
situation is generally the least used approach of the three main tools at the disposal of
workforce planners to significantly affect the supply of labour (the others being to
increase training rate and immigration supply). Several workforce planning studies
have shown how sensitive labour markets are to a change in the net wastage rate of
labour (that is the difference between workforce losses and workforce re-entry in any
one year). For instance, a study of the pharmacy workforce (Health Care Intelligence
1999) showed that a one and a half percent change in wastage rate (from 3.0 to 1.5%)
could add nearly 2,500 FTE to the projected workforce supply by 2010, thus
ameliorating or even averting a serious labour market shortage. The elements of
wastage are almost all within the domain of recruitment (e.g. increased and faster re-
entry, higher workforce participation) and retention (delayed retirement, reduced
occupational change, delayed workforce exit).

Factors that influence recruitment and retention decisions
All workers
In the dynamic context of the labour market, recruitment and retention actions /
decisions are being made continuously by actors on both the demand and supply
sides of the market. They are the natural mechanisms by which the market operates.
A major study of turnover in New Zealand (all workforces) demonstrated that the
reasons for job change are complex and multidimensional; rarely could one factor
explain the decision (Boxall, Macky & Rasmussen 2003). Notwithstanding this
evidence, the search for specific factors that might influence decision making on
where to seek and take up employment and when to leave (or stay) in employment
has been subject of keen interest.
For instance, a survey of Australian employees across eight industry groups (Day
2005) identified ten main factors influencing recruitment and retention decisions. As
shown in the table below, the most important factor influencing decisions in both areas
is whether the work is rewarding or not.
Table 5 Factors influencing decision making on recruitment and retention

                                              Important to join      Important to stay
  Factors
                                               Rank        %         Rank         %
  Rewarding work                                1         80%          1         88%
  Level of pay/benefits                         2         79%          3         82%
  Career prospects                              3         74%          5         78%
  Good super benefits                           4         67%          8         70%
  Company culture                               5         64%          6         72%
  Training and development                      6         61%          7         71%
  Relationship with manager                     7         58%          3         82%
  Flexible work arrangements                    8         58%          9         65%
  Relationship with colleagues                  9         54%          2         83%
  Other financial benefits                      10        44%          10        38%




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Recruitment & retention of allied health professionals in Victoria – a literature review

According to the same survey results the influence of these factors remains
remarkably stable across the different industry categories.
Table 6 Most popular “attractors” for employees in various industries




                                                                                                                                    Chemical/Coal/




                                                                                                                                                                                             Manufacturing
                                                                                                                                                         Construction/
                                                                                                  Government




                                                                                                                                                         Engineering
                                                                                                                Technology
                                                                                                                Information
Factors




                                                         Education
                               Business
                               Services




                                                                                Finance




                                                                                                                                       Mining
Rewarding work                   2                   1                      1                 2                    2                    1                   2                     1
Level of pay/benefits            1                   2                      1                 1                    3                    1                   1                     2
Career prospects                 2                   4                      3                 2                    1                    3                   4                     3
Good super benefits              5                   4                      4                 7                    4                    3                   4                     4
Company culture                  7                   8                      5                 7                    5                    5                   4                     4
Training and development         4                   2                      6                 9                    6                    6                   9                     8
Relationship with manager        8                   7                      8                 5                    7                    8                   3                     4
Flexible work arrangements       5                   8                      7                 2                    8                    6                   7                     9
Relationship with colleagues    10                   4                      9                 5                    8                    9                   7                     7
Other financial benefits         8               10                         9                 10                  10                  10                   10                    10



What limited differences between industries that were identified existed in respect to
factors influencing retention decisions (see table below).

Table 7 Most popular “retainers” for employees in various industries




                                                                                                                                                                             Manufacturing
Factors
                                                                                                                                                            Construction/
                                                                                                                                          /Coal/Mining
                                                                                                   Government




                                                                                                                                                            Engineering
                                                                                                                      Technology
                                                                                                                      Information
                                                                Education
                                          Business




                                                                                                                                          Chemical
                                          Services




                                                                                   Finance




Rewarding work                              2                        2                    2              2               1                   1                 1                    1
Level of pay/benefits                       2                        4                    5              5               2                   2                 1                    2
Career prospects                            2                        8                    4              5               2                   7                 4                    5
Good super benefits                         7                        6                    9              1               7                   3                 8                    7
Company culture                             6                        6                    7              5               6                   5                 6                    7
Training and development                    7                        4                    6              9               7                   8                 8                    6
Relationship with manager                   2                        2                    1              5               2                   3                 3                    4
Flexible work arrangements                  9                        9                    8              2               9                   9                 7                    9
Relationship with colleagues                1                        1                    2              2               2                   5                 4                    3
Other financial benefits                  10                         10              10               10               10                  10                10                  10



Boxall et al. (2003) found very similar results to Day (2005) at least in respect to
turnover. They found the five main reasons persons who had recently left their job
offered for their decision were:
   For more interesting work elsewhere (67%);



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Recruitment & retention of allied health professionals in Victoria – a literature review

    For better training opportunities (54%);
    Because management didn’t recognise employee merit (51%);
    To obtain better balance between the demands of work and life outside work
    (51%):
    For a change of career (47%).
Those that stayed offered different reasons for their decision except in respect to one
major factor. The top five reasons again were:
    Happy with co-workers (94%);
    Interesting work (90%);
    Good relationship with supervisor (90%);
    Good job security (87%);
    Personal reasons, eg like living in the area (78%).
Again similar to Day (2005), Boxall et al (2003) found little differences in response
across the industries. However, they did find that age was an important characteristic;
younger workers and non unionised workers were more likely to have changed
employment in the recent past. Boxall et al. (2003: 209) concluded:
    “… younger people’s career choices are more provisional; they experiment more
    with career choices and types of employer… the study identifies the under 30’s
    as the workers most likely to use labour mobility to gain better pay and better
    access to good training opportunities…. The young, as ever, fancy their
    chances.”
They go on to further note that young employees’ behaviour is mimicked by newly
arrived migrants who explore the labour market by ‘trial and error’ for the first few
years of their settlement.
The findings of Boxall et al. (2003) on age effects are supported by a growing body of
literature into intergenerational differences in workforce behaviour (e.g. Hill 2002,
McKenna 2003). In particular the basic approach to workforce participation is thought
to vary importantly between the ‘Baby Boomer’, ‘Generation X’ and ‘Generation Y’
generations as shown in the tables below taken from Schoo, Stagnitti, Mercer and
Dunbar (2005)5.




5
 They in turn adapted their tables from the work of McKenna (2003) and Spin
Communications and Sweeney Research (2004).




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Recruitment & retention of allied health professionals in Victoria – a literature review

Table 8 Optimising workforce recruitment for members of three generations: Baby
Boomers, and Generation X’ers and Y’s.*

      Baby Boomers                    Generation X                         Generation Y

 Value experience and        Making a difference as an            Emphasise the mission and
 maturity                    individual                           actively demonstrate it
 Support professional
                             Balance, time off and support        Value multiple career
 development and
                             are important                        opportunities
 acquiring new skills
                                                                  Value making daily differences
 Desire to get ahead         Fun in work environment
                                                                  in the lives of others
 Desire to achieve balance   Value technology and
                                                                  Forefront of technology
 in the job                  autonomy


Table 9 Optimising workforce retention for members of three generations: Baby
Boomers, and Generation X’ers and Y’s.*

      Baby Boomers                    Generation X                        Generation Y

                             Provision of quality training that   Competing in pay and
 Provision of mentoring
                             is easily accessible                 benefits
 Recognition of              Encouragement of working             Demonstrating ways to
 contributions               independently                        progress
 Creating harmony in the     Pointing out project                 Desire to speak up and take
 workplace                   opportunities                        part in projects
                                                                  Teamwork and inter/intra
 Name recognition            Provision of direct feedback
                                                                  departmental collaboration

 Flexible working hours      State of the art technology          State of the Art technology

 Point out value to          Recognition of balance as an
                                                                  Dislike for corporate politics
 organisation                important factor in life

 Recognition of achieving    Recognition of the need for job /    Value optimism, diversity and
 balance in life             career changes                       updates on status quo



Health workers
Do these factors which seem to most influence recruitment and retention decisions of
the broader workforce approximate also the influences on decision making by health
professionals? Benchmarking data from nurses at a number of public and private
hospitals (surveying almost 17,000 nurses) provided by Parle (2003, a) suggests
health professions (at least nurses, who would appear to be a good proxy also for
allied health professionals) do behave in a very similar way to other forms of labour.
For instance, when asked to identify the reasons why they would consider staying in
their organisation, the top reasons given by nurses and the percentage of nurses who
gave each reason were:
   The people I work with (51%)
   Convenient (close to home) (28%)
   Enjoy the work (25%)



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Recruitment & retention of allied health professionals in Victoria – a literature review

   Hours and shifts (18%)
   Current position/type of work (16%)
   Money (13%)
   Education and experience (12%)
These reasons, and their rank order, are similar to those identified by Day (2005) and
Boxall et al (2003).
Another Best Practice Australia study (Parle 2003, b) reinforces the primary place of
work colleague relationships in retention decision making. They looked at the
relationship between ‘social cohesion’ and intention to leave employment. They define
“Social Cohesion in the Workplace” as:
   “The extent to which employees feel a sense of belonging to a friendly, cohesive
   community – versus – the extent to which they feel alienated from their work
   colleagues.”
The chart below looks at the benchmarking partners in their Benchmarking Study and
compares each organisation’s rating for Social Cohesion in the Workplace with its
Nursing Turnover Risk (defined as the percentage of nurses who often think of leaving
the organisation). A strong inverse relationship was found between social cohesion
and turnover risk, with the relationship able to explain over 60% of turnover risk
variation.
Figure 1 Nursing Turnover Risk vs. Social cohesion in the workplace




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Recruitment & retention of allied health professionals in Victoria – a literature review

Nurses gave the following reasons when considering leaving their organisation (Parle
2003, a):
   Workload/staffing (33%)
   Management (23%)
   Shiftwork/hours (21%)
   Pay (21%)
   Career/growth opportunities (16%)
   Stress/frustration (15%)
   Lack of support (12%)
   Lack of recognition/respect (11%)
   Conditions and equipment (10%)
There are similarities here, too, with studies of the broader workforce, although the
reasons for nurses wanting to change employers appear to be more negative, driven
more by unacceptable work conditions, pay and management rather than by a desire
to find more interesting work or a change of career.
In the same benchmarking study (Parle 2003, b) nurses cited the following reasons for
being initially attracted to work in their organisation:
   Location (31%)
   The type of position/role (22%)
   Development and experience (15%)
   Reputation (10%)
   Money (7%)
   Flexible work arrangements / Hours (7%)
Apart from ‘location’ (which is also important for retention), the factors influencing
recruitment decisions of nurses are similar in nature and order to the rest of the
workforce. One could hypothesise in respect to ‘location’ that this is a peculiar option
for nurses in so far as there are only a few other occupations (e.g. other health
workers and teachers) where a potentially acceptable place of work is highly probable
to be geographically close. So, they have the option to choose to work close to home,
or to choose their home location and then be confident an employment opportunity will
be nearby.

Allied health workers
Shifting the focus to the allied health workforce, the available literature is slimmer.
Saggers and Tilley (2004) identified five primary factors associated with recruitment
and retention for three categories of therapist labour as follows:
   Career structure;
   Workload;
   Quality of management and management structures;
   Rural versus metropolitan location; and



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Recruitment & retention of allied health professionals in Victoria – a literature review

   Professional development opportunities.
Saggers and Tilley (2004) identified management issues as critical to many of the
other areas. At the heart of the management concern was the need to value and
support therapists in their role and their work; such valuing could “melt away” a
number of the otherwise important factors such as salary, excessive workloads and
even career advancement (at least in the short term).
Most of the other literature relevant to allied health workers that exists is in relation to
recruitment and retention ‘difficulties’; essentially employment opportunities that are
less attractive (primarily rural locations). For instance, Belcher et al. (2005) focused on
the decision making of only those allied health professionals who had been recruited
into rural positions. In the two following tables, the top 10 reasons they identified for
choosing to go to rural employment and stay in rural employment respectively are
listed.
Table 10 Recruitment factors: Top 10 categories grouping

                Factors influencing recruitment              % of sample
                decision                                   mentioning factor
                1. Lifestyle choice                              57.8
                2. Career opportunities                          37.1
                3. Current or past rural person                  34.4
                4. Good for the family                           29.5
                5. Spouse/partner issues                         20.8
                6. Positive attributes of rural practice         20.0
                7. Satisfaction with rural practice              15.2
                8. Rural community attributes                    13.4
                9. Good working conditions                       10.3
                10. Not urban                                     9.5


‘Lifestyle choice’ essentially equates with location; that is choosing a place to live (in
this case a rural community). It was noted earlier that nurses too (independent of the
attractiveness of employment opportunity) placed ‘location’ as their number one
consideration in recruitment decision making. Allied health workers have the fortune to
make this choice, many other workers (for instance those working in manufacturing
industries) do not.


Table 11 Retention factors: Top 10 categories grouping

              Factors influencing decision to stay            % of sample
                                                            mentioning factor
              1. Rural practice attributes                        45.7
              2. Professional satisfaction                        36.1
              3. Work environment                                 20.3
              4. Good working conditions                          19.0
              5. Career opportunities                              8.5
              6. Professional support and supervision              6.7



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Recruitment & retention of allied health professionals in Victoria – a literature review


               Factors influencing decision to stay         % of sample
                                                          mentioning factor
               7. Lifestyle and family                            6.0
               8. Organisational issues                           3.5
               9. Financial return                                2.1
               10. Clients                                        1.7


The factors identified by Belcher et al. (2005) as influential on decision making are
consistent with findings from similar studies of allied health professionals (e.g. Central
Hume Primary Care Partnership, 2005) but appear quite different to those found by
Day (2005) and Boxall et al. (2003) from broader workforce surveys. This appears to
be further confirmed in the factors that act as triggers to a decision by allied health
professionals to leave rural employment.
Table 12 Top triggers to leave

               Factors influencing decision to leave       % of sample
                                                         mentioning factor
               1. Family issues                                  22.1
               2. Health and well being                          21.8
               3. Career advancement                             16.6
               4. Job opportunities                              12.9
               5. Spouse/partner issues                          12.2
               6. Lifestyle                                      11.2
               7. Professional satisfaction                      7.5
               8. Lack of support and supervision                7.0
               9. Personal working conditions                    6.3



Summary
Interestingly, the Belcher et al. (2005) results show that:
   ‘personal’ factors are the strongest influences in the decision to be recruited to a
   rural location (four of top five factors);
   ‘professional / occupational’ factors dominate the decision making about staying in
   rural practice (five out of top five); and
   mixed ‘personal’ and ‘professional’ factors are most influential on the decision to
   leave (three and two respectively out of the top five factors).
In this perspective, the allied health specific data is fairly consistent with the broader
workforce and nurse workforce results. That is, workers primarily stay in their jobs
because they enjoy the work, their colleagues and the work environment. Equally,
they tend to leave their jobs because of a mixture of professional (e.g. better career
prospects) and personal (e.g. family / life – family balance) reasons.
The main difference between the results of Belcher et al. (and the many similar
studies) and the broader workforce studies lies in the factors associated with
recruitment. The difference can probably best be explained not so much because of


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Recruitment & retention of allied health professionals in Victoria – a literature review

the focus on the allied health (or other health) workforce, but rather the restricted
focus on recruitment to unattractive employment opportunities (in this case rural
locations). It would appear that successful recruitment to such positions relies more on
‘personal’ factors to influence the decision making (e.g. lifestyle choice, rural
background), or personal career circumstances (e.g. actual job availability, chance to
fast track career in a less competitive environment).

Recruitment and retention difficulties
In a labour market where there is an absolute shortage in supply, attention falls on
recruitment and retention difficulties. These are made observable in the form of
industry / occupational / organisational chronic vacancies, insufficiently skilled new
recruits or substitute labour choices (recruitment) and high turnover and poor staff
morale (retention). In this context, ‘recruitment strategies’ are aimed essentially at
improving efforts to fill unattractive employment opportunities, that is addressing the
disincentives to moving to perceived poorer work locations and areas of practice.
‘Retention strategies’ similarly distil to reducing turnover rates from unattractive areas
of employment. The aggregate outcome of successful ‘strategies’ is lower wastage
from the active (allied health) workforce.
The obvious question is what makes an employment opportunity less attractive and
therefore a potential recruitment or retention difficulty?
This question has been most explored in regards to employment in rural and remote
locations. The first National Rural Health Strategy (Department of Community
Services and Health 1991) developed a conceptual framework or taxonomy for
categorizing disincentives to employment in any unattractive area of practice. The
taxonomy comprise of four broad categories, as follows:
•   economic;
•   professional;
•   educational; and
•   family/social/cultural.
Economic disincentives in the case of public sector salaried practitioners (e.g. hospital
employees) relate primarily to the nature of industrial awards. Awards in the public
sector are still determined through a centralised industrial relations system. Public
sector disincentives are exacerbated by awards fashioned to suit the majority of the
workforce located in urban employment and by the inflexible manner in which health
administrators often choose to interpret awards, both locally and centrally (Central
Queensland Therapy Task Force (CQTTF), 1991).
It is argued that uniformly applied award conditions do not properly remunerate the
added value of rural practice positions—the result of broader competency
requirements and higher levels of job responsibility other than staff supervision. In
private sector employment, these costs would generally be accommodated through a
range of remuneration (over award payments) and non financial benefits (such as
company housing, child education packages) to compensate for the difference
between the attractiveness of urban and rural employment.
The cost of living in rural areas is claimed, on balance, to be higher than in
metropolitan areas. Higher costs of living in rural areas have been attributed to child
education, continuing education, travel, and sometimes housing (Craig 1992). As well,
there are opportunity costs associated with forgone capital gain on assets such as
property, forfeiture of opportunities for promotion and sacrifices in spouse income.




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Recruitment & retention of allied health professionals in Victoria – a literature review

Professional disincentives relate mostly to disparities between the actual conditions of
work and the standards espoused in undergraduate training and by professional
associations. Adequate levels of professional direction and supervision are often
absent in unattractive areas of practice, and access to case-related professional
advice and opinion is difficult. Added to these conditions are the frustrations of being
asked often to work outside recognised professional boundaries (Hodgson, 1992). In
the case of hospital employees from the allied health professions in rural areas,
individuals can often be professionally accountable to health administrators who may
possess limited understanding of the role and use of the professional (Hill, 1991).
Educational disincentives, which occur at post graduate and continuing education
levels6, are closely intertwined with economic and professional concerns: they are at
the heart of practitioners' anxiety that they will be isolated from mainstream
professional developments if they work for any extended period in an unattractive (and
therefore poorly respected) area of practice (Watts, 1992; Gadiel and Ridoutt, 1994;
Human Capital Alliance, 2004). Their fear is that future employment prospects will be
diminished, in turn limiting their expected lifetime income stream and their standing
amongst their peers. Constraints to rural practitioners' access to education most
frequently quoted are:
•   remoteness from regular peer group meetings;
•   time required in travelling to attend educational interventions;
•   difficulty in obtaining cover for professional responsibilities while absent attending
    courses;
•   irrelevance to rural practice of much metropolitan-designed education; and
•   higher cost to the rural practitioner of simply getting to courses.
Finally, there are the family, culture and social life disincentives which are most likely
to affect the morale of practitioners working in rural and remote locations. For the
single practitioner, rural employment can involve lengthy separation from family,
friends and partners, in conjunction with the prospect of residing in communities that
offer limited social and recreational opportunities for meeting with people of like age
and congruent interests (Menere, 1992).
Belcher et. al. (2005) offer a very similar taxonomy as follows:
•   Personal factors
    -   Lifestyle choice
    -   Current or past rural person
    -   Family concerns
•   Professional factors
    -   Career opportunities
    -   Case load variety of rural practice
•   Community factors
    -   Rural community attributes


6
 Technically, undergraduate education is not a disincentive to rural practice, although the
selection processes, curriculum and clinical practice aspects of most health professional
undergraduate training courses have been shown to act against rural practitioner supply
(Kamien & Butterfield, 1990).


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Recruitment & retention of allied health professionals in Victoria – a literature review

    -   Physical environment
•   Occupational factors
    -   Working conditions
    -   Financial incentives
    -   Organisational attributes
While being similar to the National Rural Health Strategy framework, there is one
marked difference with the Belcher et al taxonomy; it is structured deliberately in a
way to allow attributes to be either disincentives or incentives. It gains dynamism
accordingly−for instance career opportunities associated with a less attractive position
may be an incentive to a young allied health professional (less competition, faster
promotion prospects) but a disincentive to an older professional (the result of the
lower credibility of the experience ultimately placing a ‘ceiling’ on career
advancement).
A conceptual framework that accommodates a more dynamic relationship between
allied health labour and employment opportunities is welcome.




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5. Notes on the definition of allied
 health
Defining “allied health” has been a challenging endeavour for many researchers.
Different researchers and professional bodies have varied preferences as regards
which professions to include under the “allied health” umbrella.

An Overview of Workforce Planning Issues, December 2004 by AHWAC encapsulates
the situation as follows:

    “In Australia, there is no clear and consistent agreement on what comprises the
    allied health workforce at either the stakeholder, jurisdictional or national level.
    There is also an array of different interpretations of the occupations that
    comprise the allied health workforce.

    Attempts to define the allied health workforce have primarily been approached in
    two ways; by identifying criteria that define the allied health workforce, and by
    identifying those professions considered part of the allied health workforce. This
    has often led to the allied health workforce being defined by what it is not (and in
    particular being defined as non medicine or nursing7, although even some
    definitions have chosen to include aspects of nursing). Jurisdictional and
    stakeholder differences are apparent, as are differing inclusions of occupations
    for various government programs. However, there are clearly professions that by
    any definition or inclusion process are consistently considered to constitute the
    ‘core’ allied health professions in Australia.”

AHWAC attempted to develop parameters around ‘allied health’ by seeking to identify
overlaps from a variety of definitions proposed by different sources. The table below
outlines the findings. Of a potential list of 25 occupations, only 9 were nominated by
all studies for inclusion in the ‘allied health’ framework.




7
  For example, some researchers took on board the definition of allied health professionals as
“university trained health professionals, other than nurses and medical practitioners, who are
involved in direct patient care or services to the community, or both.” (Hodgson et al, 1993)



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Table 13 Allied health professions identified within stakeholders definitions
    Profession                              AAHCS            ABS/             HPCA           NAHCC           SARRAH
                                                            AIHW (a)
    Aboriginal health workers
    Audiology                                   X               X                X               X               X
    Chiropractors
    Dentists
    Diagnostic radiography                                                       X                               X
    Dietetics and nutrition                    X (b)           X (c)             X               X               X
    Exercise physiology                                                                         X (g)
    Medical illustration/
    photography
    Medical imaging technology                                                   X                               X
    Mental health workers
    Music therapy                                                                                X
    Occupational therapy                        X               X                X               X               X
    Optometrist                                                 X                                                X
    Orthoptics                                  X               X                X               X               X
    Orthotics and prosthetics                   X              X (d)             X              X (i)            X
    Osteopaths
    Pharmacy                                    X                              X (f)            X (h)           X (j)
    Physiotherapy                               X               X               X                X               X
    Podiatry                                    X               X               X                X               X
    Psychology                                  X               X               X                X               X
    Radiation therapy                                                           X                                X
    Social work                                 X                               X                X               X
    Speech pathology                            X               X               X                X               X
    Therapy aide                                                X
Notes (a) Grouped under the term ‘allied health workers’ in the joint ABS/AIHW publication ‘Health and community
services labour force survey, 2001’; (b) identifies dietetics (c) identifies dietitian (d) identifies orthotist (f) identifies
hospital pharmacy (g) identifies exercise and sports science (h) identifies hospital pharmacy (i) identifies orthotics (j)
identifies community and hospital pharmacy
                                                                             Source: AIHW 2003; SARRAH/NRRAHAS 2004


AHWAC cautioned that the above examples indicated only broad stakeholder opinion
and that the inclusion of any occupation in the table should not be taken as an
endorsement by AHWAC as being part of ‘allied health’. It further noted that:

    “… (as) a general point it would seem the medical, nursing, dentistry, retail
    pharmacy and Aboriginal health workforces should not be considered to
    comprise the allied health workforce. In making this observation it is recognised
    that on occasions stakeholder’s accepted definitions of the Australian allied
    health workforce may be broader than government program objectives would
    suggest and vice versa. Program funding is linked to stakeholder goals and
    objectives that are largely based on service need, and the service need may
    focus attention on specific occupations for particular policy reasons. Even so,
    much debate on which professions are considered allied health does seem to
    arise when funding is attached to a particular government programs.”
For this review, the consultants have been assigned by the Department of Human
Services 128 professional groups that collectively have been defined as ‘allied health’.
The allied health professions included in this review are:

1. audiologist
2. clinical psychologists
3. dieticians

8
  Diagnostic radiography, Medical illustration/ photography and Radiation therapy are grouped under
“Radiograhers” by HPCA.



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4. occupational therapists
5. orthoptists
6. pharmacists
7. physiotherapists
8. podiatrists
9. prosthetists/orthotists
10. radiographers
11. social workers
12. speech pathologists
There is strong overlap between these 12 and those highlighted in Table 13. Indeed,
the only occupation not common is medical radiation technology. All 12 chosen
professions are members of the HPCA.

The value of the allied health construct
The intense search for a definition of ‘allied health’, only partly captured in the
previous section, itself bears analysis. A better definition for allied health is frequently
sought in the literature as a means to a range of positive outcomes. Typical is the
observation by Belcher et al. (2005) that a:
   “… lack of definition of Allied Health Professions has contributed to a poor
   understanding of their roles. This has implications for professional satisfaction,
   in particular management and professional support”
They further argued that use of a generic term for allied health was justified on the
grounds of profession size and similarities between professions. A “group approach”
would be especially valuable to:
   “… build up a body of knowledge about the allied health professions and relate
   this to on-going workforce reform …”
The most cursory examination of the individual professions that are generally
accommodated within the allied health term tends to reveal more striking differences
than similarities, a point which the professions themselves often emphasise (Boyce
1996). Indeed the strongest advocates for considering allied health professions as a
single grouped entity have done so not because of any perceived natural synergies,
but rather to obtain economies of scale in human resource management (e.g. Gadiel
& Ridoutt 1994) or efficiencies in service and personnel management (e.g. Boyce,
2001). Outside of this purpose in fact, and especially if human resource issues are
going to be addressed on an individual basis, grouping the professions as a single
entity potentially hinders the development of appropriate solutions.
In this document, no specific argument is developed for consideration of ‘allied health’
problems or ‘allied health’ solutions; the emphasis is rather on profession specific
considerations. This is not to suggest a generic approach has no merit; Rowe, Boyce
and Boyle (2001) have demonstrated that the allied health concept holds value for
both services and professions when it underpins organisational structures. However,
in this document only when problems and solutions are truly common across all or
nearly all allied health professions will they be labelled ‘allied health’.

Allied health labour supply
Between the 1996 and 2001 censuses, the number of people working in health
occupations increased by 11.4%, compared with an 8.6% increase in the total civilian
workforce. The health workforce in 2001 was approximately 558,000 – that is, 7% of
the total civilian workforce – and, the increases in the health workforce have been
primarily in part-time employment (ABS 2001, cited in AIHW, 2005).



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Most allied health occupations were still numerically small in 2001, the total allied
health workforce counted as 60,573 (that is 11% of the total health workforce). Allied
health professional numbers recorded relatively large increases between 1996 and
2001; the allied health workforce overall expanded by 26.6% with the numerically
largest occupations of physiotherapy (10,246), clinical psychology (7,567) and
occupational therapy (5,353) increasing by 15.1%, 44.1% and 22.7% respectively
(ABS/AIHW 2001).
There is every reason to believe the next census will uncover similar growth rates
between 2001 and 2006, since most allied health professions have seen a significant
expansion in the new graduate supply – the result of a sudden spurt in new
educational institutions mounting relevant undergraduate courses. Generally
speaking, any supply ‘shortages’ could not be blamed on insufficient new graduate
training rates.
In a series of separate appendices labour market details (to the extent they exist) are
provided for each of the allied health workforces covered by this review. The paucity
and / or lack of currency of the details in most of the appendices is instructive in itself,
and an area of needed remedy.
In the following chapters (Chapter 6 to Chapter 14) each of the selected allied health
professions is dissected and (again where possible) issues are identified affecting
recruitment and retention and the type of strategies appropriate to improve recruitment
and retention outcomes for that profession. To the extent possible the more common
issues (that is across allied health professional categories) are afforded less
prominence and the focus is on profession specific issues; there is, nevertheless
some duplication.
In discussing the strategies to improve recruitment and retention, where possible
strategies are divided into those specifically addressing labour market problems, those
aimed at recruitment, and those targeting keeping workers in place.




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6. Podiatrist
Recruitment and retention issues
Belcher et al. (2005) list a range of factors (at least for rural employment) that affect
recruitment decision making. As for other allied health professions, personal factors
seem to be most important. Of the total number of podiatrists surveyed:
•   88.3% stated that the following personal factors were important in considering
    work in rural areas:
           o Health and wellbeing
           o Lifestyle
           o Spouse/Partner
           o Family
•   70% considered the following professional factors as important:
          o Professional Satisfaction
          o Support and Supervision
          o Job Opportunities
          o Advantages of Metropolitan Practice
          o Career Development
•   30% considered the following occupational factors as important:
          o Working Conditions
          o Operating Costs
          o Organisational Issues
•   33.3% considered following community factors as important.
          o Family is happy
          o Like the community one lives in
          o Have many friends
          o Work is respected
In a survey of employers, DEWR found that many recruits to rural podiatry positions
(at least in the public sector) were deemed unsuitable:
     “The main reason (given by employers that job) applicants were
     considered unsuitable were their unwillingness to relocate, a lack of
     experience, inability to fill required session times and poor
     communication skills. There were also specific issues associated with
     peripatetic applicants where mismatches occurred due to a lack of local
     registration or employers seeking long-term, permanent staff.” (DEWR
     2003)
Somewhat different to other allied health professionals, podiatrists identified lifestyle
considerations as paramount for staying in rural practice (Belcher et al. 2005).
Interestingly, salary is also listed as important.
Podiatrists tend to leave rural practice again for personal reasons (Belcher et al,
2005). DEWR (2003) research though seemed to focus more on the difficulties of
profession practice as the ultimate disincentive:
     “Podiatrists and other health professionals practicing in regional areas
     face a number of pressures including:
         • they commonly operate as sole practitioners
         • lack of peer support
         • circumstances may force them to cope with cases outside their
            expertise


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          •   isolation from on-the-job and formal training opportunities
          •   the increased incidence of home visits increases the risk of injury
              due to the lack of sophisticated lifting equipment.”
The most commonly mentioned recruitment and retention issue though for podiatrists
tends to be money:
      “… The occupation falls under a variety of state awards covering the
      private and public sectors. Additionally, funding for allied health services
      is a state responsibility and varies across Australia. It appears that some
      states have more attractive employment conditions than others, and this
      can vary between the public and private sectors.” (DEWR 2003)
The fact that 31.5% of the national podiatry workforce chooses to work in Victoria may
imply that its awards are more attractive to podiatrists than those offered by other
states and territories.

Strategies to recruit & retain
A more balanced labour market
According to analysis based on registration authority data, only 3% of registered
podiatrists of working age are not in the labour force. It is possible that there are other
qualified podiatrists participating in the workforce who are not registered. However, if
the behaviour of other registered health professionals can be used as a guide, any
professional contemplating even a remote notion of returning to professional practice
tends to maintain registration status.
It is therefore likely that there is a “level 1” or “level 2” shortage of podiatrists as
defined in chapter 4. That is, all available supply is being utilised already in the
workforce, and there is limited scope through increasing workforce participation (for
instance through increased average hours of work or an increase in the rate of
workforce re-entry) to quickly increase supply. We would be tempted to categorise the
podiatrist shortage more as “Level 2” given that the capacity to increase training
supply seems significant.
    Given that the current overall podiatry workforce shortage is a comparatively
    new phenomenon (Table 4 shows that there was only one year in the last 10
    and 25 years that the podiatry workforce experienced a shortage) the labour
    market should be quite sensitive to any substantial increase in training supply.
    Hence, an immediate way to address recruitment problems would be to resolve
    the current low training rate9.
This will not be simple. While little literature has so far been uncovered on the subject,
low weekly wages for podiatrists (60% of average ‘all occupation wages’) suggest that
increasing undergraduate podiatrist enrolments in a market economy will be
demanding. DEWR (2003), using the entrance level requirements for courses as a
proxy, surmised that podiatry was not a popular course option. The cause of the
suspension of courses at the University of Western Sydney could not be determined
for this study however it may offer further signs of a broader difficulty in attracting
students. The extension of most university courses from a 4-year Bachelor degree
instead of the previous three years will further erode the competitiveness of podiatry


9
  We have not in this section looked at demand reduction approaches to labour market
adjustment such as those advocated by Kathleen Doole “Applying Self Management in
Podiatry Practice” or the “Foot Care” options described by Rivendell (2000). Recruitment and
retention issues are normally considered as ‘supply side’ variables only.


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We have not in this section looked at demand reduction approaches to labour market
adjustment such as those advocated by Kathleen Doole “Applying Self Management
in Podiatry Practice” or the “Foot Care” options described by Rivendell (2000).
Recruitment and retention issues are normally considered as ‘supply side’ variables
only.courses vis a vis other health courses that require similar investment but deliver
better post graduation remuneration (at least in the short term).
Looking optimistically at the podiatrist labour market, DEWR (2003) note the
workforce is relatively younger (only 9% of the current workforce is over 55) than
many of the other allied health professions. This means that in the next decade,
provided that the stream of new recruits is maintained / increased, the retirement rate
should be lower than replenishment rate.
Furthermore, podiatry has over 60% of podiatrists working ≥35 hours a week. This
may be explained by the fact that over 78% of the workforce is ≤44 years of age
and/or that they need to work longer hours to feed their young families.

Recruitment to unattractive employment opportunities
Most podiatrists (85%) work in the private sector, attracted by better financial returns.
Like several other health professions where a vigorous private sector exists (eg
pharmacy, general practice, physiotherapy) public sector employment is generally
considered less attractive. In the case of podiatry this is exacerbated by quite large
disparities between private and public sector income earning potential.
As a consequence, the burden of the overall workforce shortage problem will be
disproportionately carried by the public sector. In other words, hospital and
community health employers are more likely to experience unfilled vacancies while
their remuneration packages remain uncompetitive.
   It was noted earlier though that significant rising capital cost is associated with
   establishing a private practice, and this can pose a genuine barrier to young
   graduates trying to enter private practice (at least as an owner not an
   employee). This may work to the advantage of the public sector if it is properly
   exploited. Interpreting the research of Belcher et al (2005), young podiatrists
   might be attracted to salaried work in the public sector ahead of the private
   sector if it offers:
       Professional Satisfaction (varied and challenging work experiences);
       Secure employment / income;
       Support and Supervision (so learning is steady and appropriate);
       Accelerated career development and advancement opportunities.
Currently podiatry employment in the public sector is too often at odds with the above
characteristics, being insecure in nature (sessional and short term contract), with
limited supervision and with an ‘assembly line’ quality about the service setting. The
challenge is for employers to construct whole jobs, and attract young podiatrists that
will want to prolong their public sector employee status before they fulfil the dream of
owning a practice.
   DEWR (2003) also note an evidenced general lack of understanding of the
   podiatrist’s work both by patients and health professional peers (and thus they
   consequently make unrealistic demands−too much or too little challenge). This
   causes stress to the profession and its workforce, especially those who have
   been trained in more recent years and developed significantly advanced
   competencies. Awareness campaigns conducted to educate the patients as
   well as other allied health professions could be useful in building a greater value




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   around public sector employment, and may even advance the credibility of the
   profession to prospective students.

Retention approaches
It would seem inevitable that the majority of competent young podiatrists will find their
way to the private sector. Public sector employers can hope that they delay this
process as long as possible and thereby extract a return on their investment in the
professional’s development. Retention strategies, again if the research of Belcher et al
(2005) can be used as a guide, should focus on addressing personal issues (lifestyle
– work balance, good living environment) and remuneration. The later issue is a
consistent theme for podiatrists, and a source of difference to other allied health
professions.
   In possible acknowledgement of the primacy of financial incentives, some
   employers in regional and isolated areas are offering employees ‘loyalty
   bonuses’ to induce them to stay for longer than 1 or 2 years (DEWR 2003).
   Regional employers are also offering relocation assistance, company cars and
   bonuses in an attempt to retain staff. Public employers are increasingly seeking
   to attract staff by offering to employ them at higher award classifications than for
   which they would normally be eligible. In recent years applicants have been
   demanding salaried positions rather than ad hoc sessional employment to
   guarantee a regular income (DEWR 2003). This should be offered wherever
   possible rather than demanded.




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7. Pharmacists
Recruitment and retention issues
In a recent survey of newly registered pharmacists (Kainey, 2004) found they are
looking to commence their career with jobs that provide:
   Work to fit in with lifestyle – flexible and reasonable working hours, close to home
   etc.
   Variety in the work they do – the ability to work in different sectors, different
   settings within a sector and to work or study in fields outside pharmacy while
   continuing their pharmacy career.
   Patient contact and contribution to patient outcomes.
   Balance between job satisfaction and workload.
   Reasonable remuneration in line with the demands of their job.
   Mentoring and support especially early in their career.
This list largely focuses on ‘professional’ issues and is consistent with the factors that
influence recruitment decisions identified in the broader workforce (Day 2005) but in
contrast to the findings of Belcher et al. (2005) which emphasised ‘personal’ factors,
especially to less attractive employment opportunities.
In a survey of pharmacy students undertaken by HCA to evaluate the Rural Pharmacy
Incentive Program (HCA, unpublished; see the Pharmacy Guild of Australia website
for details of the Program) the factors important in attracting pharmacists to rural
areas were identified. The survey of undergraduate pharmacy students revealed that
a “good income” was the most commonly mentioned aspect of rural practice that was
potentially attractive, followed closely by a number of lifestyle and work satisfaction
factors.
Table 14 Proportion (%) of students identifying different aspects of rural pharmacy
practice potentially attractive (n=153)
                                                                             % of students
                                                                              identifying
        Aspects of pharmacy practice                                            aspect
       Flexible hours                                                              52%
       Enjoyable work tasks, more variety                                          64%
       Good working conditions                                                     61%
       Access to continuing education                                              36%
       Good income                                                                 75%
       Greater opportunity to interact with other health
       professionals                                                               40%
       Being part of a close community                                             62%
       Lifestyle e.g. near good sporting/recreational facilities                   61%
                                                                   Source: HCA survey of pharmacists, 2004




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A survey of practising pharmacists was also conducted. They were asked to look
retrospectively at their decision making. They too primarily identified satisfying work
conditions and attractive lifestyle as key factors in attracting them to rural practice (see
table below). A “good income” supposedly played a lesser role in influencing their
(actual) decision making, although half of the respondents nevertheless identified this
aspect as important.
Table 15 Proportion (%) of practising rural pharmacists identifying aspects that
attracted them to rural pharmacy practice (n=335)
                                                                          % of
                                                                      pharmacists
                                                                       identifying
         Aspects of pharmacy practice                                    aspect
        Flexible hours                                                     12%
        Enjoyable work tasks, more variety                                 61%
        Good working conditions                                            60%
        Access to continuing education                                     2%
        Good income                                                        47%
        Family reasons                                                     52%
        Professional satisfaction                                          39%
        Greater opportunity to interact with other health
        professionals                                                      15%
        Community or social interactions                                   43%
        Previous rural experience                                          41%
        Lifestyle                                                          60%
                                                            Source: HCA survey of pharmacists, 2004

One might construe from the above that the attractions of rural work practice and
lifestyle are the main factors involved in recruitment of new pharmacists to rural areas.
Unfortunately it is not so simple; when asked what was potentially most influential
amongst the current Rural Pharmacy Incentive Program (RPIP) initiatives in
determining a rural practice pathway the majority of students identified the RPMA
(57%) and the succession allowance (58%)−both of these are ‘income’ factors. When
asked what other possible incentives would be likely to influence their decision
whether to enter rural pharmacy practice, economic factors such as reduced debt
(“HECS rebate”) and future income (“ownership/partnership opportunities”) were again
prominent in the student responses.
Table 16 Proportion (%) of students identifying possible incentives to rural pharmacy
practice (n = 153)
                                                                   % of students
                                                                    nominating
           Possible incentives                                       incentive
          Shared hospital/community pharmacy salaried roles              59%
          Longer term locum support services                             32%
          Teaching opportunities                                         30%
          Changes allowing "branch" services                             17%
          Ownership/partnership opportunities                            67%
          Special support to enable purchase partnership                 41%




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                                                                  % of students
                                                                   nominating
           Possible incentives                                      incentive
          HECS rebate                                                  67%
          Bonded scholarship                                           29%
          On-line, real time, professional support                     48%
          Closer inter-professional collaboration                      45%
                                                          Source: HCA survey of pharmacists, 2004

These results highlight the difference that can exist between what people say are their
intentions and what they actually do, and between what might be of influence and
what is most influential. We will return to these themes in a later chapter. Suffice it to
be summarised here that pharmacists are influenced in their recruitment choices by
primarily professional concerns balanced by lifestyle considerations, but that income
seemingly plays a greater role in their decision making than for many other allied
health professions. This may reflect the widely understood capacity of community
pharmacists to earn good incomes, which in turn likely drives the attractiveness of
pharmacy courses (itself indicated in high entrance score requirements at nearly all
universities).
Several important factors influence pharmacists to remain working in pharmacy (HCI,
2003). The Table below shows that more than half of the respondents of a survey of
practicing pharmacists nominated the following as important influences:
   •   enjoyable tasks (72%);
   •   good income (70%);
   •   flexible hours (64%); and
   •   good working conditions (57%).
Table 17 Why respondents currently working in pharmacy intend to continue pharmacy
work (n = 338)
       Reasons for continuing pharmacy                               Respondents
                                                                         (%)*
       Flexible hours                                                    64.2
       Enjoyable tasks                                                   73.1
       Job satisfaction                                                   9.2
       Good working conditions                                           57.4
       Access to continuing education                                    42.0
       Good income                                                       71.0
       Economic necessity                                                10.9
       Felt they could do no other job                                    3.0
       Shortage of pharmacists, felt obligation to continue               1.5
       Other                                                              6.8
                       * Respondents could state more than one reason
                                                          Source: Pharmacy workforce survey, 2001

Again, these results are entirely consistent with Day (2005) and Boxall et al. (2003).
The HCA evaluation identified what keeps (mostly community) pharmacists in rural
practice. In terms of the RPIP incentives, few were influential except for the Rural
Pharmacy Maintenance Allowance (income), the emergency locum service (lifestyle)
and education / quality support. What they most desired to remain in rural practice
was salaried (or other) pharmacist support and longer term locum support. Those
pharmacists who indicated they intended to leave rural practice in the next few years
were, apart from retirement, most likely to do so because of the work conditions.


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Table 18 Proportion (%) of rural pharmacists intending to leave identifying aspects that
would influence their decision to leave rural pharmacy practice (n = 148)
                                                                        % of
                                                                    pharmacists
                                                                     identifying
        Aspects of pharmacy practice                                   aspect
       Dissatisfaction with pharmacy work tasks                          12%
       Not enough income                                                 13%
       Lack of career advancement opportunities                           8%
       Long work hours                                                   44%
       Limited support staff                                             27%
       Lack of availability of pharmacists                               45%
       Medical practitioner likely to leave                              12%
       Loss of local population                                          15%
       Family reasons                                                    33%
       Health reasons                                                     7%
       Professional isolation                                            23%
       Poor community/social interactions                                 8%
       Lack of access to continuing education                            16%
       Retirement from the workforce                                     45%
                                                          Source: HCA survey of pharmacists, 2004

Kainey (2004) identified mostly professional factors as influencing young pharmacists’
decisions to stay in hospital pharmacy practice. The two main factors identified were:
   Rewarding and satisfying work for the duration of their career, i.e. including for
   pharmacists working part time because of family commitments.
   A career path and promotional opportunities, but not leading them away from
   patient contact.
Again, professional considerations are tinged with lifestyle considerations. On the
other hand, Kainey identified remuneration as the most common reason for
pharmacists choosing to leave the hospital sector and for pharmacists having never
worked in the hospital sector.

Strategies to recruit & retain
A more balanced labour market
Based on a range of workforce assumptions−including an optimistic assessment of
workforce loss, “high” community demand for dispensing services, and conservative
view about the demand for hospital pharmacists−the 2003 HCI study estimated a
future labour market for pharmacists characterised by labour shortage.
   “The scenario for demand is projected to cause overall demand for FTE
   pharmacists to increase between 2000 and 2010 from some 13,100 to 17,200—
   in turn contributing to the overall shortfall of FTE pharmacists increasing from
   about 2000 to around 3,000. The overall shortfall is likely to be primarily
   attributable to the current shortage and the endemic problem of wastage in




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   conjunction with the behaviour of the demand for community pharmacists.” (HCI,
   2003)
HCI noted that, as with all labour markets, the least attractive employment areas
would bear a disproportionate burden of the labour shortages; in this case therefore
the hospital pharmacists and rural areas, both of which at the time of the study were
undersupplied and likely to remain so, unless changes are made to mitigate the
recruitment and retention factors of the sector. They further contended:
   “While alternative scenarios for supply and demand of FTE hospital pharmacists
   are presented … they do not alter the conclusion (based on the structural
   characteristics of the model in this study) that an overall excess demand for
   pharmacists is likely to continue during the next 10 years. The only issue in
   contention is the degree of excess demand over supply.” (HCI, 2003)
Such a labour market will continue to provide recruitment difficulties for the least
attractive employment opportunities. The hope is that the labour market will adjust
quicker than anticipated through:
   Unanticipated significant increases in new graduate supply and possibly through
   immigration;
   Slower growth in demand, especially for community pharmacy, as the expected
   growth in cognitive pharmacy services and PBS dispensing is somewhat stalled
   through the new Guild / Commonwealth Agreement;
   Growth in the use of dispensing technicians / assistants as competence is
   enhanced of assistants. This will happen in both the public and private sectors, but
   will be most immediately useful in the hospital pharmacy sector.
   The last point, increasing the size and capacity of the dispensing assistant /
   technician workforce, remains the most likely strategy option, especially as the
   pharmacy profession is not too violently opposed to this approach as other
   professions have demonstrated.

Recruitment to unattractive employment opportunities
The most difficult areas to recruit have traditionally been to hospital pharmacy, even in
a more balanced labour market. The SHPA (Kainey, 2004) argue for strategies that
pick up on the positive association with pharmacists choosing to practice in the
hospital sector, viz.:
   exposure to hospital practice via hospital-based pre-registration training;
   exposure to hospital practice via hospital-based PBV student hours;
   a desire to work in an environment where pharmacists are part of the
   healthcare team and are able to develop and use their clinical knowledge;
   and
   a clinical residency program that is structured and supported by adequate
   resources, and adheres to the requirements and delivers the educational
   outcomes detailed in the SHPA Victoria Clinical Residency Program
   Manual.
The Kainey study of pre-registration training showed 45% was completed in each of
the hospital and community pharmacy settings, while a further 8% was completed in a
combination of both settings. Pre-registration training influenced 48% of respondents
to stay in the sector in which they trained. As a consequence 83% of hospital pre-




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registrants and only 14% of community pre-registrants were found to be currently
employed in hospitals.
   An appropriate strategy therefore might be to increase the role of hospitals in
   pre-registrant training, despite the likelihood a majority of these will ultimately
   end up in community pharmacy, and acknowledging that this would impose a
   potential strain on the supervision resources of existing hospital pharmacists.
   However, this might bring more recruits to the hospital sector, after which the
   challenge would be to retain them as long as possible.
A range of factors with negative association to practice in the hospital sector would
need to be addressed otherwise exposure to hospital pharmacy as envisaged above
would be ‘negative marketing’. These include:
   poor remuneration of hospital pharmacists relative to community pharmacists;
   hospital politics;
   workload and short staffing in hospital pharmacy departments;
   poor experience of hospital pharmacy as an undergraduate;
   an informal, incomplete or poorly resourced clinical residency program where the
   educational outcomes as outlined in the SHPA Victoria Clinical Residency Program
   Manual are not achieved; and
The roles and duties of hospital pharmacists and the ability to continue learning and
expand clinical knowledge would be continued ‘selling points’ to retain pharmacists in
hospital practice.
HCA (unpublished), when reviewing recruitment to rural pharmacy positions, offered
the following strategy focus for investment:
   Provide opportunities to experience favourable rural practice work and lifestyle (eg
   undergraduate and pre-registration rural placements, with appropriate support and
   mentoring);
   Reward a decision to practise in rural areas economically (e.g. HECS rebate or
   reimbursement of fees, CPE, availability of short term locum relief);
   Promote viable economic opportunities to create initial attractions (e.g. RPMA,
   succession allowance, low interest loans to support partnership purchase, local
   government support with cost of premises).
Matthews (2004) writing on behalf of the SHPA asked AHWOC and Health Ministers
to adopt the following strategies specific to hospital pharmacy.
What                            How                               Opportunity for
                                                                  national collaboration?
Create new pre-registration     START NOW AND                     YES
training places in hospitals    INCREASE IN INCREMENTS
                                                                  SHPA has experience and
using sequestered funding for   to have more places in all
                                                                  can assist with national
up to 50% of pharmacy           jurisdictions until there are
                                                                  coordination / implementation
graduates                       places for up to 50% of
                                                                  to avoid duplication in each
                                graduates (also need funding
                                                                  jurisdiction so that this can
                                for one clinical supervisor for
                                                                  start ASAP
                                10 pre- registration places),
                                then monitor outcomes and
                                review
Market hospital pharmacy        QUICK WIN                         YES
actively to all 3,000 current
                                Support SHPA’s aim to             This program has started with



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What                             How                             Opportunity for
                                                                 national collaboration?
pharmacy undergraduates          conduct regular talks at all    seed funding from SHPA –
                                 pharmacy schools as part of     but needs a funded national
                                 the “Hospital Pharmacy – a      annual promotion campaign
                                 world of possibilities”
                                 campaign
Incentives for newly qualified   QUICK WIN                       YES
pharmacists
                                 Pro-rata yearly refund of       Suitable to be developed and
(2-5 years post registration)    HECS debt for recently          administered as a national
to work in public hospitals      registered pharmacists who      scheme
                                 work in public hospitals

Advertise job opportunities on   QUICK WIN                       YES
the SHPA national job
                                 Easy to put in place to         SHPA national job register for
register, which is ‘marketed’
                                 support the current workforce   hospital pharmacy could be
to all pharmacy students and
                                 Also good for CAREER            funded for all public hospitals
pharmacists as a ‘one-stop
                                 LONG recruitment                on a national basis
shop’


Retention approaches
It would seem inevitable that the majority of competent young pharmacists will find
their way eventually to the private sector. Public sector employers can hope that they
delay this process as long as possible and thereby extract a return on their investment
in the professional’s development. Retention strategies, again if the research of
Belcher et al (2005) can be used as a guide, should focus on addressing personal
issues (lifestyle – work balance, good living environment), remuneration, and career
development. Hospital employers can take heart from the widely held perception that
better professional growth on average is possible in hospital practice and that the
clinical skills developed in pharmacy course is almost certainly put to better immediate
use in hospital than community practice.
HCA (unpublished) identified a number of retention incentives for rural employment
where investment should be focused:

•   Provide income support to those pharmacists where it is a genuine problem (eg
    targeted RPMA, Start up and Succession Allowances, other financial support
    arrangements for marginal practices);

•   Reduce the gap between rural and urban pharmacists in professional education
    opportunities (eg CPD allowance, on-line professional support, mentors);

•   Offer suitably affordable staffing support (eg emergency, short and longer term
    locum support services, pharmacy assistant and dispensing technician staff
    training, subsidised pharmacist recruitment).




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Matthews (2004) suggested the following retention specifically for hospital
pharmacists.

  WHAT                            HOW                            Opportunity for
                                                                 national collaboration?
  Appropriate award structure     UPDATE ASAP                    NO
  and adequate
                                  Restructure awards in next     This must be undertaken in
  remuneration for hospital       EBAs. Learn from changes       each jurisdiction unless a
  pharmacy to be                  in South Australia to          federal award for hospital
  competitive” with other         improve both recruitment       pharmacy could be created
  sectors                         and retention for CAREER       (which would be welcome)
                                  LONG applicability

  CAREER LONG Create              START IMMEDIATELY              YES
  formal re-entry programs for
                                  Needs to be developed, so      SHPA could develop a
  hospital pharmacy practice
                                  work needs to start now        national deliverable
  to entice 5,000 non-working
                                  (but can leverage off some     package to avoid each
  pharmacists or those who
                                  existing courses) and be       jurisdiction “re-inventing
  have not worked in
                                  applicable                     wheels”
  hospitals

  Maintain an adequate            ONGOING                        YES
  workforce to provide                                           These are all suitable for
                                  Continue salary packaging
  hospital pharmacy services,                                    national collaboration,
                                  and the recruiting of
  which includes using the                                       development and
                                  overseas pharmacists
  skills of pharmacy                                             implementation
                                  (holiday visa, permanent)
  technicians who are trained
  to meet new national            START IMMEDIATELY
  competency standards
                                  Promote and facilitate
                                  improved training of the
                                  pharmacy technician
                                  workforce using the new
                                  national competencies
                                  QUICK WIN
                                  Fund LOCUM relief for rural
                                  hospital pharmacy services
                                  under the existing national
                                  rural and remote workforce
                                  development program,
                                  which currently only applies
                                  to community pharmacy
                                  ONGOING
  Create family friendly and                                     YES
  flexible working conditions     Actively encourage             The NHS in the UK has
  with professionally             improved and flexible          created a working lives
  rewarding roles for part-time   working conditions to retain   series. SHPA could develop
  staff                           staff. Collaborate and share   and maintain this nationally
                                  good news stories via
                                  SHPA website as working
                                  lives series, to be promoted
                                  widely building on the
                                  “Hospital Pharmacy – a
                                  world of possibilities”
                                  campaign




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Other strategies in practice
O’Leary & Allinson (2004) have suggested the introduction of automated distribution
systems into hospitals as a way of both making hospital pharmacist time more
productive but also improving the content of their work. They estimate pharmacists
spend 39-43% of their time on distribution activities whereas they could increase the
time they spend on clinical activities (currently 41%).
Automated medication distribution systems can reduce the labour requirements of
individual patient-based distribution systems throughout a hospital, but only if they are
integrated with other technologies already in use (e.g. electronic prescribing,
dispensing, administration and patient management systems).




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8. Physiotherapists
Recruitment and retention issues
No literature can be found directly discussing attraction into the physiotherapy
profession, although Nall (2005) infers that the profession is attractive based on high
entry score requirements from high school matriculation examinations. In support of
this assertion is the slightly above average income for physiotherapists, which is
especially competitive in the early years of workforce participation (see Appendix).
Australian Job Search (2005) also notes the additional attraction (for some
prospective workers) of the inherent important work values of the profession, including
that jobs give incumbents (future and current) a sense of being of service to the
community.
There is little research on the broad parameters of physiotherapy recruitment and
retention. However there is a building body of literature on recruitment to, and
retention in unattractive areas of employment, especially rural locations. In this vein
the VURHC Study (Belcher, et al., 2005) is prominent. It found the following factors
were important in influencing recruitment of physiotherapists to rural areas:
•   93.2% of physiotherapists surveyed stated that the following personal factors were
    important in considering work in rural areas:
           o Health and wellbeing
           o Lifestyle
           o Spouse/Partner
           o Family
•   51.9% considered the following professional factors as important:
          o Professional Satisfaction
          o Support and Supervision
          o Job Opportunities
          o Advantages of Metropolitan Practice
          o Career Development
•   23.4% considered the following occupational factors as important:
          o Working Conditions
          o Operating Costs
          o Organisational Issues
•   22% considered following community factors as important.
          o Like the community one lives in
          o Family is happy
          o Feel valued
          o Work is respected
In the Victorian context, a recent survey on rural physiotherapists (Motshidisi et al.,
2003) showed that preference for rural lifestyle and job diversity are the most common
reasons physiotherapists choose rural practice. These findings agree with those of
the VURHC Study.
Those who are already in the profession / workforce treasure a positive experience
about having made achievements by use of their individual abilities and this is
important to staying in an employment situation. If the workplace is not a solo
practice, having colleagues who are easy to get along with, supportive and
professional would certainly help retain the physiotherapist’s services (Stagnitti, et al.,
in press). Motshidisi et. al. (2003) found that the most common reason for leaving rural
practice was professional isolation.


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All of the above is not unexceptionable in respect to much of the discussion in earlier
chapters; nor does it represent any real departure from the recruitment and retention
circumstances common to other allied health workers. Some issues though that seem
peculiar to physiotherapy are:
Work-related injuries
Cromie et al. (2000) note a high level of musculoskeletal disorders amongst practising
physiotherapists, and estimates one in six physical therapists have changed their
specialty area or left the physical therapy profession because of work-related
musculoskeletal problems. In a subsequent paper Cromie et al. (2003) discuss the
process of claiming workers’ compensation for these disorders resulted in physical
therapists being in the uncomfortable position of simultaneously being a patient and a
claimant. The authors noted that injured physiotherapists’ discomfort arises from a
number of sources, including their own backgrounds, the attitudes of colleagues to
workers’ compensation, and their dealings with insurance and medical personnel.
One benefit arising from this unpleasant experience is that the physiotherapist can
gain insight into some of the issues and experiences faced by their own patients who
were claimants. Unlike many of their patients, they were able to choose to extricate
themselves from the situation and determine their own intervention and career
changes. (Cromie et al, 2003)
Lack of career path
Physiotherapy Business Australia (PBA), a national body representing
physiotherapists in private practice, cites lack of career path in private practice as an
attrition factor. This opinion is supported by Nall that experienced Physiotherapists
often suffer a high level of frustration at the artificial barriers placed in their way:
     “Due to their high level of knowledge and ability, as evidenced by their
     high ENTER scores and comprehensive education, physiotherapists
     have significant untapped capacity to contribute to the healthcare
     system…. this frustration and lack of challenge in the workplace roles
     impacts on retention of skilled clinicians in physiotherapy.” (Nall 2005)

Strategies to recruit & retain
A more balanced labour market
Table 4 on page 16 shows that there were respectively 9 years and 17 years in the
last 10 and 25 years that the physiotherapy workforce experienced a shortage. This
indicates a “level 1 shortage”, especially after taking into consideration the time
necessary to prepare for qualified personnel to enter the workforce10. Nall (2005)
notes that as the population ages and experience a higher prevalence of chronic
disease, there will be an increasing need for physiotherapy services, relative to other
healthcare services. This could further exacerbate the labour market situation.
As noted elsewhere, an overall shortfall in supply will translate into recruitment
difficulties in particular market segments. Shortages of physiotherapists are
particularly evident in Victoria in aged care, women’s health, working with children with
disabilities, cardio-thoracic, oncology, palliative care and rural areas. Of course, rural
and outer metropolitan areas of employment also present significant recruitment
challenges.


10
  Although this might change if a current perceived trend towards graduate masters
professional preparation programs spreads rapidly (see APA submission to the Productivity
Commission, 2005).


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In terms of the age of the workforce (currently about 8% of the workforce are 55+;
about 29% of the workforce will be 55+ in the next decade), there is some risk of
future rising attrition but compared to other health professions (eg medicine, dentistry,
pharmacy) and the rest of the Australian workforce, physiotherapy is not so badly
placed.
Similarly, the fact that over 70% of the physiotherapy workforce is female, of which
37.4% work part-time should not be seen as too much of a problem. Workforce
participation of females is steadily rising, and given the higher relative earning
capacity of physiotherapists vis a vis the average worker, one would expect female
physiotherapist workforce participation to outperform the rest of the workforce.
   This natural labour market process though might be supported through the
   creation of more flexible conditions for part-timers to encourage them to extend
   their working hours.
Nall (2005) is concerned by the lack of national workforce planning in physiotherapy,
citing the last report being 1998 data. She notes arguably the most important
consequence of this workforce planning vacuum is that higher education places are
funded without adequate planning. Hence, and despite significant increases in training
numbers in recent years, there is no way of knowing if the training rate should be
increased or not. Several have argued for more physiotherapy enrolments to be
funded, however this is a typical (potentially knee-jerk) response to a workforce
shortage. Discussion of training rates are complicated by increasingly self-interested
decision making behaviour of relevant training providers, forced by the new
‘economics’ of higher education. Nall laments that enrolments may often be set by
individual institutions largely based on income considerations rather than workforce
planning motives.
   One area of labour market response that shows promise is to use supplemental
   labour sources to increase the efficiency of utilisation of scarcer (and higher
   order) physiotherapy competencies. The approach can qualitatively improve the
   content of remaining physiotherapy roles (adding to retention prospects) and
   even free physiotherapy labour for possible enhanced scope of practice (see
   APA submission to the Productivity Commission, 2005)
Supplemental labour tends to imply physiotherapy assistants, but can also include
exercise therapists and others. Schoo and Taylor (2004) comment that the
physiotherapy assistant role at the Bendigo Health Care Group has evolved over time
as physiotherapists started to recognise the advantages. The authors remarked that
the model may not be generalised to other disciplines at this stage since professionals
from these disciplines may not be as accustomed to working with assistant staff.
Physiotherapists seem to be more comfortable with this model that uses postgraduate
exercise therapists and qualified allied health assistants.
The authors caution that senior staff members of regional health agencies should not
use this model as a cost-cutting exercise. Instead, they conclude that enhancing
recruitment and retention of health professionals is a complex issue which requires
cooperation between managers, educators, health professionals, government officials,
members of the community and others in order to create an environment in which
needs of all are met in a most responsible manner. (Schoo & Taylor 2004)
Nall confirms that there is a need for more appropriately qualified physiotherapy
assistants and reports that the APA is working with the Community Services and




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Health Industry Skills Council to develop new competencies for a Certificate IV in
Physiotherapy Assistance11. (Nall 2005)
One short term strategy currently used to fill vacancies is to recruit overseas trained
physiotherapists. However, Nall noted that current examination requirements for
overseas-trained practitioners are a disincentive for ‘working holiday’ physiotherapists
for two reasons (Nall 2005):
•    limited registration has been introduced in many jurisdictions but is unavailable in
     Queensland and Western Australia;
•    where it has been introduced, there are indications that problems may arise at the
     end of the period of limited registration.

Recruitment to unattractive employment opportunities
Over 90% of physiotherapists indicate lifestyle as the most influencing factor to join
the rural workforce. Evidence has long been available that those who have rural
background and rural experiences in training are more likely to practice in rural areas,
that is choose a rural lifestyle. For instance, a comprehensive literature review by
Brooks et al suggested that both rural background and rural experiences in training
were predictive of rural practice (Leggat 2003).
Leggat has hence proposed the following strategies to attract and prepare
physiotherapy students to practise rurally:
      Strategies to encourage students with appreciation of rural lifestyles to
      consider physiotherapy as a career:
        o   Continue to promote physiotherapy careers to young people in rural
            communities
        o   Improve access to post-secondary physiotherapy opportunities for
            rural students.
      Strategies to prepare physiotherapy students for rural practice:
        o   School curriculum recognises that preparation of rural
            physiotherapists is different from the preparation of practitioners for
            metropolitan areas, with the relative lack of support available to
            rural physiotherapists.
        o   Continue to build on the existing mechanisms to place
            physiotherapy students with mentoring staff in rural and remote
            communities.
        o   Increase opportunities for rural placement, with financial support
            and free accommodation mechanisms.
In the U.K., a specially designed program was implemented to initiate overseas
trained physiotherapists. After a short induction, these practitioners would work in a
rotation scheme to help them settle into their new role gradually. Each overseas
physiotherapist would be provided one core element – from respiratory,
musculoskeletal or neurology – to ensure they can focus on their particular area of
expertise and meet professional guidelines. In the recruitment process, clinicians were
involved so as to ensure the best available staff members were brought in from
abroad (AHPB 2004.06).



11
  Currently assistants are trained at the Certificate III level which practitioners argue is
insufficient for the demands of the role.


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Elsewhere in the UK, workplace redesign efforts have introduced greater flexibility for
physiotherapists – providing better services for patients and relieving tension between
frontline staff and managers. One of the key changes was bringing in new early
morning and evening outpatient sessions, (thus offering) extra flexibility of working
hours. It also gave physiotherapy assistants the chance to work more closely with
physiotherapists during quieter periods.
New on-call guidelines were also drawn up and this led to a fall in inappropriate calls,
reducing pressure and any sense of unfairness among on-call staff. Physiotherapists
were consulted widely first before changes were implemented. The partnership is
claimed to have had a more dramatic effect than just on the balance of work and life
but also getting a more permanent and positive results and better work relationships
between management and staff (AHPB 2005.02).
Nall (2005) recommends that Australia follow the footstep of the National Health
Service (NHS) of the United Kingdom and resolve to drive policy in partnership with
carers which appears to be yielding excellent results. She reckons that workplace
redesign, such as has occurred in the NHS, should overcome much of the frustration
at the artificial barriers and ensures that physiotherapists can undertake expanded
roles for which they clearly have the capacity and skill (and thereby increase the
efficiency of use of other service providers, notably orthopaedic surgeons).
She also argues that there is the need for Medicare to be expanded to include
services provided by other health professionals for which there is evidence of cost
effectiveness. This may be difficult to achieve under current Commonwealth / State
funding arrangements and the strong policy support of the Commonwealth
Government for the private health insurance industry.

Retention approaches
Cromie et al. (2003) propose that further research is needed to investigate the current
strategies used by therapists to prevent their own injuries. The authors add that these
findings also have implications for the teaching of beginning practitioners to ensure
not only that they (newest members) are socialised into caring for their patients, but
also that they are taught the importance of caring for their own bodies.
The APA has identified the need for manual handling guidelines for the movement of
patients for therapy purposes. (Nall 2005)
Leggat (2003) recommended the following strategies to retain Physiotherapists to
practise rurally:
       o   Assist in increasing the understanding within metropolitan
           physiotherapy practices of the nature of rural physiotherapy
           practice so that rural skills are awarded greater recognition in
           metropolitan practices, enabling greater transfer among areas.
           Consider mechanisms to allow staff rotations between metropolitan
           and rural sites
       o   Consider additional means of recognising rural practice, such as
           formal qualifications/certification and additional scholarships,
           ensuring greater access to development opportunities by existing
           rural practitioners. The appointment of the Associate Professor
           enables greater access to postgraduate education for
           physiotherapists in Bendigo
       o   Ensure orientation packages are available for all rural and remote
           communities with requirements for physiotherapists. These
           packages should be made available for recruitment purposes as



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           well as to assist with more detailed orientation to the community.
           Assist existing rural and remote physiotherapists with the
           development of these packages
       o   Improve working conditions for rural physiotherapists, such as
           providing a coordinated solution to assist with coverage for leave
           and continuing education and reducing unreasonable caseload and
           travel expectations. Offering locums has not necessarily been
           successful and funding should be made available to explore other
           options. Formally recognise the nature of rural practice and
           introduce mechanisms to reduce job-related stress, such as leave
           provisions, and time and stress management training
       o   Increase community-based learning opportunities, possibly through
           greater use of distance education and teleconferencing, and
           support for continuing professional development
       o   Support community innovation by resourcing community
           development initiatives that are designed to address local issues
       o   Build upon existing mechanisms to provide formal clinical and
           professional mentoring, supervision and support and assist rural
           physiotherapists to establish formal and informal networks during
           work time to decrease professional and personal isolation
       o   Facilitate the involvement of rural physiotherapists in School
           research, formal teaching and training and informal learning
           activities
       o   Establish a clearinghouse and resource centre that is easily
           accessible 24 hours a day/7 days a week to assist rural and remote
           physiotherapists with clinical and management issues.
The NHA 2004 Budget submission noted an unacceptable rate of physiotherapy
workforce attrition. It proposed the Department needs to establish/verify causes of:
   “… the vicious cycle of adverse staff ratios that lead to stress, injury and further
   exits, creating work conditions that are further unattractive to recruit
   replacements” (NHA 2004)
Despite oft repeated claims of high attrition from the physiotherapy workforce, the true
importance of this issue is difficult to gauge. The 1998 physiotherapy workforce study
found less than 5% of registered physiotherapists working outside of the health
industry, and the number of registered practitioners is normally an accurate estimate
of total qualified practitioners. More recent data (see Appendix) tends to confirm this
assessment. Hence, perceived high attrition or wastage is likely to really be more
‘churn’ or turnover within the industry. This is still costly.




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9. Clinical psychologists
Recruitment and retention issues
Given the importance of psychologists in recruitment processes, there is not a lot of
literature on recruitment and retention issues specifically in relation to psychologists.
The Belcher et al. (2005) survey of rural allied health practitioners included
psychologists, and found:
•   88.6% of psychologists surveyed stated that the following personal factors were
    important in considering work in rural areas:
           o Health and wellbeing
           o Lifestyle
           o Spouse/Partner
           o Family
•   62.6% considered the following professional factors as important:
          o Professional Satisfaction
          o Support and Supervision
          o Job Opportunities
          o Advantages of Metropolitan Practice
          o Career Development
•   13.5% considered the following occupational factors as important:
          o Working Conditions
          o Operating Costs
          o Organisational Issues
•   22.4% considered following community factors as important.
          o Family is happy
          o Like the community one lives in
          o Feel valued
          o Work is respected

Generally the psychology profession appears attractive, having had a significant
increase in workforce numbers since 1999 (DEWR, 2003), well above industry and
even general workforce average rates of increase. Since expected future earning
capacity is above average, the relative attractiveness of the profession is not
unsurprising.

Strategies to recruit & retain
A more balanced labour market
In an earlier section (Table 4 on page16) assessments from DEWR of the psychology
labour market were provided. It would appear that there is no current shortage in the
psychology labour market.
This assessment would certainly accord with the sudden growth in number of
psychologists employed and the age profile of the psychology workforce which is
comparatively young. The only potential adverse labour market issue is more than half
of the working psychologists are part-timers.
The DEWR assessment is by no means definitive. Like several other allied health
workforces, the current true labour market picture is unknown. This can be attributed
to the fact that there has been no attempt to quantify and analyse the psychology



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workforce across Australia (APS 2005). The Australian Psychological Society (APS)
has been attempting to gather at least supply data for several years from registration
authorities for analysis by the AIHW. Recently though the AIHW indicated that there
maybe insufficient resources to process the data. Hence the APS has embarked on its
own survey of membership:
       In response to the need by the APS to secure accurate and current
       information on the psychology workforce, the APS has now developed its
       own survey as an interim measure… The APS believes that a survey
       which directly involves the State and Territory Registration Boards is pre-
       requisite to achieving the most reliable outcome. (APS 2005)

An attractive labour market characteristic of the psychology discipline from a
health service planner’s perspective is that approximately 50% of psychologists
work in the health sector, with the other 50% employed in non-health
psychology fields such as:

   •    Clinical neuro-psychology
   •    Clinical psychology
   •    Educational psychology
   •    Forensic psychology
   •    Health psychology
   •    Industrial psychology
   •    Occupational psychology
   •    Organizational psychology
   •    Sports psychology

This provides a ‘reservoir’ of labour from which to potentially draw. Possibly
even more important than this though is the capacity for direct inter-substitution
of other forms of labour for psychologists in the mental health area (for
instance social workers, occupational therapists, counsellors of various types,
etc.).
Recruitment and retention

Like other allied health professionals including physiotherapists, psychologists
find it a source of frustration when:
       … many patients who would benefit form cognitive behavioural therapy
       with a psychologist (an evidence-based therapy) are forced instead to
       consult a psychiatrist because psychiatry is covered by Medicare where
       as psychology is not covered. (Nall 2005)
In its submission to the Senate Select Committee on Medicare (2003) the MHCA
called for a reorientation of Medicare towards early intervention in mental illnesses:
   “Investment of early intervention and increasing access options to effective
   treatments is urgently required. The absence of such access will ultimately result
   in greater costs at both a Commonwealth and State/Territory level becoming
   evident in other areas of service systems.”
They argued for extending access to non medical practitioners to Medicare benefits.
The APS itself argued the same case:




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   “… there is now substantial scientific evidence that some of the services
   currently unsupported by Medicare are in fact the ones as effective, if not more
   so, in treating these (mental) health disorders.”
Any extension of Medicare to psychology services could have a real impact on both
demand and supply (potentially making the area more attractive).




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10. Radiographers
Recruitment and retention Issues
Incentives (perceived key drivers / attractors / enablers /
motivators)
No direct information is available. Using the work values radiographers reportedly
treasure as a guide (refer to Appendix on the Radiography workforce profile):
    • Social service – do things for other people
    • Co-workers – have co-workers who are easy to get along with
    • Moral values – are never pressured to do things that go against their sense of
       right and wrong
    • Security – have steady employment
Then, one can design the jobs around these values to motivate potential and current
professionals to join and stay in the workforce.

Disincentives (perceived barriers / deterring factors)
Lack of acknowledgement
According to Hercus (2002), today’s graduate embarking on a career of Radiation
Therapy expects a high degree of clinical autonomy, taking responsibility for their work
and their patients’ well being. However, while academic qualifications for entry into
the profession have increased, the level of responsibility and changing role of
Radiation Therapist have not been formally acknowledged by other health
professionals.
Furthermore, due to staff shortages, radiation therapist has become increasingly
focused on technological aspects, leaving little time for patient care aspects and the
expectation of developing a close rapport with patients has largely been unfulfilled
(Hercus 2002).
Lack of defined career pathway
Hercus also noted that in reality, the jack-of-all-trades mentality exists and few
Radiation Therapists are afforded the opportunity to specialise (Hercus 2002). The
fact that today’s graduates are educated more broadly and possess skills that are
easily transported into other career options may work to disadvantage retention of the
Radiography workforce.
Indeed, Hercus commented that some of her colleagues who were considered
excellent therapists but left to work in other professions because Radiography could
not offer them:
    • Job satisfaction
    • Career path
    • Recognition of skills
    • Flexible hierarchies

She added that salary had not been a major consideration for any of these ex-
colleagues. In fact, half of them had actually taken a drop in pay but felt their new
career offered greater job satisfaction. (Hercus 2002)




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Outdated equipment
It was described as soul destroying for Radiation Therapists to work on outdated
equipment, knowingly treating patients with inferior techniques (Hercus 2002).
Overtime work
Thomas (2003) pointed out that the shortages invariably result in budget blow-outs as
staff members are required to do overtime to fulfil services needs. This places
additional burden and stress on staff and leads to lower morale and professional
dissatisfaction.

Recruitment Factors
According to the VURHC Study (Belcher, et al., 2005) which is primarily for the rural
workforce lists a range of factors (at least for rural employment) that affect recruitment
decision making. As for other allied health professions, personal factors seem to be
most important. Of the total number of Radiographers surveyed:
•   95.6% stated that the following personal factors were important in considering
    work in rural areas:
           o Health and wellbeing
           o Lifestyle
           o Spouse/Partner
           o Family
•   49.5% considered the following professional factors as important:
          o Professional Satisfaction
          o Support and Supervision
          o Job Opportunities
          o Advantages of Metropolitan Practice
          o Career Development
•   29.7% considered the following occupational factors as important:
          o Working Conditions
          o Operating Costs
          o Organisational Issues
•   31.9% considered the following community factors as important.
          o Like the community one lives in
          o Family is happy
          o Work is respected
          o Feel work is valued


Strategies to recruit & retain
In practice - Australia
Role evolution
Professional Advancement Working Party (PAWP) has been formed to “describe a
pathway for role evolution (extension/expansion) for Diagnostic Radiographers and
Radiation Therapists” (AIR 3/2005).




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Workforce re-entry
It is acknowledged that after a lengthy period of absence, practitioners would be
daunted by the significant changes in technology and clinical practice to have
necessary competence and confidence to practise. Recognising that it would be
difficult for individual clinical centres to educate re-entry of Radiographers due to
chronic staff shortages and limited resources, AIR developed the “Resumption of
Professional Practice” program as a structured pathway to encourage individuals to
recommence practice (AIR 4/2005).

In practice – U.K. National radiography recruitment and retention
strategy
The Department of Health provided new funding of £3.4 million to run the high profile
strategy to attract candidates including from black and minority ethnic groups to
(AHPB 2004.10, 2005.03, 2005.06):
    • boost the number of radiographers working in the NHS by 1,000
    • encourage returnees to the profession with special focus on diagnostic,
       therapeutic and breast screening services
    • help local managers improve retention and develop new career pathways.
Returnees
Potential returnees were targeted and received individual letters asking them to
consider returning, either as a radiographer or an assistant. It claimed that retraining
radiographers who have been out of the profession, even for many years, has been
very successful across the country in many areas (AHPB 2004.09).
An example is publicised on a radiographer who successfully returned to work after 15
years of absence. Her competencies were assessed in a series of practical
demonstrations and any gaps in her knowledge of recent developments were noted.
She then followed a tailored in-house return to practice course with periods of
observed practical assessments and written work mentored by a senior radiographer.
She recommended returning to practice to others (AHPB 2004.10).
Flexible working
The Royal United Hospital in Bath adopted a wide range of flexible working options to
retain and recruit staff in its diagnostic radiography department. They go beyond the
usual job share and part-time working to include fixed shifts (day or night), term-time
working and annualised hours. The arrangements enabled staff to meet family and
other commitments. They claimed that by being flexible, they were able to avoid
losing valuable members of staff.
In addition, radiographers regardless of grade, can choose the areas in which they
work, enhancing job satisfaction and retention (AHPB 2004.09b).
Radiography award
The Society and College of Radiographers handed out accolades to radiographers
who led service improvements and drove forward patient-led care. Nominations were
made by the Radiographers that work with those nominees each day and appreciate
their special contribution first hand (AHPB 2004.12).




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Proposed – U.K.
Career pathways
They aim to give radiographers better career progression and a clear developmental
structure which will hopefully encourage the present workforce to stay and those who
had previously left to return (AHPB 2004.09).

Proposed – Diagnostic radiography/sonography

Brough (2002) proposed that the survey results on significant manpower problems for
diagnostic radiographers and sonographers should persuade governments and
universities to take on and fund additional places for diagnostic radiographers in
Australia.

Proposed – Radiation therapy

Recruitment, retention & retraining
Smylie summarised that the issues to recruit, retain and retrain comprise:
   • Clinical autonomy recognition
   • Career pathways to include clinical, research, education, management and
       technology initiatives
   • Educational issues
   • Remuneration linked to skills (multi-tiered pathway that leads to advanced
       practitioners
   • Continuing professional development
   • Accreditation of practitioners nationally (Smylie 2002)

Key recommendations made by Smylie are to:

   •   Address disparity between existing awards
   •   Develop a nationally consistent approach to increasing remuneration
   •   Vocationally registering all Radiation Therapists with good standing
   •   Introduce legislation/registration and revoke licence if a Radiation Therapist is
       removed from the national register
   •   Develop a multi-tiered workforce
   •   Remuneration linked to experience, skills, qualification and education
   •   Encourage re-entry of Radiation Therapists who left the workforce
   •   Make available a postgraduate entry program (Smylie 2003)




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Radiation therapy career pathway

In a discussion paper by Smylie et al, it described the U.K. Four Tiered system that is
primarily designed to encourage clinical role development and a culture of life long
learning as well as enables use of radiation therapy assistants:
    1. Assistant Practitioner
    2. Practitioner (State Registered)
    3. Advanced Practitioner (State Registered)
    4. Consultant Practitioner (State Registered) (Smylie, Cleary & Crean 2003)

Shortage of supply

Brough’s report (2002) concludes that there are more vacancies than graduating
diagnostic radiographers in Australia and that both Victoria and NSW appear to have
the most significant manpower problems for diagnostic radiographers and
sonographers.




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11. Social workers
Recruitment and retention issues
Incentives (perceived key drivers / attractors / enablers /
motivators)
No information is available specific for social workers. The work value treasured by
the profession (refer to Appendix on Social Worker workforce profile), in this case –
being of service to others – perhaps can be seen as an indirect pointer to motivate
new and existing social workers by designing the job to maximise their positive
experience in the work they do.

Disincentives (perceived barriers / deterring factors)
Belcher et al. (2005) list a range of factors (at least for rural employment) that affect
recruitment decision making for Social Workers. As for other allied health professions,
personal factors seem to be most important. Of the total number of podiatrists
surveyed:
•   95.4% stated that the following personal factors were important in considering
    work in rural areas:
           o Health and wellbeing
           o Lifestyle
           o Spouse/Partner
           o Family
•   60.6% considered the following professional factors as important:
          o Professional Satisfaction
          o Support and Supervision
          o Job Opportunities
          o Advantages of Metropolitan Practice
          o Career Development
•   10.3% considered the following occupational factors as important:
          o Working Conditions
          o Operating Costs
          o Organisational Issues
•   21.1% considered following community factors as important.
          o Family is happy
          o Like the community one lives in
          o Feel work is valued
          o Involved locally

Strategies to recruit & retain
Prof Stephen Duckett (2003) supports the professional doing more assessment and
skilling up allied of health assistants to implement the "treatment". This causes the
Australian Association of Social Workers (AASW) concern as most members do not
see it as a safe option for clients as it stands (Bawden 2005).




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12. Speech Pathologist
Recruitment and retention issues
Little information is available specific for speech pathologists. The non-existence of
this type of information is confirmed by Speech Pathology Australia that:
    “…. there is very little written on the factors influencing incentives and
    disincentives to join/stay in the profession”. (Atherton 2005)
Belcher et al. (2005) identified a slight difference between rural speech pathologists
and other allied health professionals in their higher valuing of professional factors in
their recruitment decisions, and their higher emphasis on social issues for leaving.
Atherton argued that it is work value (refer to Appendix on Speech Pathology
workforce profile) that is treasured by the profession:
    • Social service – do things for other people
    • Co-workers – have co-workers who are easy to get along with.
    • Ability utilisation – make use of their individual abilities
    • Achievement – get a feeling of accomplishment
One can perhaps use these treasured values as indirect pointers to motivate new and
existing speech pathologists by designing the job to maximise positive experience in
the work they do.
Belcher et al. (2005) list a range of factors (at least for rural employment) that affect
recruitment decision making. As for other allied health professions, personal factors
seem to be most important. Of the total number of podiatrists surveyed:
•   86.2% stated that the following personal factors were important in considering
    work in rural areas:
           o Health and wellbeing
           o Lifestyle
           o Spouse/Partner
           o Family
•   78.8% considered the following professional factors as important:
          o Professional Satisfaction
          o Support and Supervision
          o Job Opportunities
          o Advantages of Metropolitan Practice
          o Career Development
•   19.1% considered the following occupational factors as important:
          o Working Conditions
          o Operating Costs
          o Organisational Issues
•   20.2% considered following community factors as important.
          o Like the community one lives in
          o Family is happy
          o Feel work is valued
          o Work is respected

Strategies to recruit & retain
There is no specific information available on strategies for recruitment and retention.
Given that the speech pathology workforce has been in shortfall for almost a third of



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the last 25 years (see Table 4), it is probably fair to suggest that broad labour market
strategies would be helpful.
It is also possible to infer strategies from a paper discussing career choice (Byrne
2005) in speech pathology. The paper mentions that speech pathologists providing
therapy may influence the career choice decisions of the people (the therapy recipient
or his/her families) they meet. It further reports that 56% of speech pathologists
surveyed indicated that they had prior personal experience of the therapy.
If this is a confirmed influential factor for future candidates to choose Speech
Pathology as their career, then strategies can be formulated to target an audience so
as to achieve the recruitment objective.




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13. Dietitians
Recruitment and retention issues
No Information available

Strategies to recruit & retain
Although Table 4 on page 16 shows no shortage in the supply of Dietitians (DEWR),
Australian health issues including obesity, diabetes as well as dietary requirements of
the ageing population may increase the demand for this workforce in the coming
decades.
Estimated demands need to be properly measured and mapped with the future supply
of the workforce to ensure that the balance is maintained.




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14. Occupational Therapists
Recruitment and retention issues
Rural students
Leggat (2003) noted that a recent study of Occupational Therapy students by Crowe
and MacKenzie demonstrated that students who would choose rural positions for their
first work position after graduation was influenced by their experiences in their clinical
placements, particularly in the following areas:
     • Feedback from fieldwork while a student
     • Level of comfort with the required skills
     • A supportive working environment.
Australian health system
The multi-level government programs and initiatives in the current Australian health
system create duplication and hinder coordination, cooperation and innovation within
the system. OT Australia claims that removal of these barriers will “directly result in
improved health outcomes for consumers and increased job satisfaction, which will in
turn improve staff retention.”
In addition, the current Medicare Benefit Schedule (MBS) under the Enhanced
Primary Care allied health program assumes a clinic based approach towards patient
care whereas many allied health professionals, including OTs, visit clients in their own
homes to assess and prescribe treatments. As a result, there is no recognition for
travel and associated costs incurred by the practitioners in their service delivery.
The “gap fees” the OTs can charge their clients to cover costs means that equity of
service access by clients cannot be ensured. The problem is further aggravated for
clients in rural and remote communities. OT Australia notes that the $44 MBS
schedule fee barely covers fuel costs for a commonly 4-hour return journey.
Pay
As noted in Appendix on OT workforce weekly earnings, there may be challenges of
keeping OTs view the profession as a life-time career when the initial advantage
wears off.
There is already evidence that OTs left rural practice reported dissatisfaction of pay
(Schoo et al. 2005)
Recruitment Factors
Belcher et al. (2005) list a range of factors (at least for rural employment) that affect
recruitment decision making. For the Occupational Therapists surveyed:
92.2% of Occupational Therapists surveyed, the following personal factors were
important in considering work in rural areas.
   • Health and wellbeing
   • Lifestyle
   • Spouse/Partner
   • Family
65.5% considered the following professional factors as important:
   • Professional Satisfaction
   • Support and Supervision
   • Job Opportunities
   • Advantages of Metropolitan Practice


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   •   Career Development
19.8% considered the following occupational factors as important:
   • Working Conditions
   • Operating Costs
   • Organisational Issues
27.6% considered the following community factors as important:
   • Like the community one lives in
   • Family is happy
   • Involved locally
   • Feel work is valued

Strategies to recruit & retain
Rural graduates
As advocated by many allied health workforce planners, OT Australia proposed that
greater incentives must be provided for (its) students and graduates. Some possible
solutions include the expansion of scholarship numbers and the expansion of the
Commonwealth bonded rural scholarships to include allied health professionals (OT
Australia 2005).




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15. Analysis of Professions
Commonalities
In Chapter 4 a conceptual framework was developed to understand the underlying
decision making of workers that would influence behaviour in respect to recruitment
and retention situations. It was found, not unsurprisingly, that the factors that impact
on the broader workforce’s decision making processes also impact largely in workers
in the health, and allied health, workforces. We believe these to be:
Recruitment
   Personal factors, particularly associated with choice of place to live;
   Job satisfaction / interesting and challenging work;
   Career prospects, especially the potential to ‘fast track’ progression;
   Income earning capacity, including salary, benefits, security;
   Balance between work / life (style) / family.
Retention
   Relationship with work colleagues;
   Job satisfaction / interesting and challenging work;
   Personal factors, particularly associated with choice of place to live;
   Work environment, including a supportive culture;
   Balance between work / life (style) / family.
These factors also are primary in respect to decision making about marginal
employment opportunities, that is, those areas of employment in most labour markets
that are described as ‘recruitment difficulties’. However, it was noticed that personal
lifestyle choices, possibly often influenced by personal background characteristics (for
instance growing up in a rural area), are of greater importance in recruitment
decisions especially in these areas of less attractive employment opportunity.
This broad finding is reflected too in comparing the allied health professions. Despite
the sometimes significant differences in workforce age and gender composition,
sector distribution and professional cultures between the allied health professions,
there is more commonality than difference in terms of what drives recruitment and
retention decision making. This is illustrated in the table below adapted from Belcher
et al. (2005) which shows the percentage of persons from each profession identifying
a particular factor as influential in their recruitment decision making.
Table 19 Factors influencing recruitment to rural areas: Major factor groupings by
professions (Figures are % of persons surveyed in respective profession)

Professional group           Personal      Professional    Community         Occupational
                              factors        factors         factors           factors
Dietitians                     86.0            64.0            16.0              14.0
Occupational Therapists        92.2            65.5            27.6              19.8
Physiotherapists               93.2            51.9            22.0              23.4
Podiatrists                    88.3            70.0            33.3              30.0



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Professional group          Personal       Professional    Community       Occupational
                             factors         factors         factors         factors
Psychologists                  88.6            62.6            22.4            13.5
Radiographer                   95.6            49.5            31.9            29.7
Social Workers                 95.4            60.6            21.1            10.3
Speech Pathologists            86.2            78.8            19.1            20.2
Combined Others                88.6            62.9            22.9            31.4
Total Respondents              91.5            59.9            24.0            20.3

Differences
Table 16 also demonstrates that where differences between the allied health
professions exist they are quite subtle. Some of the professions for instance place a
higher premium on earnings, some on professional achievement and satisfaction.
Where appropriate these differences will be explored in a section when looking at
profession-common and profession-specific recruitment and retention strategies.
It would be fair to say that differences within rather than between professions in
decision making behaviour is more pronounced. Those differences used to be largely
gender based (see for eg Ridoutt, 1987), but now the literature is less marked possibly
in response to a growing awareness of the converging workforce participation
behaviour of males and females (see Chapter 3). The differences now are to do more
with age.
Much is made in discussing the impact of age of the generational differences and how
generation X and Y ‘think’ and are motivated so differently from earlier generations.
This focus probably diverts attention from arguably the more fundamental (and
constant) action of maturation. People always have been motivated and therefore
acted differently at various stages of their career.
Saggers and Tilley (2004), based on a survey of therapists, suggested that
recruitment decisions of younger workers are more based on obtaining a broader
experience to progress (most rapidly) their career. Decisions to stay in jobs are largely
determined they believe by the quality of their work experiences, client relationships
and professional development; all closely related to career progress. As workers age
and move to later career stages, the influence of broad experience becomes less
powerful, and assumes more the form of job satisfaction; being able and supported to
perform high quality work to deliver good outcomes while in the ‘peak’ of capability. At
the same time family concerns are likely to impact, and so flexible work hours will be
important in both recruitment and retention decisions.
These broad observations of Saggers and Tilley are very much supported by Day
(2005) and Boxall et a.l (2003), the latter pointing out that young workers are generally
more willing (and able) to take employment risks, and are therefore prone to higher
job turnover.
This of course does not suggest workers at different stages of their career should
automatically be subject to tailored strategies; good personnel management as always
recognises the individual worker and their specific circumstances and needs.

Summary of strategies
The review of profession-specific literature revealed a number of potential recruitment
and retention strategies, many of which were identified in relation to several
professions (or could easily be applied across professions), but some which were


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specific to one or two professions. In the following text common strategies are
discussed and in the table below specific strategies are highlighted.
The commonly identified strategies are:
Labour market adjustment strategies: these include increasing the number of
       enrolments in appropriate training courses, seeking to increase the flow of
       supply from immigration by streamlining and making uniform assessment
       processes for migrant workers, increasing the flow of ‘inactive’ practitioners
       back into the active workforce through facilitating retraining programs, and
       seeking to identify and rectify the causes of occupational wastage. These
       strategy suggestions raise a general concern; the paucity of labour market
       analysis. Very little data was able to be obtained for this study on any
       profession subsequent to 2001, while any substantive workforce planning for
       any of the professions other than pharmacy was not available after 199812. The
       only current labour market analysis derives from DEWR estimates (see Table
       4), which, reliant as they are so much on vacancy data, have serious
       methodological flaws when assessing private sector workforce conditions. As
       Nall (2005) notes, this is a very poor basis on which to base critical decisions
       on course enrolments, which represent significant personal and government
       investments.
Extension of Medicare provisions to selective services able to be offered by allied
       health professionals: several professions argue that allied health service
       providers often present a more efficient and effective source of service than
       medical practitioners for selected clinical interventions. For instance, the
       Australian Physiotherapy Association submission to the Senate Select
       Committee on Medicare (2003) argued that physiotherapy management of
       knee joint osteoarthritis was the most cost effective treatment for that
       condition, and yet they noted many people would still seek treatment for that
       condition from a general practitioner (because it was covered under Medicare).
       Extending MBS to selected items and professions could potentially act to
       increase the scope of practice, and thus enhancing the attractiveness of the
       role.
Enhancing career pathways: this includes creating more ‘scales’ in public sector
      awards (generally by increasing the top rate of pay and inserting more
      classifications) so that a career ‘ladder’ becomes more apparent. It can also
      imply creating non administrative high classification roles, so that quality
      clinicians do not have to progress into management in order to benefit from
      higher wages. Of course this strategy is most difficult to adopt where it is most
      needed; for the private sector where staff numbers are normally very ‘thin’, and
      in professions where numbers are small grades are difficult to justify.
Reconstruct remuneration arrangements: a related strategy to the above is to allow
      wage fixing arrangements to better mimic the market. Thus, individual
      employers faced with recruiting to unattractive employment circumstances
      could be allowed to negotiate remuneration packages (through over award
      payments, AWA agreements, or innovative salary packaging arrangements)
      that placed them in a more competitive situation vis a vis ‘mainstream’
      employers. This might include ‘Loyalty bonuses’ to induce them to stay for
      longer than 1 or 2 years, company cars, bonuses for clearing waiting lists, etc.
      Adjustments to their budget would be required accordingly.




12
     And these are not labour market analyses but rather a description of workforce supply only.


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The above two strategies, while ‘common’ are more immediately applicable to some of
the allied health professions than others. Some of the numerically smaller professions
have limited opportunities to create supervision hierarchies within their own
‘department’ structure, a traditional way of extending the top rate of pay and providing
a career structure. Payment for the best in these professions should be on the basis of
recognised skill. Podiatry and radiography awards for historical reasons have placed
public sector employers at a disadvantage, and these might be addressed in priority
order.
Promotion of work – life – family balance approaches: this would involve developing
      and disseminating a range of template approaches to constructing flexible
      work arrangements. This could include job share; part-time work; fixed shifts
      (day or night), term-time working and annualised hours arrangements.
Increase the proportion of graduates from training programs likely to prefer
       unattractive employment locations: this strategy area might include:
          Offer selective university placements to students with rural (or other
          disadvantaged) background;
          Expansion of scholarship numbers and the expansion of the Commonwealth
          bonded rural scholarships to include allied health professionals;
          Increase (enjoyable) clinical practice experience in areas of disadvantage. If
          necessary, provide accommodation/transport subsidy
          Influence students to choose rural positions for their first work position after
          graduation by giving them positive experiences in their clinical placements;
          Recognition of rural practitioners;
          Involve rural practitioners in School researches
Investigate and deploy substitute labour: this strategy option is more attractive to
        those professions that tend to be more secure in their belief that their
        competencies are unique. Increasingly assistant level labour is being
        conscripted successfully in physiotherapy, community and hospital pharmacy,
        radiography. Labour substitution in everything but name only has been
        significant in the mental health and podiatry (nurses / chiropodists / podiatrists)
        labour markets for a long time. Planned labour substitution, that increases the
        efficiency of higher competent labour without compromising quality and patient
        safety standards, has the capacity to significantly improve job satisfaction of
        well paid professionals.
In the table below, we highlight some profession-specific strategies.
Table 20 Selected recruitment and retention strategies by profession
 Profession               Description of strategy
                          • Increase the role of hospitals in pre-registrant training, despite
 Pharmacists
                              the likelihood a majority of these will ultimately end up in
 (particularly targets        community pharmacy, and acknowledging that this would impose
 recruitment                  a potential strain on the supervision resources of existing hospital
 difficulty in hospital       pharmacists.
 pharmacy)                • The expanded roles and duties of hospital pharmacists and the
                              ability to continue learning and expand clinical knowledge would
                              be continued ‘selling points’ to retain pharmacists in hospital
                              practice


                          •   Research to establish/verify causes of stress, injury to reverse a
 Physiotherapists



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 Profession               Description of strategy
                              perceived high rate of occupational wastage through worker
                              musculoskeletal disorders.
                          • Beginning practitioners are socialised into caring for their
                              patients, but also they are taught the importance of caring for
                              their own bodies (as well as their patients).
                          • Need for manual handling guidelines for the movement of
                              patients for therapy purposes
                          • Introduce a nationally consistent approach to the assessment of
                              overseas-trained physiotherapists for both permanent and
                              holiday employment.
                          • Provide further training opportunities for interested
                              physiotherapists to upskill them in specialist areas of practice
                          • Awareness campaigns conducted to educate the patients as well
 Podiatrists
                              as other allied health professions to build a greater sense of the
 (particularly targets        value of public sector services, and this may even advance the
 recruitment                  credibility of the profession to prospective students
 difficulty in hospital   • Replace ad hoc sessional employment in the public sector with
 pharmacy)                    salaried positions to guarantee a regular income
                          • Construct whole jobs to attract young podiatrists that will want to
                              prolong their public sector employee status before they fulfil the
                              dream of owning a practice
                          •   Clinical autonomy recognition
 Radiographers
                          •   Vocationally registering all Radiation Therapists with good
                              standing
                          •   Introduce legislation/registration and revoke licence if a Radiation
                              Therapist is removed from the national register
                          •   Create and present a Radiography award to radiographers who
                              lead service improvements and drive forward patient-led care



Currently the Department of Human Services (DHS) is funding a number of projects
whose primary strategies are:
       Continuing professional education;
       Mentor links;
       Undergraduate scholarships;
       Rural retention bonus;
       Locum services.
These are strategies of interest in the literature, but not indicated as prominently as
the current DHS investment approach would warrant.




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16. Broad strategies
The need for focus
It was noted in an earlier chapter how the literature reviewed had a propensity to
create ‘shopping lists’ of factors that influence recruitment and retention, but that little
evidence was offered that would allow a value or ‘weight’ to be applied to different
factors. Hence, strategies appear to be developed in one to one correspondence with
each factor of (potential) influence identified.
In a recent review of allied health professional issues in rural and remote areas
(NRHA, 2004) 16 separate recruitment and retention strategies were mooted as
worthy of investment. A similar study undertaken in rural Victoria identified at least 13
possible recruitment and retention strategies and mentioned many others (Central
Hume Primary Care Partnership, 2005). The Rural Pharmacy Initiatives Program
(Pharmacy Guild of Australia, 1998) has funded 17 separate recruitment and retention
strategies for rural pharmacists over a five year program.
No doubt the authors and program designers behind these papers and programs,
along with many others of a similar nature (e.g. Holub and Williams, 1996), would
argue that a comprehensive solution needs to be adopted, that deals with the multi-
faceted aspects of the recruitment and retention ‘problem’. We would argue that in the
absence of compelling evidence on the efficacy of different strategies that go to make
up the ‘comprehensive’ program, there is the danger that such a large multi-strategy
approach could be seen as (and actually be) a ‘shot gun’ approach, where hope is
placed in some successes emerging from the many components.
To illustrate we take the example of the Rural Pharmacy Initiatives Program (RPIP).
This was recently evaluated after five years of operation (HCA, unpublished). The $55
million program distributed the funding across the program components as shown in
the table below.
Table 21 Average annual investment level ($’s) in different RPIP initiatives
          Program Initiative                                       Estimated % of
                                                                    Program $’s
          Emergency Locum Service                                      1.34%
          Rural and Remote Pharmacy Infrastructure Grants              5.28%
          Scheme (RRPIGS)
          Undergraduate Scholarship Scheme                             1.16%
          Aboriginal & Torres Strait Islander Scholarship Scheme       0. 79%
          Undergraduate Rural Placement Allowances                     2.31%
          Continuing Education Allowance                               0.67%
          Pharmacist Academic positions at University                  1.88%
          Departments of Rural Health (PAUDRH)
          Rural Pharmacy Newsletter                                     0.18%
          Administrative Support to Pharmacy Schools (ASPS)             0.06%
          Rural Pharmacy Promotion Campaign                             0.67%
          Rural Pharmacy Maintenance Allowance (RPMA)*                 66.87%
          Start-up Allowance                                            1.82%
          Succession Allowance                                          2.49%
          Section 100 Support Allowance                                 2.31%
          Rural Pharmacist Pre-registration Incentive Allowance        12.16%


Apart from one component, the Rural Pharmacy Maintenance Allowance Scheme, the
funding was spread relatively evenly over a number of initiatives. However, the



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relative value of the different initiatives, at least as determined through a survey of
‘beneficiaries’ (rural pharmacists), was not so even.
Table 22 Initiatives identified by rural pharmacists as an important influence on their
decision to remain in rural practice
                                                                    % of survey
                                                               respondents nominating
        Initiative                                                    initiative
        Emergency Locum Service (ELS)                                   31%
        Rural & Remote Pharmacy Infrastructure Grants
        Scheme (RRPIGS)                                               7%
        Continuing Education Allowance (CPE)                         29%
        Rural Pharmacy Newsletter                                     6%
        Rural Pharmacy Promotion Campaign                             3%
        Rural Pharmacy Maintenance Allowance (RPMA)                  65%
        Start-up Allowance                                            5%
        Succession Allowance                                         10%
        Section 100 Support Allowance                                 3%
        Rural Pharmacist Pre-Registration Incentive
        Allowance (RPPIA)                                            27%
                                                    Source: HCA survey of pharmacists, 2004


This is by no means definitive evidence, especially considering the fact that the RPIP
still has some considerable time to further evolve during which time the perception of
some initiatives may change13. However, it does convey a sense that some strategies
are worth more investment than others (that is they are likely to provide a better return
on investment).

Focus on recruitment and retention factors
Conceptually it would seem sound, if it was decided to concentrate investment on a
limited number of strategies, to choose those strategies that addressed the factors
most influential on workers’ decision making. These were discussed at length in
Chapter 4, and the key or most influential factors on allied health professionals’
decision making summarised in Chapter 15.
We also believe that a good understanding needs to be developed of what strategies
are best implemented at different (national, state, regional, organisational and
individual) operational or administrative levels. This will depend on who has the
greatest capacity to realistically impact on recruitment and retention factors. For
instance, DHS will have limited capacity to influence the way work is constructed
within individual organisation environments to generate interesting and challenging
roles (other than offering broad support and appropriate rewards), but it can impact on
remuneration arrangements and career pathways.
Schoo et al (2005) in their conceptualisation of recruitment and retention strategies
traversed a similar thought pathway in their approach to strategy development and
assessment of strategy worth. They borrowed Stephen Covey’s ‘circle of concern and
influence’ concept and identified three such circles that need to be addressed viz:
     Individual needs;
     Organisational needs; and


13
  Indeed the authors of that evaluation were careful to point out that at this stage of
implementation few of the strategies can be ‘ruled out’.


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   Community needs.
These three areas are illustrated in the Figure below, adapted from Schoo et al.
(2005).


Figure 2 A multidimensional interactive allied health workforce recruitment and
retention conceptual model




Taking all of the above into account ― the factors that most seem to influence
individual worker decision making; the relative influence of different operational levels,
‘circles of concern’ ― and using evidence as much as possible when assessing
strategy options, we propose three basic ‘strategy streams’ viz.:
   Industry strategies;
   Organisational change strategies; and
   Organisational development strategies.
Each of these streams is explored in the following sections.
Before proceeding though, a note is required on an absence from the above streams
and subsequent discussion. In each of the chapters on the separate allied health
professions, a section was devoted to the strategy approach of labour market
adjustment. This approach generally advocated efforts to reduce or eliminate a broad
labour shortage, and thereby reduce recruitment problems at the respective labour
market margins of unattractive employment options. This will not be considered
because:
   Discussing labour market solutions for ‘allied health’ makes little sense given the
   significant variation within allied health between the separate professions (see
   discussion of ‘allied health’ in chapter 5);




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   Developing labour market solutions are minor or even major projects in themselves
   (see for instance HCI, 1999 and 2003 for the pharmacy labour market alone).

Industry strategies
Industry strategies are initiatives aimed at improving recruitment and retention
outcomes which a single organisation (such as a hospital, community health service,
private practice) could not feasibly attempt. This may be because of cost
considerations, but is more likely because many industry stakeholders are required to
collaborate (including public and private sector health service providers, educational
institutions, different levels of government, regulators, etc.).

Personal issues
A prominent industry strategy relates to the long recognised relationship between the
propensity to practice in a certain area and having a strong and long standing
relationship with that area. This has typically been most explored in respect to rural
recruitment issues; research showing a decision by a health professional to practice in
a rural area is highly related to whether they have a rural background or a spouse with
a rural background (e.g. Huntley 1991; Laven, Beilby, Wilkinson & McElroy 2003).
Knowing this relationship has led administrators to propose strategies aimed at
increasing the number of persons of rural background enrolling in health profession
courses (school promotion, enrolment quotas, scholarship schemes) or increasing
undergraduate and postgraduate student exposure to rural practice in their formative
training stages (e.g. Bent 1999). A related strategy has been to tie undergraduates to
future rural practice through bonded bursaries and scholarships.
The logic and wisdom of these strategies has been largely unchallenged. However a
recent evaluation of the Rural Pharmacy Initiative Program has questioned the
economics of scholarship programs that target rural background students (HCA,
unpublished). Successful outcomes for such schemes depend principally on the
extent to which it encourages rural students who would not otherwise have enrolled in
a health profession course to enrol. The likelihood is that a scholarship scheme will
not contribute as many additional practising professionals in rural areas as it might
appear. Even if it is assumed that all scholarship holders are newly attracted to study
pharmacy because of their scholarships, some of the students they displace will be
from rural backgrounds. Moreover, the probabilistic nature of the graduates’ decisions
on where to practice post graduation means that the scheme will result in far fewer
additional professionals working in rural areas than scholarships funded. HCA
estimated that 12 scholarships for a single cohort of students would result in no more
than 2 additional practicing professionals in rural areas compared to if enrolments had
been unmanaged. Thus 12 scholarships translate into few additional practising rural
professionals; and hence the cost per additional rural practitioner will be much greater
than the originally assumed cost of a single scholarship.
The foregoing is not meant to suggest that scholarship type funding be immediately
abandoned. Rather, that these strategies should be viewed from the proper
perspective, with real cost and benefit considerations, and compared with alternative
strategies in a more realistic light.
In terms of the aim to increase the participation of rural background students in
undergraduate health courses, the best option is still to train in situ. The Workforce
Planning Unit (1989) for instance in successive studies of the nursing workforce over
the decade from 1980 identified an emerging problem with nurse labour in regional
areas only after the introduction of university based training and the loss of localised




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(hospital based) training programs. Prior to that, rural nurse vacancies had always
been proportionately lower than metropolitan.
More persuasive evidence can be derived from pharmacy course graduate data from
the regionally located Charles Sturt University (CSU). It appears that pharmacy
students attending such a rural university are more likely to find employment in the
local region (Giglio, 2004). The first cohort of pharmacy graduates from CSU
completed their study in 1999, attended their graduation in April 2000 and completed
the necessary pre-registration training by the end of 2000 (Simpson and Angel, 2003).
About 60-70% of students taking the course were originally from rural areas. A
qualitative study by Simpson and Wilkinson (2002) showed that by the end of 2000,
62% of all graduates and 88% of female graduates had accepted pre-registration
training places in non-metropolitan locations. In a follow-up study in May 2003, about
60% of respondents were working in a rural or regional site, with the remainder in a
metropolitan location (Simpson and Angel, 2003).
There is similar evidence from other universities. The Bachelor of Pharmacy course at
La Trobe University, Bendigo, commenced in 1999. Of the 18 fourth year graduating
students, almost all of whom were recruited from country areas, 14 continued their
pre-registration year in regional/rural Victoria (La Trobe University, undated).
While it is not always possible to manage (for instance with the smaller allied health
professions where a single course only might be conducted in Victoria), effort invested
in trying to establish and maintain allied health professional course infrastructure in
areas where labour is desired (and often difficult to obtain, such as rural and outer
metropolitan areas) should provide the best returns. Where completely separate
course structures are not able to be established, the next best option would be to
construct ‘feeder’ school arrangements in peripheral locations. For example, the first
one or even two years of a course could be completed at a regional institution before
completion at a metropolitan campus. Such a ‘feeder’ course may be made more
viable by combining the classes of different disciplines (eg physiotherapy and
occupational therapy; psychology and social work). A further step down option is to
extensively use the clinical practice experiences through undergraduate training, or
any pre-registration experience requirements, to expose students to perceived
unattractive employment situations. In this regard, Kainey (2004) offered evidence that
such exposure had increased the flow of new pharmacy graduates into hospital
practice.

Remuneration issues
Remuneration as an issue is consistently underplayed by most authors, the argument
being that most allied health professionals are (a) motivated by higher order service
goals, and (b) are sufficiently well paid compared to other workforce sectors for it not
to be a primary issue. Some authors concede at best that remuneration can be a
limiting factor, and if set too low could be a strong influence on recruitment behaviour.
On the other hand, income level is consistently identified as an important factor in
recruitment in the non health workforce (e.g. Day, 2005).
Remuneration issues within the allied health workforce would appear to be most
important for salaried workers, especially those working in the public sector. At the
very least there are particular allied health professions (e.g. podiatry, radiography,
orthotists) where public sector remuneration levels are perceived as unattractive, and
probably act as a disincentive to new recruits and for those considering stay.
In non health, non public sector environments labour markets act invariably to
recognise the unattractiveness of certain employment opportunities (because of
remoteness, safety, other hardship) and compensate with higher associated
remuneration levels. In contrast, public sector employers generally march to the beat


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of a centralised drum, and are loath to accommodate the logic of variable
remuneration levels for the same level of competence and work, based on ‘market’
forces. The anxieties of allowing variable remuneration levels are the immediate cost
issues of potentially unbudgeted wage liabilities, and of flow on effects into other allied
and other health professionals’ claims.
As far back as the early 1990s when enterprise bargaining first became a possibility,
Gadiel and Ridoutt (1993) argued:
   “…financial incentives are the most important potential and untried variable that
   might be employed in bidding for the retention of quality resources in … areas
   that have been poorly serviced.”
This statement remains largely true still today. In areas of health workforce where the
private sector is dominant (pharmacy, general practice) financial incentives have
come to form the centre piece of recruitment and retention campaigns. Why should
the same approach not be successful in affecting the behaviour of persons who
otherwise are on fixed salaries; is there any reason to believe allied health labour is so
different to all other forms of labour in what would influence their behaviour?
Some will counter argue that any public sector effort to compete with the private
sector will always be frustrated by the private sector’s greater capacity to out bid the
public sector. However, this misses the point that the public sector does not have to
have the highest salary offering, it simply needs to be competitive as part of a total
package. That package will include greater security, potentially more interesting and
varied work, and a career path. Most private sector organisations are small, owner
operated companies with flat structures that offer little future promotional incentive.
Clever approaches in the public sector can provide realistic career pathways.

Locum services
Repeated surveys of health professionals identify locum relief services or deputizing
services as an important support mechanism, especially for those working in
employment situations with some attached ‘hardship’ (as a result of the work location,
the work conditions, the type of work). Interestingly though the services are often not
used very much and as a consequence are hard to sustain based on their own
revenue earning capacity.
For instance, a review of emergency locum services for rural pharmacists found that
less than 5% of eligible pharmacists actually used the service over a five year period,
and yet nearly one third of the same population felt the existence of the service was
crucial to their decisions to stay in rural practice (HCA, unpublished). The conclusion;
locum services are an important safety valve, whose true value is not in their actual
use but in the fact that that they can be used. Establishment of a service, for
emergency relief or as most practitioners would prefer for respite, provides an
available coping mechanism that can be drawn on when recourse to other more
common coping approaches have been exhausted. Moreover, locum services indicate
someone cares.

Organisational change strategies
The worth of organisational change
A range of authors have long argued that industry led efforts to improve recruitment
and especially retention outcomes are often effectively made redundant by
entrenched cultures in hospitals and other health service organisations that eschew
best practice, or even reasonable personnel management approaches (e.g. Nall,
2005, Schoo et al., 2005). Several of the main factors influencing both recruitment and


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retention decision making are all mostly within the control of employing organisations,
viz.:
   Relationship with work colleagues (e.g. organisation of work, team work processes,
   self management approaches) ;
   Job satisfaction / interesting and challenging work (e.g. work / job design,
   delegation approach, workforce planning);
   Work environment, including a supportive culture (e.g. professional supervision,
   leadership, incentive / reward system, performance management system);
   Balance between work / life (style) / family (e.g. approach to flexible work hours,
   leave provisions, use of casuals, rostering).
Research conducted by Best Practice Australia (Parle 2003) has shown that
establishing the right organisational culture can have a powerful effect on retention
behaviour. In a benchmarking survey of a number of Australian hospitals they were
able to identify five types of culture as follows:
1. Culture of Blame
2. Culture of Reaction
3. Culture of Consolidation
4. Culture of Ambition
5. Culture of Success
The Figure below shows the average percentage of nurses “At Risk of leaving the
organisation” in each of the five cultures. Since the cultural types are arranged in
ascending order of perceived likelihood of achieving human resources and
organisational outcomes, it is not surprising that the figure clearly shows the almost
linear relationship between culture type and a human resource outcome measure.
Figure 3 The relationship between organisational culture and propensity to leave the
organisation




It is worth dwelling on the characteristics of each cultural type as described by Parle
(2003, a).


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   CULTURE OF BLAME
       Large numbers of employees are openly pessimistic about the organisation‘s
       future.
       It is common to hear “Communication is poor”, “There is no leadership”, or
       “Morale is bad”.
       There is a perceived climate of FEAR throughout the organisation.
       There is a “Them and Us” mentality.
   CULTURE OF REACTION
       There is a lot of organisational repair work – often on the run. Ad hoc
       “strategic” decision-making may be common.
       Management is putting significant resources into improving communication
       with employees.
       A lot of management time is wasted on continually putting out fires
       throughout the organisation.
       Opportunities may slip by unnoticed because management is distracted with
       day-to-day crises.
   CULTURE OF CONSOLIDATION
       Organisational culture is fragmented (some segments in low-end cultures and
       some in high-end cultures).
       There is pressure to consolidate the gains already made.
       Employees refer to the need for ‘a breather’.
       Where organisations that have stabilised in this type of culture:
   -   Consolidation has turned into Contentment.
   -   There is a strong sense of stability – no urgency to fix problems.
   CULTURE OF AMBITION
       Organisations at this stage are not satisfied with their current levels of
       performance or their current ways of doing business.
       They are ambitious for new and better ways of moving ahead.
       An ”anything is possible” mentality is quite common.
       Could be too many commitments and insufficient cash-flow.
       At its best, this type of culture may become very pioneering. But they may
       also be prepared to ‘bet the farm’ in pursuit of a first-mover competitive
       advantage.
   CULTURE OF SUCCESS
       Large numbers of employees are optimistic about the organisation‘s future.
       There is a strong sense of success and achievement. ‘Things are getting
       better all the time’.
       Employees are very positive about tackling problems. There is a “Can Do”
       mentality.


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      Very close-knit, very cohesive, and very focused. A possible adverse
      consequence is that anyone who doesn’t ‘fit in’ will be squeezed out by peer
      pressure.
      There is a high degree of confidence in the organisation’s strategy.

Employer of choice
Cultures of ‘ambition’ and ‘success’ are given a ‘face’ and an operational framework
through the ‘Employer of Choice’ (EOC) concept. A working definition of an EOC
(2005) is an organisation intent on:
   Fostering an inclusive and employee-centred culture.
   Providing meaningful and challenging work.
   Developing people to realise their potential.
   Creating opportunity for growth and development.
   Recognizing contributions and rewarding achievement.
   Offering frequent, open and two-way communications.
   Providing economic opportunity through exceptional benefits packages.
Large private sector companies who have adopted an EOC approach are now
working to gain the confidence of a number of stakeholders including employees,
potential and actual. Their sites use the language of diversity and values but are
characterised by an absence of discourse around the older terms of “equity” and
“EEO”. The focus of EOC companies (at least as promoted in their websites) is what
the company will do for and with the employee and the community.
While largely a private sector phenomenon, governments are increasingly becoming
involved in EOC initiatives. For example, the Australian Government’s research into
the conditions of companies engaging with the EOC framework, and then providing
advice, information and other support to companies to adopt the approach (e.g. DIMIA
2004).
Some public service organisations and instrumentalities are beginning to recognise
that the EOC approach is imperative to future public policy capacity and public sector
service delivery (OECD 2002). Ironically, many observers acknowledge that the public
service in most OECD countries has lost ground as an employer of choice (e.g.
McPhie & Marshall 2004) over the last 20 years; especially through reform under the
direction of New Public Management (NPM) philosophies (Manning 2000). Aucoin and
Bakvis (2003) for instance argue that NPM has diminished the public sector’s ability to
differentiate itself from the private sector, and worse leaving itself “on the nose” as an
employer. One reason maybe that while the public sector promotes private sector
work practices, it cannot generally afford to pay private sector rates (especially at the
more highly skilled workforce levels) or provide private sector ‘perks’. Their research
suggests a pathway for the sector to become an EOC is to return to older public
service cultural values:
   “ … young people, especially young public servants… (identify) job content-
   interesting work, capacity to have an impact-make a difference-promote the
   public good, flexible work conditions that afford a work-life balance, and even
   traditional job security are becoming the most important factors in career
   choices. .. Becoming an ‘employer of choice’ requires, ironically, that public
   services pay greater attention to what were once considered, at least in some
   public services, to be fundamental career public service ideals and values.”
Apart from some government departments (e.g. NSW Department of Health 2004),
the EOC terminology is only just becoming vogue in the health industry. A more



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commonly heard term is ‘magnet’ hospitals (American Nurses Association 2002), or
else discussion is focused on commitment from and to the organisation (Manion
2004). The Magnet Hospital movement in the United States has now established a
Recognition Program, and through this accredits hospitals to be designated as
magnets. It is a rigorous assessment process focusing on issues such as:
   Staff turnover
   Vacancy rate
   Decision-making delegation
   Nurse – patient ratios
   Licensed to unlicensed nursing staff ratios
   Absenteeism rate
   Overtime worked, especially of a ’mandatory’ nature
   Service quality indicators
Since 1983 only 57 organisations have been conferred ‘Magnet’ status, but the ANA
claim evidence that these organisations retain staff for twice as long as comparable
organisations and deliver significantly better patient care.
EOC principles are embodied in Studer’s ‘Five-Pillar Leadership’ approach to (private)
hospital administration, the end outcome being:
   “… a culture of service and operational excellence, and a great place for
   employees to work, physicians to practice, and patients to receive care.” (Studer
   2004)

Practical issues
One of the problems of advocating an EOC / magnet hospital type approach is that it
seems to place all the power for change in the hands of many health administrators
and health service managers, whose competence (or will) to affect change appears
manifestly inadequate. Indeed some authors are prepared to lay the bulk of most
developed countries’ health system woes at the feet of administrators whose
personnel management approaches have driven high quality people from the system
and keep those that remain in the least motivated mental state (e.g. Bell 2000, Manion
2004, Studer 2004). While this is probably overstating the cause, the obvious question
remains … if these administrators/managers were capable why are they not already
performing personnel management well? Which inspires a second question; is there
some way that organisational change in many separate organisations across an entire
system can be facilitated by actions from a centralised authority (like DHS)?
We can best answer this question by examining the recent efforts of the National
Health Service (NHS) in the UK. The NHS seems to have embarked on an extremely
ambitious campaign to lead, support and, where necessary enforce, a comprehensive
change in the way individual NHS organisations manage their human resources.
Acknowledging that “… recruitment has been damaged by a growing public perception
that the NHS is a pretty awful place to work …” (Bell 2000), the NHS has been jolted
into attempting widespread reforms.
Some of the primary components of the NHS strategy are:
   Providing a broad statement of intent (“Improving Working Lives” and “Human
   Resources Performance Framework”) and to promote this widely as a primary
   objective of the system;


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     Planning more deliberately the human resource component within the planning and
     delivery of health services (“HR in the NHS Plan”);
     Providing ideas / models on ‘good practice’ for administrators to copy and
     implement as model employers. There is a growing database of good practice. As
     well, there are strategically placed change agents (“Improving Working Lives
     Leads”) for local administrators to draw upon for advice;
     Constructing career pathways (including non professional labour categories) from
     existing workforce categories or by including newly designed work roles and
     mapping training (“skills escalator”) pathways in order to achieve career progress;
     Building personnel management skills of administrators and service managers
     across the breadth of the NHS;
     Re-fashioning remuneration structures so they are universally fair, sufficiently
     competitive and an appropriate way of recognising the importance of the skills
     patients need;
     Recognising administrators and managers for attempting change (through
     recognition / awards programs14) and by rewarding for improved outcomes (eg
     reduced staff turnover).
The NHS campaign could offer a starting template for other central authorities (such
as DHS) wanting to change the culture of the many organisations that form the overall
approach of the health system to human resource management.

Organisational development strategies
Boyce (1996) has argued that different forms of allied health organisational structure
can have a profound effect on the way individual allied health workers feel, think and
behave. One model of organisational structure first mooted and trialled in rural South
Australia achieved valuable recruitment and retention outcomes and has subsequently
been expanded and advocated by Gadiel and Ridoutt (1993) and Boyce (1996). It is a
‘Division of Allied Health’ and is described elsewhere (Boyce1996, Nihill 1992).
The value for recruitment and retention of the Division model is that it creates an
organisation structure of sufficient critical mass and with economies of scale to deliver
management consistent with the requirements of key retention and recruitment
strategies. For example, significant management resources are required to develop
and implement within an organisation strategies that:
     Create work roles / jobs that will deliver satisfaction and remain interesting and
     challenging work;
     Foster career progress on an individual basis, especially for those who desire ‘fast
     track’ progression;
     Actively manage to balance the organisational needs and individual worker work /
     life (style) / family needs.
     Consistently foster strong and productive relationships between work colleagues;
     Manufacture a positive work environment, including a supportive culture;



14
  For example, the awards conferred on allied health service managers. See Department of
Health (2004) Fresh Thinking: Smarter working – promoting the voice of allied health
professionals. Allied Health Professionals Bulletin, April May


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Traditional ‘department’ structures based around separate allied health disciplines
have insufficient critical mass (staff FTE) to enable real resources to be applied to
making the above strategies work. This applies even to the largest of the disciplines
(for instance physiotherapy) unless the department is located in a very large teaching
hospital.
Gadiel and Ridoutt (1993) identified the following supportive functions that managers
in a larger ‘divisional’ structure might play:
   Allocation of personnel and resources effectively across priority tasks within
   budgetary constraints;
   Regular supervision and appraisal of staff;
   Development of customer service strategies;
   Co-ordination of professional support;
   Development of quality improvement processes;
   Improving strategic planning;
   Advocating more effectively for allied health within acknowledged forums of power
   and decision making (where currently allied health’s voice is weak, see Rowe,
   Boyce & Boyle 2001).
Another way of organising allied health work to achieve improved retention (and
possibly recruitment) outcomes would be through team work across professional
boundaries. Schoo et al. (2005) note a strong evidence-base for practices in health
care requiring input from more than one discipline, particularly in the prevention and
treatment of chronic diseases.
A multi-disciplinary team, co-ordinated care, or patient centred approach to organising
the work and the resources of health care services delivery in theory can significantly
improve the content of allied health professionals’ work, reduce the frustrations of
cross disciplinary / cross service communication, and improve patient outcomes; all of
which will enhance the job satisfaction. Successful multidisciplinary team effort in past
though has proven at times elusive. Teams need to evolve with a common purpose
and performance goals, possess complimentary skills and keep themselves mutually
accountable in order to be effective (Katzenbach & Smith 1993).
Schoo et al. (2005) further state:
   “For a team to function effectively there must be a motive for operating together,
   an awareness that joint input is more effective than working alone, a
   dependence for members on each other to attain the agreed goal, joint
   accountability within an organisation or community, and leadership. Functioning
   in a team requires professionals to trust and respect each other, to remain
   flexible, to accept program protocols, to understand the procedures, to take part
   in team development, and to be able to let go or accept particular roles.”
Duckett (2001) places some of the burden of the difficulty for forming and operating
successful team approaches on the education process which has failed to create
‘team work’ competencies. He claims the educational sector has made marginal
adjustments only to the existing monodisciplinary frame of educational preparation,
consistent with a model of learning and working that can be best characterised as of
“learning alongside” rather than “learning together”. It is not surprising then that most
team work approaches in the service delivery world equate to ‘working alongside’,
what Schoo et al. (2005) would label multidisciplinary teamwork based on separate
disciplinary treatment plans. More substantial gains would be obtained from



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interdisciplinary (shared plan and monitoring of progress) or even transdisciplinary
(crossing professional boundaries) modes of service delivery.
A Division of Allied Health organisational structure is not inconsistent with patient
centred care models for organising work; indeed one could argue it supports such an
approach since it models collaborative behaviour at an organisational level and begins
to familiarise the different professional groups with setting common goals and
achieving shared beneficial outcomes.

Conclusion
In this last chapter an attempt has been made to draw some sense from the literature,
which has been shown in earlier chapters to be significant in volume but deficient in
breadth (a) by not covering a wide range of health professions and (b) by focusing
almost exclusively on recruitment and retention difficulties (and even there on rural
problems).
No attempt is made here to develop recommendations; it is not the type of research
that should lead to recommendations, moreover the evidence to support any strongly
asserted direction is too thin. However, it is possible to develop some ‘best bet’ future
investment directions to discuss, negotiate and possibly explore in practical ways.
These directions are:
   Reduce the number of recruitment and retention strategies for investment. Better to
   invest adequately in a few strategies with good prospects than under-invest in a raft
   of strategies in the name of ‘comprehensiveness’;
   Commit resources and investment at appropriate levels and in ways that equate to
   real levels of influence;
   Accept that the most important influence on recruitment and especially retention
   outcomes are employing organisations. This should be the focus of effort, in ways
   that are again appropriate to the level and type of influence that can be brought to
   bear;
   Supportive infrastructure development (capacity building in the lexicon of public
   health) might be more important than a range of short term funded ‘programs’,
   even if the latter are easier to organise, fund and promote.




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17. Glossary
AAHCS             Australasian Allied Health Classification System
ABS               Australian Bureau of Statistics
AHPB              Allied Health Professionals Bulletin
AHRI              Australian Human Resources Institute
AHWAC             Australian Health Workforce Advisory Committee
AIHW              Australian Institute of Health and Welfare
AIR               Australian Institute of Radiography
AMWAC             Australian Medical Workforce Advisory Committee
APODC             Australasian Podiatry Council
APS               Australian Psychological Society
DAA               Dietitians Association of Australia
DEWR              Department of Employment and Workplace Relations
DIMEA             Department of Immigration and Multicultural and Indigenous Affairs
EOC               Employer of Choice
HPCA              Health Professions Council of Australia
IPPR              Institute of Public Policy Research, UK
NAHCC             National Allied Health Casemix Committee
OECD              Organisation for Economic Co-operation & Development
Practice area     Specialties or sub-groupings within professions
SARRAH            Services for Australian Rural and Remote Allied Health




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