Impact of support initiatives on retaining rural general practitioners

Moral distress in rural veterinarians as an outcome of the Mycoplasma bovis incursion in southern New Zealand

AIMS

To gain insight into the world of rural veterinarians during the Mycoplasma bovis incursion within southern Aotearoa New Zealand by exploring their experiences during the incursion, and to understand the consequences, positive and negative, of these experiences.

METHODS

A qualitative social science research methodology, guided by the philosophical paradigm of pragmatism, was used to collect data from an information-rich sample (n = 6) of rural veterinarians from Otago and Southland. Interview and focus group techniques were used, both guided by a semi-structured interview guide. Veterinarians were asked a range of questions, including their role within the incursion; whether their involvement had any positive or negative impact for them; and their experience of conflicting demands. Analysis of the narrative data collected was guided by Braun and Clarke's approach to reflexive thematic analysis.

RESULTS AND FINDINGS

All six participants approached agreed to participate. Analysis of the data provided an understanding of the trauma they experienced during the incursion. An overarching theme of psychological distress was underpinned by four sub-themes, with epistemic injustice and bearing witness the two sub-themes reported to be associated with the greatest experience of psychological distress. These, along with the other two identified stressors, led to the experience of moral distress, with moral residue and moral injury also experienced by some participants.

CONCLUSIONS

Eradication programmes for exotic diseases in production animals inevitably have an impact on rural veterinarians, in their role working closely with farmers. Potentially, these impacts could be positive, recognising and utilising veterinarians' experience, skills and knowledge base. This study, however, illustrates the significant negative impacts for some rural veterinarians exposed to the recent M. bovis eradication programme in New Zealand, including experiences of moral distress and moral injury. Consequently, this eradication programme resulted in increased stress for study participants. There is a need to consider how the system addresses future exotic disease incursions to better incorporate and utilise the knowledge and skills of the expert workforce of rural veterinarians and to minimise the negative impacts on them.

CLINICAL RELEVANCE

To date, the experience of moral distress by rural veterinarians during exotic disease incursions has been under-reported globally and unexplored in New Zealand. The findings from this study contribute further insights to the existing limited literature and provide guidance on how to reduce the adverse experiences on rural veterinarians during future incursions.

ABBREVIATIONS

MPI: Ministry for Primary Industries; PITS: Perpetration-induced traumatic stress; PTSD: Post-traumatic stress disorder.

Job Satisfaction of Health Practitioners Providing Outreach Health Services during COVID-19 in Rural New South Wales (NSW) and the Australian Capital Territory (ACT), Australia

Background: Outreach health practitioners play a key role in enhancing access to healthcare for remote, rural, regional, and Aboriginal and Torres Strait Islander communities in Australia. Outreach health practitioners are those providing ongoing and integrated health services in communities that would otherwise have limited access. In the context of the COVID-19 pandemic, it is important to understand the job satisfaction of health workers as it correlates with long-term retention of the workforce, as well as effectiveness in the role and clinical outcomes for patients. Method: The study analysed data from 258 outreach health practitioners who responded to two cross-sectional surveys conducted by the NSW Rural Doctors Network during the COVID-19 pandemic in 2020/21 and 2021/22 in NSW and the ACT, Australia. Both bivariate and multivariate analyses were employed to assess the associations between the outcome variable (outreach health practitioners' job satisfaction) and independent variables (sociodemographic factors, motivation, self-confidence, communication, capability). Results: Overall, the study showed that 92.2% of health practitioners were satisfied in their role providing outreach health services during the COVID-19 pandemic. In the multivariable model, factors significantly associated with higher satisfaction included good communication with other local health practitioners, using telehealth along with in-person care, and having high self-rated capability compared to those health practitioners who said they had lower job satisfaction. Conclusions: Outreach health practitioners' job satisfaction is important because poor satisfaction may lead to suboptimal healthcare delivery, poor clinical outcomes, and poor retention of staff in rural settings. These findings should be taken into consideration when developing future strategies to improve job satisfaction among rural outreach health practitioners and to enhance attraction, recruitment and retention and may be applicable to the broader health workforce.

“Unchaining the doctor from the desk”: deliberate team-based care in action

Purpose

As a model of integrated care (IC), deliberate team-based care (DTBC) can help address workforce shortages facing rural communities by improving the health and wellbeing of healthcare providers. This study focuses on a GP practice implementing DTBC in rural Australia. The aim of this research was to understand the perspectives of the healthcare workers involved and to ascertain factors impacting on the day to day running of the model, patient care and clinician work-life. The authors conducted a qualitative study on the experiences of the DTBC workers.

Design/methodology/approach

Team members were invited to participate in semi-structured interviews (n = 9). Interviews were analysed using an iterative thematic analysis, summarised, collated and explored for emergent themes.

Findings

Key themes included: creating change from old ways of doing things, development and implementation processes outlining how the model evolved and how it ran from day to day, model outcomes for patients and clinicians, as well as practical considerations like funding, technology and time.

Originality/value

Building DTBC from the ground up has produced a high functioning team who demonstrate trust and equality, share information freely and all have a voice which is heard and respected. By acting as a champion and a leader, the GP has created a psychologically safe environment allowing the team to share knowledge, collaborate in problem solving and provide effective patient care which is holistic and community grounded. This work environment holds promise for creating improved work-life for rural clinicians and potential for workforce retention.

Why they leave: Small town rural realities of northern physician turnover

Introduction

This study seeks to explore influential factors leading to physician turnover in designated Rural Northern Physician Group Agreement (RNPGA) communities in Northern Ontario, as well as physician's perceptions of the RNPGA contract and effects of the Northern Ontario School of Medicine (NOSM) on physician retention in these communities.

Methods

Twelve qualitative semi-structured interviews were completed with rural physicians who had RNPGA contracts within the past 5 years but had left their practice community. Data collected from recorded interviews were analysed using a thematic analysis approach in order to identify common themes.

Results

A range of factors influencing physician's decisions to leave were identified including lack of partner career prospects, burnout and lack of opportunities and amenities. Common challenges were sometimes also perceived as rewards of rural practice. The concern of lack of flexibility of the RNPGA contract was identified, as well as a perceived lack of presence of NOSM graduates in RNPGA communities.

Conclusion

A variety of factors influence physician turnover in RNPGA communities. These may be considered by communities hoping to inform recruitment and retention policy. Renewal of the RNPGA contract may require consideration for availability of part-time positions, increasing the number of physicians funded and incentivising physician wellness. NOSM may consider mandatory postgraduate programme placements in RNPGA communities and further development of infrastructure in these communities to improve learner, graduate and institutional engagement.

Current status and related factors of turnover intention of primary medical staff in Anhui Province, China: a cross-sectional study

BACKGROUND

The shortage of primary medical staff is an important issue in the management of health human resources, and it is also a problem that all countries in the world need to face together. Since 2009, China has implemented a new series of medical system reforms and the shortage and loss of primary medical staff have been alleviated accordingly. However, China has a large population and it is difficult to distribute health human resources evenly across regions. This study aimed to explore the current status of turnover intention and its relationship with psychological capital, social support, and job burnout, as well as how these factors influence turnover intention of primary medical staff in Anhui province, China.

METHODS

Using structured questionnaires to collect data, including demographic characteristics, turnover intention, psychological capital, social support, and Chinese Maslach Burnout Inventory scale. A total of 1152 primary medical workers of Anhui were investigated. Data were analyzed by t-test, analysis of variance (ANOVA), Pearson correlation analysis, and multiple linear regression model.

RESULTS

Total scores of turnover intention, psychological capital, social support, and job burnout of subjects were 14.15 ± 4.35, 100.09 ± 15.98, 64.93 ± 13.23 and 41.07 ± 9.437, respectively. Multiple linear regression showed the related factors of turnover intention were age, job position, work unit, and scores of job burnout. Pearson correlation showed psychological capital and social support were negatively correlated with turnover intention, while the score of job burnout was positively correlated with turnover intention.

CONCLUSION

The improvement of psychological capital and social support and the reduction of job burnout may play an important role in reducing turnover intention of primary medical staff. Primary medical managers should strengthen the humanistic care for primary medical staff, optimize the incentive mechanism, and improve internal management of medical institutions for stability.

The global prevalence of turnover intention among general practitioners: a systematic review and meta-analysis

BACKGROUND

General practitioners (GPs) are the foundation of any primary healthcare system. Their quality and quantity are directly associated with the effectiveness and quality of the health services of a nation. GPs' shortage and turnover have become an important issue in developed and developing countries. An accurate estimate of turnover intention prevalence among GPs would have important health policy implications, but the overall prevalence is unknown. We aimed to summarize the global prevalence of turnover intention and associated factors among GPs.

METHODS

We systematically reviewed the PubMed, Embase, Web of Science and China National Knowledge Infrastructure (CNKI) databases from their inception up to May 2020, as well as the reference lists of all included studies. We included observational studies that reported data on turnover intention or their prevalence rate among GPs could be calculated based on the information provided. The prevalence rate of the turnover intentions was estimated using a random-effects meta-analysis. The heterogeneity was evaluated using I² statistic. Differences by study level characteristics were estimated via subgroup analysis and meta-regression.

RESULTS

A total of 25 cross-sectional studies were included (a total of 27,285 participants). The prevalence of turnover intention was 0.47 (95% CI: 0.39-0.55). Those having a lower level of salary (OR = 1.38, 95% CI: 1.13-1.63) and job satisfaction (OR = 1.35, 95% CI: 1.12-1.70) or having lower level of morale (OR = 2.68, 95% CI: 1.56-3.80) had a higher intention. In contrast, GPs with a lower level of professional title had a lower turnover intention (OR = 0.81, 95% CI: 0.65-0.98).

CONCLUSIONS

In this systematic review, approximately half of the GPs had the intention to leave their current posts worldwide. The factors associated with turnover intention were higher professional title, lower income level, lower job satisfaction and lower morale.

Why do doctors work in rural areas in high-income countries? A qualitative systematic review of recruitment and retention

OBJECTIVE

To identify and assess the drivers and barriers to recruiting and retaining doctors in rural communities of high-income countries.

DESIGN

A systematic review and thematic analysis.

SETTING

Publications were sourced from medical and scientific databases online.

PARTICIPANTS

Qualitative, mixed-methods and review studies from peer-reviewed journals published since 2000 that discussed recruitment or retention of doctors to rural areas in high-income countries.

MAIN OUTCOME MEASURES

Identification and assessment of themes in the literature pertaining to recruitment and retention of rural doctors. Recurrent themes were assessed for relevance and applicability to current rural shortages.

RESULTS

A thematic analysis was completed on 41 papers assessed as in scope of the review. Papers were scrutinised for relevance to established rural recruitment and retention strategies. Key themes were rural background, education and training, personal and professional circumstances, and integration with the community.

CONCLUSION

While rural origin has long been promoted as the key factor for recruiting rural doctors, initiatives targeting only these individuals ignore a potentially larger cohort of future rural doctors. Rurally focused medical education and training need to encompass students and doctors from all backgrounds. The major barriers to rural recruitment are family-unit considerations for partners and children, concerns over isolation and a poor perception of rural practice. Attracting doctors to practise rurally is only half the challenge however, and strategies to retain rural doctors need a greater focus on personal and professional support networks and community integration. Additional strategies are needed to retain international and bonded doctors restricted to rural areas.

A national survey of turnover intention among general practitioners in China

Studies on turnover intention among Chinese general practitioners (GPs) at the national level are limited. This study aimed to assess intention to leave and its associated factors among a nationally representative sample of GPs. The participants were selected using a multistage stratified random sampling method. A self-administered structured questionnaire was used to collect data from 3236 GPs in China between October 2017 and February 2018. A multiple linear stepwise regression analysis was used to identify factors associated with turnover intention. Over 70.0% GPs had a moderate or high turnover intention. GPs who were male, were younger, had a higher education level, had a lower professional title, had a lower income level, and had a temporal work contract had higher turnover intention. In addition, GPs who worked night shifts, had low job satisfaction, and had few opportunities for professional development reported higher turnover intention. Substantial gender and regional differences in predictors of turnover intention among GPs were observed. The study showed that turnover intention in Chinese GPs is high, and the factors influencing turnover intention were low professional title and income level, high education level, having a temporary work contract, working night shifts, and limited opportunities for professional development.

Impact of participation in continuing medical education small group learning (CME-SGL) on the stress, morale, and professional isolation of rurally-based GPs: a qualitative study in Ireland

BACKGROUND

The pressures of general practice contribute to high levels of stress, low morale, and burnout in some GPs. In addition, rurally-based doctors may experience significant professional isolation. Participation in continuing medical education (CME) appears to reduce stress, and may improve the retention of rural GPs.

AIM

As part of a larger study devised to examine the effectiveness of regular participation in CME small group learning (SGL) on rurally-based Irish GPs, this study explored whether CME-SGL had any impact on GP stress, morale, and professional isolation.

DESIGN & SETTING

This was a qualitative study involving four CME-SGL groups based in rural Ireland.

METHOD

Semi-structured focus group interviews were conducted in established CME-SGL groups in four different rural geographical locations. Interviews were audiorecorded, transcribed verbatim, and analysed thematically.

RESULTS

All members of these CME-SGL groups (n = 43) consented to interview. These GPs reported that regular meetings with an established group of trusted colleagues who are 'in the same boat' provided a 'safe space' for discussion of, and reflection on, both clinical concerns and personal worries. This interaction in a supportive, non-threatening atmosphere helped to relieve stress, lift morale, and boost self-confidence. The social aspect of CME-SGL sustained these rural GPs, and served to alleviate their sense of professional isolation.

CONCLUSION

Delivery of CME through locally-based SGL provides as an important means of supporting GPs working in rural areas. The non-educational benefits of CME-SGL, as described by these Irish GPs, are of relevance for rural doctors in other countries.

Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study

Background

UK general practice faces a workforce crisis, with general practitioner (GP) shortages, organisational change, substantial pressures across the whole health-care system and an ageing population with increasingly complex health needs. GPs require lengthy training, so retaining the existing workforce is urgent and important.

Objectives

(1) To identify the key policies and strategies that might (i) facilitate the retention of experienced GPs in direct patient care or (ii) support the return of GPs following a career break. (2) To consider the feasibility of potentially implementing those policies and strategies.

Design

This was a comprehensive, mixed-methods study.

Setting

This study took place in primary care in England.

Participants

General practitioners registered in south-west England were surveyed. Interviews were with purposively selected GPs and primary care stakeholders. A RAND/UCLA Appropriateness Method (RAM) panel comprised GP partners and GPs working in national stakeholder organisations. Stakeholder consultations included representatives from regional and national groups.

Main outcome measures

Systematic review – factors affecting GPs’ decisions to quit and to take career breaks. Survey – proportion of GPs likely to quit, to take career breaks or to reduce hours spent in patient care within 5 years of being surveyed. Interviews – themes relating to GPs’ decision-making. RAM – a set of policies and strategies to support retention, assessed as ‘appropriate’ and ‘feasible’. Predictive risk modelling – predictive model to identify practices in south-west England at risk of workforce undersupply within 5 years. Stakeholder consultation – comments and key actions regarding implementing emergent policies and strategies from the research.

Results

Past research identified four job-related ‘push’ factors associated with leaving general practice: (1) workload, (2) job dissatisfaction, (3) work-related stress and (4) work–life balance. The survey, returned by 2248 out of 3370 GPs (67%) in the south-west of England, identified a high likelihood of quitting (37%), taking a career break (36%) or reducing hours (57%) within 5 years. Interviews highlighted three drivers of leaving general practice: (1) professional identity and value of the GP role, (2) fear and risk associated with service delivery and (3) career choices. The RAM panel deemed 24 out of 54 retention policies and strategies to be ‘appropriate’, with most also considered ‘feasible’, including identification of and targeted support for practices ‘at risk’ of workforce undersupply and the provision of formal career options for GPs wishing to undertake portfolio roles. Practices at highest risk of workforce undersupply within 5 years are those that have larger patient list sizes, employ more nurses, serve more deprived and younger populations, or have poor patient experience ratings. Actions for national organisations with an interest in workforce planning were identified. These included collection of data on the current scope of GPs’ portfolio roles, and the need for formal career pathways for key primary care professionals, such as practice managers.

Limitations

The survey, qualitative research and modelling were conducted in one UK region. The research took place within a rapidly changing policy environment, providing a challenge in informing emergent policy and practice.

Conclusions

This research identifies the basis for current concerns regarding UK GP workforce capacity, drawing on experiences in south-west England. Policies and strategies identified by expert stakeholders after considering these findings are likely to be of relevance in addressing GP retention in the UK. Collaborative, multidisciplinary research partnerships should investigate the effects of rolling out some of the policies and strategies described in this report.

Study registration

This study is registered as PROSPERO CRD42016033876 and UKCRN ID number 20700.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Turnover intention and related factors among general practitioners in Hubei, China: a cross-sectional study

Background

High turnover among general practitioners (GPs) is a significant challenge in China’s efforts to build a sustainable, effective primary care system, but little data is available to help understand and address this issue. The study was aiming at assessing the intention to leave their posts among a sample of GPs and investigating associated factors.

Methods

A cross-sectional survey was conducted between December 12, 2014 and March 10, 2015 in Hubei Province, Central China. A total of 1016 GPs (response rate, 85.67%) were investigated by using a structured self-administered questionnaire. A generalized linear regression model was used to identify the associated factors with turnover intention among GPs.

Results

Based on a full score of 24, the average score for GPs’ turnover intention was 15.40 (SD = 3.43). 78.35% of the GPs had a moderate or higher level of turnover intention. Six hundred and thirty one (62.37%) GPs had ever been exposed to abuse of any kind (physical assault, 18.92%; verbal abuse, 54.38%; threat, 33.79%; verbal sexual harassment, 22.66%; and physical sexual harassment, 7.59%). Generalized linear regression analysis indicated that GPs who were male; who had a vocational school or higher; who had a temporary work contract; who were with lower level of job satisfaction; who reported higher scores on emotional exhaustion; who had been exposed to higher frequency of workplace violence were expressed higher intention to leave their present positions.

Conclusion

This study shows that GP’s intention to leave general practices is high in Hubei, China. In addition, the prevalence of workplace violence is high among GPs, particularly in the verbal abuse and threat. Measures such as offering permanent contract status, increasing overall job satisfaction, and improving doctor-patient relationship, are needed to moderate GP’s turnover intention in order to maintain the foundation of China’s three-tier health system.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0752-3) contains supplementary material, which is available to authorized users.

What Do We Mean by Physician Wellness? A Systematic Review of Its Definition and Measurement

OBJECTIVE

Physician wellness (well-being) is recognized for its intrinsic importance and impact on patient care, but it is a construct that lacks conceptual clarity. The authors conducted a systematic review to characterize the conceptualization of physician wellness in the literature by synthesizing definitions and measures used to operationalize the construct.

METHODS

A total of 3057 references identified from PubMed, Web of Science, and a manual reference check were reviewed for studies that quantitatively assessed the "wellness" or "well-being" of physicians. Definitions of physician wellness were thematically synthesized. Measures of physician wellness were classified based on their dimensional, contextual, and valence attributes, and changes in the operationalization of physician wellness were assessed over time (1989-2015).

RESULTS

Only 14% of included papers (11/78) explicitly defined physician wellness. At least one measure of mental, social, physical, and integrated well-being was present in 89, 50, 49, and 37% of papers, respectively. The number of papers operationalizing physician wellness using integrated, general-life well-being measures (e.g., meaning in life) increased [X ² = 5.08, p = 0.02] over time. Changes in measurement across mental, physical, and social domains remained stable over time.

CONCLUSIONS

Conceptualizations of physician wellness varied widely, with greatest emphasis on negative moods/emotions (e.g., burnout). Clarity and consensus regarding the conceptual definition of physician wellness is needed to advance the development of valid and reliable physician wellness measures, improve the consistency by which the construct is operationalized, and increase comparability of findings across studies. To guide future physician wellness assessments and interventions, the authors propose a holistic definition.

The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians

PURPOSE

To examine the literature documenting successes in recruiting and retaining rural primary care physicians.

METHOD

The authors conducted a narrative review of literature on individual, educational, and professional characteristics and experiences that lead to recruitment and retention of rural primary care physicians. In May 2016, they searched MEDLINE, PubMed, CINAHL, ERIC, Web of Science, Google Scholar, the Grey Literature Report, and reference lists of included studies for literature published in or after 1990 in the United States, Canada, or Australia. The authors identified 83 articles meeting inclusion criteria. They synthesized results and developed a theoretical model that proposes how the findings interact and influence rural recruitment and retention.

RESULTS

The authors' proposed theoretical model suggests factors interact across multiple dimensions to facilitate the development of a rural physician identity. Rural upbringing, personal attributes, positive rural exposure, preparation for rural life and medicine, partner receptivity to rural living, financial incentives, integration into rural communities, and good work-life balance influence recruitment and retention. However, attending medical schools and/or residencies with a rural emphasis and participating in rural training may reflect, rather than produce, intention for rural practice.

CONCLUSIONS

Many factors enhance rural physician identity development and influence whether physicians enter, remain in, and thrive in rural practice. To help trainees and young physicians develop the professional identity of a rural physician, multifactorial medical training approaches aimed at encouraging long-term rural practice should focus on rural-specific clinical and nonclinical competencies while providing trainees with positive rural experiences.

A systematic review of strategies to recruit and retain primary care doctors

Background

There is a workforce crisis in primary care. Previous research has looked at the reasons underlying recruitment and retention problems, but little research has looked at what works to improve recruitment and retention. The aim of this systematic review is to evaluate interventions and strategies used to recruit and retain primary care doctors internationally.

Methods

A systematic review was undertaken. MEDLINE, EMBASE, CENTRAL and grey literature were searched from inception to January 2015. Articles assessing interventions aimed at recruiting or retaining doctors in high income countries, applicable to primary care doctors were included. No restrictions on language or year of publication. The first author screened all titles and abstracts and a second author screened 20 %. Data extraction was carried out by one author and checked by a second. Meta-analysis was not possible due to heterogeneity.

Results

Fifty-one studies assessing 42 interventions were retrieved. Interventions were categorised into thirteen groups: financial incentives (n = 11), recruiting rural students (n = 6), international recruitment (n = 4), rural or primary care focused undergraduate placements (n = 3), rural or underserved postgraduate training (n = 3), well-being or peer support initiatives (n = 3), marketing (n = 2), mixed interventions (n = 5), support for professional development or research (n = 5), retainer schemes (n = 4), re-entry schemes (n = 1), specialised recruiters or case managers (n = 2) and delayed partnerships (n = 2).

Studies were of low methodological quality with no RCTs and only 15 studies with a comparison group. Weak evidence supported the use of postgraduate placements in underserved areas, undergraduate rural placements and recruiting students to medical school from rural areas. There was mixed evidence about financial incentives. A marketing campaign was associated with lower recruitment.

Conclusions

This is the first systematic review of interventions to improve recruitment and retention of primary care doctors. Although the evidence base for recruiting and care doctors is weak and more high quality research is needed, this review found evidence to support undergraduate and postgraduate placements in underserved areas, and selective recruitment of medical students. Other initiatives covered may have potential to improve recruitment and retention of primary care practitioners, but their effectiveness has not been established.

How effective and acceptable is Web 2.0 Balint group participation for general practitioners and general practitioner registrars in regional Australia? A pilot study

Objective

General practitioners (GPs) and general practice registrars report work‐related stress. Balint groups may improve coping mechanisms. However, attendance at a face‐to‐face Balint group is difficult for rural doctors due to distance constraints. The study aim was to evaluate online Balint groups for rural doctors and determine effect size for a full‐scale trial.

Design

A mixed‐methods approach, including a pre–post controlled trial and thematic analysis of qualitative data.

Setting

Rural primary care.

Participants

Thirteen GPs and 8 general practice registrars completed the study.

Interventions

Balint groups were delivered over 8–9 fortnightly online sessions. GPs and GP registrars participated in separate groups. Data were collected on work‐related affect, psychological medicine skills and professional isolation using the Warr's Work‐Related Affect Scale, the Psychological Medicine Inventory, and a professional isolation scale.

Main outcome measures

Change scores on Warr's Work‐Related Affect Scale, the Psychological Medicine Inventory, and a professional isolation scale.

Results

Balint participants' scores were significantly higher post‐intervention on the Psychological Medicine Inventory (mean 6.49 (±0.20) versus 5.43 (±0.26); P < 0.01) and Warr's Work‐Related Affect (mean 4.09 (±0.09) versus 3.60 (±0.12); P < 0.01) scales than control group scores. Effect size on these scales ranged from 0.46 to 0.50. The greatest challenge was technical problems related to insufficient broadband speed.

Conclusions

Online Balint groups appear to improve rural doctors' psychological medicine skills and work‐related affect. New data on effect size will inform a full‐scale trial. Improved national broadband infrastructure may enhance online support opportunities for rural doctors.

Occupational isolation among general practitioners in Finland

BACKGROUND

It is proposed that isolation in general practice is one of the factors that leads to work-related stress and the low attraction of this work. In Finland, 71% of physicians who worked or had worked in a primary health care centre agreed with the statement 'working as a doctor in a health centre is too often isolated work'.

AIMS

To gain a deeper understanding of this feeling and to find out which factors constitute it.

METHODS

A qualitative in-depth interview study of 32 physicians working in a primary health care centre in Finland. Qualitative analysis of transcribed verbatim interviews using a constant comparison method.

RESULTS

The main components of isolation were making decisions alone, lack of collaboration with other workers in the health centre and secondary care specialists, not being a part of the work community and lack of mentoring at work.

CONCLUSIONS

Enabling flexible teamwork and social and professional support networks are the key issues in solving the problem of occupational isolation in general practice.

Evaluated strategies to increase attraction and retention of health workers in remote and rural areas

The lack of health workers in remote and rural areas is a worldwide concern. Many countries have proposed and implemented interventions to address this issue, but very little is known about the effectiveness of such interventions and their sustainability in the long run. This paper provides an analysis of the effectiveness of interventions to attract and retain health workers in remote and rural areas from an impact evaluation perspective. It reports on a literature review of studies that have conducted evaluations of such interventions. It presents a synthesis of the indicators and methods used to measure the effects of rural retention interventions against several policy dimensions such as: attractiveness of rural or remote areas, deployment/recruitment, retention, and health workforce and health systems performance. It also discusses the quality of the current evidence on evaluation studies and emphasizes the need for more thorough evaluations to support policy-makers in developing, implementing and evaluating effective interventions to increase availability of health workers in underserved areas and ultimately contribute to reaching the United Nations' Millennium Development Goals.

GP registrar well-being: a cross-sectional survey

OBJECTIVES

To investigate the major stressors affecting GP registrars, how those at risk can be best identified and the most useful methods of managing or reducing their stress.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional postal questionnaire of all GP registrars in one large regional training provider's catchment area.

MAIN OUTCOME MEASURES

The Depression, Anxiety and Stress Scale (DASS), a specifically developed Registrar Stressor Scale consisting of five subscales of potential stressors, plus closed questions on how to identify and manage stress in GP registrars.

RESULTS

Survey response rate of 51% (102/199). Rural difficulties followed by achieving a work/life balance were the principal stressors. Ten percent of registrars were mildly or moderately depressed or anxious (DASS) and 7% mild to moderately anxious (DASS). Registrars preferred informal means of identifying those under stress (a buddy system and talks with their supervisors); similarly, they preferred to manage stress by discussions with family and friends, debriefing with peers and colleagues, or undertaking sport and leisure activities.

CONCLUSIONS

This study supports research which confirms that poor psychological well-being is an important issue for a significant minority of GP trainees. Regional training providers should ensure that they facilitate formal and informal strategies to identify those at risk and assist them to cope with their stress.

Doctors trading places: the Isolated Practitioner Peer Support Scheme

We describe the outcomes of a practice exchange in which an isolated general practitioner from a remote region traded work and living arrangements with a rural group practice GP. An exchange can provide an opportunity for mid- and senior-career professionals to refresh their outlook on their careers. Involving the rural medical workforce in practice exchanges can enable the development of peer networks that can improve retention of isolated practitioners in Australia. A fresh experience in a new setting can provide opportunities for practitioners to improve practice management and sharpen their clinical skills. Uprooting families and preparing homes for unfamiliar visitors add stress to doctors and their families on exchange. Patients in isolated practices could feel concerned that they may lose their doctor as a result of an exchange. In this instance, the benefits far outweighed the difficulties.

[Social support and physicians' health]

OBJECTIVES

Over the last decades, social support (SU) has proved to be an important psychological health resource in the prevention of mental and physical illness as well as for the promotion and restoration of general health. This study evaluates the relevance of social support for the health and well-being of physicians.

METHOD

This is a systematic literature review using PubMed from 1970 to 2007 with the keywords "social support", "physicians", "physician's role", and respectively "medical staff, hospital" from medical subheadings (MeSH). From the retrieved articles the additionally relevant keywords "marriage", "spouse", "friends", and "self-help groups" (MeSH) were identified and researched.

RESULTS

Social support with distinct effects on physician's health could be shown in the areas of colleagues and professional network (30 sources), marriage/spouse (47), friends (3), and support groups (13). Female physicians appeared to seek and profit more from SU than did male physicians. Informal friendships have yet to be evaluated thoroughly.

CONCLUSION

In the light of a physician's daily stress, SU appears to be a jeopardized resource that could significantly contribute to the prevention of burnout or other profession-related symptoms or illnesses.

Work climate perception and turnover intention among Korean hospital staff

AIM

To examine the impact of work climate perception (WCP) on turnover intention among public hospital personnel in Korea.

BACKGROUND

With increased competition and high staff turnover in hospitals, managers focus on human resource management. Positive work climate is considered as a strategy to retain valued staff, but previous studies have shown occupationally different relationships between turnover intention and work environment characteristics as perceived by staff.

METHODS

A cross-sectional questionnaire survey was conducted of employees (n = 852) in four public hospitals in Korea to gather information about WCP, intention to leave and demographics. The work climate was measured by 32 items categorized into 13 factors in five dimensions. For each occupation, logistic regression analyses were performed to determine the significant factors of WCP that influenced turnover intention.

FINDINGS

Positive WCP inversely influenced turnover intention. For all occupations, the most significant factor was 'workgroup friendliness and warmth' (OR = 0.01-0.21). For the nursing group, an additional significant factor was 'adherence to job standard' (OR = 0.63). In contrast, there were different significant factors for other hospital staff: 'workgroup esprit de corps' (OR = 0.16) and 'role clarity' (OR = 0.19) for physicians, 'adherence to job standard' (OR = 3.08) and 'role adaptation' (OR = 2.23) for paramedicals, and 'flexibility and innovation' (OR = 0.14) and 'interdepartmental cooperation' (OR = 0.19) for administrators.

CONCLUSIONS

Nurses with perceptions of work climate emphasizing 'workgroup friendliness and warmth' and 'adherence to job standard' had lower turnover intention. Physicians, paramedicals and administrators have different WCPs. To retain qualified personnel, hospitals should focus on human relations, maintaining a consideration for occupation-specific characteristics.

Medical teaching in rural Australia: should we be concerned about the international medical graduate connection?

The two rural workforce strategies of rural clinical schools and deployment of international medical graduates (IMGs) geographically overlap in Australia's large expanse of under-served rural and remote areas. We used the Rural Clinical School of Western Australia (RCSWA) as a model to examine the relative numbers of IMG clinical academics, and the contribution of IMGs to rural clinical school development and education. IMGs have established six of 10 rural clinical school sites, maintained an academic presence, and continue to staff the RCSWA in high proportions. In a fragile rural work ecology, WA's IMGs are contributing to both meeting current workforce needs and the education of future rural doctors. The "double debt" Australia owes to IMGs, stemming from the rich cross-fertilisation of these two workforce strategies, should be acknowledged.