Journal of Community & Public Health Nursing
Open Access

What is already known on this subject?

• There is low retention of Remote Area Nurses in remote Australia.

• Retention of Remote Area Nurses is improved by a supportive environment, including good management, professional development and supervision.

• Retention is multi-factorial, and includes professional support, personal/financial rewards, regulatory frameworks of operation, and educational opportunities.

What this study adds:

• Experienced Remote Area Nurses value Indigenous culture, remote locations and like working in an effective and supportive team environment.

• Turnover is increased by ineffective management practices and rigid models of employment.

• Retention could be increased by RANs being able to take regular short breaks, filled by using returning staff / the same short-term locum nurses with the ability to return to the same locations.

Remote Health Practice and Remote Area Nurses

The term ‘remote health’ is often combined with the term ‘rural health’ but remote health has distinct characteristics [1]. Compared with rural health, remote health refers to settings with greater distances and geographical isolation, less access to health care and availability to services, smaller and more mobile populations with a higher percentage of Indigenous residents, and different models of health care delivery with health professionals generally being employed by state, territory health services or Aboriginal and Torres Strait Islander Health Organisations, rather than the small hospitals with local GPs practices in rural areas. In a remote health context the social dimensions are also different with less power, resource distribution and greater inequality than in rural areas [1].

In many very remote areas registered nurses, often called Remote Area Nurses (RANs), along with Aboriginal and Torres Strait Islander Health Practitioners (ATSIHPs) are the main providers of health care, generally with visiting GPs and allied health professional [2]. RANs work in an advanced practice role, dealing with acute and chronic health conditions as well as health promotion and public health activities, often accomplished in a cross-cultural situation that operates with separate language, knowledge and cultural systems to that of the health care providers [2,3].

Patterns of workforce recruitment and retention

The maldistribution of the health professional workforce between urban, rural and remote areas of Australia has been well recognised, with much lower percentages of GPs and allied health professionals in remote areas compared to urban areas. Nursing is the most evenly distributed health profession, with the highest distribution in very remote areas [4-7]. However, remote area nursing is a very unstable workforce with very high turnover rates, on average 148% annually in the Northern Territory Department of Health from 2013 to 2016 [8]. Due to the high turnover rate, there is a heavy reliance on short-term or fly-in, fly-out/drive-in, drive in-out staff [9,10]. The Covid-19 pandemic has highlighted the vulnerability of this reliance, with increased difficulty sourcing RANs and increased burnout of the existing workforce [10].

Retention of Remote Area Nurses

Although recruitment and retention are intrinsically linked, this study concentrates on the retention of RANs. The inability to provide and maintain health staff, especially RANs, in primary health care services in remote communities, contributes to health disparities in already vulnerable populations [11]. Poor retention of RANs continues to be an issue in many remote areas of Australia and has a negative impact on the provision of health services [12]. This poor retention and high turnover rates of RANs has led to a growing reliance on the use of shortterm locum RANs [9]. While a number of key factors influencing the high nursing turnover in remote areas have been identified, including social and geographical isolation; high workload; extended scope of practice; poor management, housing and infrastructure issues; and workplace and community violence [9,13,14], the literature offers little insight to the characteristics of the casual nursing workforce in remote regions [15].

Retention of RANS is influenced by those factors that influence individual nurses’ decisions about their careers and workplace location, and the organisational polices and interventions that are implemented to influence individual decisions [16]. These factors can be categorised into four incentive types: professional support, personal/financial reasons, regularly frameworks and educational programs [16]. Tyrell et al looked at the motivations associated with long term retention of health practitioners in Very Remote Indigenous Australian communities noting eight motivations: remote living location preferences; clinical self-containment; intercultural interests; challenge seeking; personal demand preferences; clinical competence; relationship imperatives; and lifestyle preferences [17]. Other studies have identified feeling ‘part of a team’, job satisfaction and relationships as frequently reported by RANS as factors increasing retention [18]. Having the right ‘fit’ of a RAN with a particular community and having strong cultural skills was also seen as important [12].

Reviews of the effectiveness of interventions designed to increase retention have found that financial incentive programs are effective, but also that building supportive relationships, providing information and communication technologies, and having remote health career pathways were effective [19]. Good management and supervision practices have been frequently identified [8, 20]. These reviews of the literature have identified that a number of remaining knowledge gaps remain, including understanding the drivers of turnover, retention patterns of RANs and the lack of evaluation of effective retention interventions [8,21]. One review recommended that it should be a priority of policymakers to implement current global evidence to slow “excessive remote health workforce turnover, resulting in significant cost savings and improved continuity of care” [8] and evaluate staffing models which effectively stabilise the remote workforce [21].

The aim of this study was to examine the experiences of currently employed and experienced RANS about remote Australian nursing staff retention strategies.

Design

This is a qualitative study using a phenomenological framework [22]. A phenomenological approach aims to explore the lived experiences of a particular group that describes the nature of a particular aspect of the group. The research question was: How do experienced remote area nurses perceive nursing staff retention strategies?

In-depth, semi-structured interviews were conducted via telephone by one of the authors (JA) The interview questions were based on personal experiences of enablers and barriers of RAN retention by two of the authors (JA, SL) in the context of the literature on effective retention strategies. Interviews were audio recorded and transcribed by the first author (JA). Two of the authors (JA, SL) independently analysed the transcriptions to identify common themes, then discussed the data until a consensus was reached.

Participants

Registered nurses who had a minimum of three years’ experience working as a RAN were eligible to participate. Eligible participants were working or had worked in very remote (MM7) Aboriginal and Torres Strait Islander communities according to the Modified Monash Model (MMM) which measures remoteness and population size on a scale of Modified Monash (MM) category MM 1 (major city) to MM 7 (very remote) [23]. Invitations were distributed via the electronic weekly publication for nurses ‘CRANAPulse’ and via email to current students studying Remote Health Practice at Flinders University [24]. Participation was voluntary. Individuals indicating interest was given participant information sheet and returned a signed consent form to the first author.

Ethics Approval

Ethics approval for the research was received from the Flinders University Social and Behavioural Research Ethics Committee in South Australia (#2096).

Seven interviews were conducted with eligible participants, six female nurses and one male nurse. All participants had considerable remote area nursing experience, with the group average working as a RAN exceeding twelve years. Participants had all had a mix of working as a permanent resident in remote communities and as short-term locum or ‘agency’ RANs. Participants had worked in various health service sectors including Government, non-Government, communitycontrolled and independent health services. All participants were non- Indigenous Australians.

Collectively, the participants had worked in most parts of Australia, including the Northern Territory, Queensland, South Australia, Western Australia and Victoria. Six of the seven participants had spent the majority of their time remote area nursing in the Northern Territory. In addition to remote work in Australia, one participant had worked in several remote locations in Africa.

Why RANs stay

Professional

The participants identified that an interest in Indigenous health, primary health care and the advanced scope of practice were contributing factors in choosing to continue to work as a RAN.

I very much like the autonomy. I could never, ever, and sometimes I think about this, imagine myself going back to hospital (Interview 6) you are constantly learning and being confronted with different things

You can be doing primary health care, you could be then dealing with an emergency or with the highway clinics, you then could be on the road, going off to an MVA [motor vehicle accident]. So there is a variety of work involved and just looking after Aboriginal people it’s never boring (Interview 4).

Many of the participants felt that working in an effective and supportive team environment was pivotal to how long they stayed. This was particularly true for the short-term locum RANs, who identified a functional team as one of the main reasons that they would choose to return to a particular health service. The participants described the team as not only the onsite manager and clinical staff including the AHPs, but the non-clinical staff including Aboriginal liaison staff, administration staff, cleaners and drivers. It was apparent that, the smaller the team, the more emphasis was placed on the need for effective and supportive relationships within the team.

The most important thing working as a remote area nurse is the team you are working with…can be a small team, working together, five days a week, working on-call together, weekends. So yeah, it’s different to a normal job… you work very closely together. So it’s very, very important that you get along with the staff (Interview 4).

Look, you know what, you can put up with a lot if you’ve got good staff and good conditions around you (Interview 1).

Remuneration was mentioned in the responses of two out of the seven participants when asked what keeps them in their position. Two of the participants identified that the amount of money ‘earned’ reflected the ‘busyness’ and the required amount of overtime for the position. It was described as a contributing factor but not the sole reason to stay. RANs can leave a health service or a particular location, relocate and continue to earn a similar salary. It was identified that short-term locum nurses can earn more money than some resident RANs, but more importantly, they can choose when, where and for how long they work.

You expect to be paid if you’re doing your job, but it’s not a motivating factor (Interview 2).

Social and Personal

An interest in Indigenous culture was given as a reason to why people stay working as a RAN. In addition to this, the ability to live and experience remote locations not visited by mainstream populations added to a ‘sense of adventure’. One participant described a sense of being drawn to the physical environment of desert regions.

I see it as a bit of a privilege to be able to go into remote place…not everyone’s allowed to do it the land the beauty of Australia (Interview 2).

Personally I love the desert scape, that tends to always, I get drawn back to the desert and the red dirt (Interview 3).

Why RANs leave

Professional

Dysfunctional teams and ineffective management practices both onsite and via distant management made up most of the responses from participants for choosing to leave. Staff turnover contributed to a high level of frustration among the participants. Many described the workload and fatigue from on-call requirements as exhausting, unmanageable and contributed to ‘burn out’ and the need to leave a community. Participants described difficulties in obtaining relief staff which often resulted in the inability to take leave when required.

We’ve been managing for months here with no driver only two nurses, so both on-call, one hundred percent of the time, so every single call out, we both have to do and that’s not sustainable either (Interview 1).

It’s the stress of always being on-duty, not being able to get away (Interview 7).

I think a big problem with management…where I am now is they are based in, a city. A lot of the management are non-health people, so you’re answering to non-clinicians, who have never, ever lived or worked in a remote facility. I think that causes a lot of angst amongst health professionals. I think it creates a divide, it becomes us and them (Interview 3).

Social and Personal

Participants felt that the role of a RAN cannot be truly understood by people who have not experienced it. Despite not being rostered on when in a remote setting, the RAN is always, ‘the nurse’. The lack of anonymity and boundaries, a constant reminder of your position in a community. RANs can face isolation while living in a cross-cultural environment.

I am fascinated by other people’s cultures, there is a sense of isolation that comes with living in someone’s culture and you’re always a stranger (Interview 7).

I think when you’re a RAN, it’s encompassing. You know, when you’re a RAN, you identify it, you live it, you breath it, you cry it, you sweat it (Interview 5).

You don’t understand the personal and human commitment you have to give every day as a RAN, cause you know, you’re always the face of health care… You’re always the nurse, even when you go out for dinner or go the grocery store.You’re always that constant, it’s always having a face on as I call it (Interview 5).

All of the participants identified the challenges of trying to maintain their own social and cultural connections while living in isolated and remote parts of Australia. Some of the participants choose to work as a short-term locum RAN, balancing time away from the community with family and friends.

I want to go back to my family. I want to visit my friends. One of the problems with this lifestyle I’ve had is it’s very hard to keep friends because you constantly, you, something comes up and you can’t do it. Somebody’s wedding anniversary, somebody’s kids’ birthday, you can’t, you’re not there. You are always not there and it’s really hard to maintain your friendships (Interview 7).

Safety concerns were also sighted by some participants as a reason to leave and in some cases, a reason never to return to particular location.

There are some communities you wouldn’t go back to, they are just too violent (Interview 7).

What RANs value

Professional

The participants were asked what they considered to be effective retention incentives, this could include actual retention incentives offered by organisations or retention incentives that they would consider effective and like to see offered to RANs.

The responses to ‘actual’ retention incentives were dependent on locations where the RANs had worked and for what organisations they were employed. For example, remuneration bonuses based on length of service in Queensland, significant salary packaging offered by some non-Government organisations, varied access to professional development and paid isolation leave and travel assistance depending on location and organisation were discussed by some participants.

Some participants identified that recent changes in safety protocols after the murder of South Australian RAN, Gayle Woodford, were valuable to retention, as was a police presence in communities.

The amount of effort and time they’ve put into get a correct and proper safe policy in place, is to my mind, very acceptable (Interview 6). It’s quite reassuring knowing that the police are around, that they are there (Interview 6).

All of the participants identified flexible work arrangements as a valuable retention incentive. Some of the participants had been employed in organisations that worked six weeks on and three weeks off, a fly-in, fly-out (FIFO) model of employment. Some of the participants felt a rigid model of employment was responsible for RANs leaving and seeking alternative employment arrangements with different organisations, ‘many government nurses leave and come back as agency staff’. Some of the participants have chosen to work ‘agency’ or ‘casual contracts’ so they can return home more frequently than permanent employees. One of the participants has been doing ‘agency’ for five years and another, for twenty years.

The overwhelming response to why the participants valued flexible work arrangements was to create a sense of work-life balance. Other reasons identified included the importance of ‘maintaining your own social and cultural connections’, ‘heading towards semi-retirement’ and a ‘sense of normality’. One participant felt that a flexible work arrangement would also appeal to a younger cohort of RANs.

You’ve got to make it attractive to young people and thinking that young people will spend years out bush is rubbish. Why would a twenty-five-year-old spend more than a year or two out bush…and this constant harping on about, we need to get young people in and we will give them a career path, it’s not just about a career path, it’s about them having a life too. And I think something that’s flexible, like, on, off and going back to the same community is a really good solution (Interview 7).

Participants valued returning staff or for the short-term locum nurses, the ability to return to the same locations. They felt it was beneficial to the team and reduced the amount of stress associated with constant staff turnover and orientation of new nurses. Furthermore, the participants identified greater benefits to the community and the health service.

How you get your outcomes within a health service, is to have your continuity of staff. It doesn’t have to be a full-time model. It can be something that, where staff, you know, one comes in, they know exactly what they’re doing, they’re well briefed, off they go. Perfect. Absolutely perfect (Interview 6).

…this is the thing that bugs the community, it’s just another white fella coming in…just in, out, in, out nurses. As an Indigenous colleague said to me…we need to have, if we could get, nurses who are happy to come back to the same community (Interview 3).

Participants felt that returning staff are able to build relationships, familiarity and cultural competence/appropriateness. One participant expressed frustration that the importance of this is often overlooked by distant managers.

and I can’t for the life of me understand why the department, with its centralised bureaucracy, can’t grasp it properly (Interview 6).

Improving management practices both onsite and distant, with a focus on team building and leadership training were identified as an essential part of retention.

Having some experience or exposure at least to be able to manage and lead that team and understand what burns these staff out. And recognising the signs of burn out easily, which can only come when you have a relationship with those people on the ground…so when management put time and effort into having those relationships with those that are actually doing the hard yards, at the coal face of RAN work, and understand them greater. Everyone’s different… if you get to know those people and support them to do what they do, you’ve got a better chance of retaining them longer term (Interview 5).

Not many of them have done any kind of management course… they just get promoted cause they are still there and I think there’s a lot of poor management … a good manager… better than most, because every Friday she would ring up and ask how your week had been … that was important, that somebody actually rung me up on a Friday and asked me how I was (Interview 7).

It was mentioned that cultural awareness was important but felt it could be enhanced by providing cultural education, specific to a community/location. Another participant suggested staff who intended to stay in a community for any length of time, should be offer language education as part of an essential training program.

You need to learn [the language] if you want to be integrated to a community (Interview 7).

Social and Personal

All participants valued free accommodation and utilities. The standard of accommodation was linked with retention, with the focus being on non-shared accommodation.

I think that’s really important to clarify that accommodation is fine, it needs to be separate. Just because you work with someone, does not mean you want to live with them. (Interview 5).

In addition to non-shared accommodation, Wi-Fi and mobile telephone access was mentioned by most of the participants as effective retention incentives.

Participants felt the ability to get out of remote communities regularly, for a short-break was equally important as taking longer breaks, such as annual leave. Participants identified that a weekend away or a four-day break, every four to eight weeks brought some sense of ‘normality’. The ability to ‘just to get out’, ‘have a coffee’ at a café, have ‘dinner with friends’, have a ‘glass of wine’, doing some ‘shopping’ and ‘just not to be the nurse’.

Every six weeks…you need that time out, if you choose not to, then fine. But you need to have the option (Interview 5).

One participant suggested that access to a vehicle for recreational use would allow staff to get out of the community and explore the local surrounding area.

Experienced RANs said they valued Indigenous culture, liked living in remote locations and that working in an effective and supportive team environment was a critically important reason for continuing to work as a RAN. They said that turnover is increased by what they saw as ineffective management practices and rigid models of employment. In particular, a clear recommendation for improving retention was the ability to take regular short breaks within a flexible management model, with the same short-term locum nurses returning to the same locations, and encouraging returning staff.

One of the key findings identified in this study is the importance RANs place on maintaining their own cultural and social needs. The RANs in this study described feelings of ‘not belonging’ to the community, ‘you’re always a stranger’, ‘always the nurse’ and the need to leave the physical environment at regular intervals ‘just to get away’ and ‘do normal things’. All of the participants identified the challenges of trying to maintain their own social and cultural connections while living in isolated and remote parts of Australia. While the provision of continuing personal and familial support to staff working in remote areas has been identified as a key need [8], this study highlights a key difference between rural and remote health practice. While most rural health professionals are part of the community where they work, most RANs are guests, living and working in a culture and community that is not their own. The need for RANs to return to their own culture should be considered a key retention issue.

The ability to leave remote communities regularly, even for a short break, may be as important as annual leave. Psychological distance from work, which RANs are unable to easily achieve while in the community, is nonetheless essential for mental and physical wellbeing [25].

The results suggest rigid models of employment contribute to RANs leaving and seeking alternative employment arrangements with different organisations, such as employment agencies, so they can return home more frequently than permanent employees. Lifestyle and relationship preferences are important factors in retention [17] and having the choice to work shorter contracts in order to maintain relationships is an enabling factor. The flexibility of work arrangements and having control over the length of time spent in and out of remote settings offered by recruitment agencies was viewed as an advantage by locum RANs in this study. This approach could be adopted by Government health service providers with flexible work models building on the ability of RANs to return to same communities.

Locum nurses have become an increasing and essential part of the remote workforce, representing an estimated 42% and 50% of RANs employed in the Northern Territory [8,9]. This increase has raised concerns about continuity of patient care; their role within the nursing team; the increased employment costs associated with casual staff; and their impact on retention levels of permanent staff [9,12,15]. However, it may not be the high proportion of locums that is the problem, but how they are managed.

‘Agency’ staff frequently returning to the same community may increase productivity in remote health centre by maintaining professional relationships within the team, reducing ‘orientation fatigue’, contributing to better health outcomes through continuity of care, and has a positive impact on community relationships and cultural competence [26]. Continuity of staff can be achieved by the same agency staff or relieving staff returning to provide RANs with breaks but maintaining continuity and relationships.

It is increasingly recognised in the literature that RANs are subject to extreme conditions and stress [13,14,27]. Nowhere else in Australia are nurses employed to carry out such a wide range of duties under harsh and isolated conditions. RANs are frequently faced with challenges that are rarely encountered by nurses practising in urban environments. The on-call aspect of the work is onerous for nurses and contributes to the high turn-over rates and burnout for nurse working in remote areas [12,13], highlighting the need for breaks to support longer term retention.

Consistent with previous work [28], the results indicated that working in an effective and supportive team environment was pivotal to retention. A functional team was identified as one of the main reasons that they would choose to return to a particular health service. Dysfunctional teams and ineffective management practices, both onsite and via distant management, made up most of the responses from participants for choosing to leave a remote area position.

Distance management [20], particularly from managers without a clinical background and experience living and working in remote areas, was seen as a potential problem with a ‘divide’ between distant management and remote based health staff. Management all at levels, need to carefully consider how their decisions affect the dynamics of the health team and recognise that distant decision-making can impact retention of the remote health workforce. More often it is about filling a vacant position with who is available, rather than finding the “right fit” for the team [12]. Health teams in remote communities often state it is more important to have the right nurse than just any nurse and the clinical and cultural competence of the nurse is of key importance [12].

Strengths and limitations

Continuing to explore the perspectives of RANs about why they stay or leave remote settings is important for understanding what retention strategies are effective in a constantly changing work environment. The qualitative focus on experienced RANs has provided current insights not always available from survey results and systematic reviews. The relatively small number of participants means that the insights from sub-groups (ie short stay RANs) are less robust than if there were more participants, but a wide range of views was able to be canvassed.

By documenting the personal perspectives from experienced RANs, the complexities of RAN retention and living and working in these remote environments can be better understood and can contribute to stabilising the remote health workforce and improve the health outcomes of remote populations. Future research, such as prospective longitudinal studies or interrupted time series designs, could follow the work trajectories of RANs, recording their career paths and their reasons for leaving, staying or returning, which would provide more rigorous evidence less susceptible to recall bias than interviews conducted after the fact.

This study has highlighted that improving RAN retention is much more than offering remuneration and associated work conditions and entitlements. RANs particularly value the ability to maintain their own social and cultural connectedness and work within functional teams supported by effective management practices. These conditions of work are important for retention.