Introduction
Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Indigenous) peoples in Australia experience many inequities in health outcomes which could be addressed by better access to effective and appropriate primary health care services [
1]. However, Indigenous people face several barriers to accessing health care, including cost of healthcare, transport and location barriers, language barriers, and barriers due to a lack of cultural safety in many healthcare services [
2]. Indigenous primary healthcare (PHC) services play an important role in overcoming these healthcare access barriers through the provision of culturally appropriate comprehensive primary healthcare [
3]. However, to be able to meet the healthcare needs of Indigenous peoples, Indigenous PHC services need strong and stable workforces.
Indigenous PHC services depend on their workforce, and international studies have found that efforts to make care more effective, efficient, patient-centered and integrated are usually made or broken by employees [
4]. However, the efforts of Indigenous PHC services to provide consistent quality healthcare service delivery to their clients can be impeded by key challenges relating to the health workforce. There are system wide shortages of healthcare professionals, particularly in regional and remote locations (e.g. [
5]) with issues related to staffing levels, retention and turnover being identified as some of the top challenges experienced by Indigenous PHC services nationally [
6].
The National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework 2016–2023 identified six priority areas for building a strong and supported health workforce. These are: 1) improving recruitment and retention of Aboriginal and Torres Strait Islander health professionals; 2) improving workforce skills and capacity; 3) supporting the sector to provide culturally-safe and responsive workplace environments; 4) increasing the number of Aboriginal and Torres Strait Islander students studying for qualifications in health; 5) improving completion/graduation and employment rates for Aboriginal and Torres Strait Islander health students; and 6) improving information for health workforce planning and policy development [
6]. However, many Indigenous PHC services struggle to implement these priorities [
7]. A systematic review found that barriers to Indigenous health workforce retention include systemic factors such as limited organisational funding and inadequate remuneration and limited career pathways; organisational factors such as heavy workloads and demands, lack of support from management and lack of mentoring, and professional development opportunities; and proximity to community on the individual level [
8]. Factors that affect the engagement of Indigenous people with education, training and employment included racism, family and community responsibilities, stress, isolation and poor secondary education [
9].
A range of important strategies to support the sustainability and development of the Indigenous PHC workforce particularly in rural and remote areas have been identified in systematic literature reviews [
9‐
11]. Opportunities to develop professionals’ workforce skills and competencies through training, mentorship, accreditation and promotion are especially important for rural Indigenous PHC workforces. Other critical strategies include: fostering cohesive and harmonious workplaces through strong teamwork, support from colleagues and shared purpose and identity; strong leadership and management which provides effective supervision and supports effective communication across the organisations; and providing realistic and competitive remuneration [
9‐
11].
The engagement and retention of Indigenous health professionals in Indigenous PHC is a particularly important strategy. There is evidence that Indigenous health professionals can help to overcome key cultural and communication barriers for Indigenous people accessing health care [
8,
12‐
14]. For example, there is evidence to suggest that Aboriginal and Torres Strait Islander Health Workers (ATSIHW), otherwise known as Indigenous Health Workers (IHW), may help to improve attendance at appointments and acceptance of treatment and assessment recommendations [
9], reduce discharge against medical advice, increase patient contact time, enhance patient referral linkages, and improve patient follow up practices [
13]. Preliminary evidence also shows potential for IHWs to improve diabetes screening [
15,
16] and care management processes [
17,
18], as well as palliative care [
19] and maternal and infant care [
20].
While there is no nationally consistent definition of an IHW or ATSIHW, generally an IHW is a person who: 1) identifies as being of Aboriginal and/or Torres Strait Islander descent; 2) holds an Aboriginal and Torres Strait Islander Primary Health Care Qualification; and 3) adopts a culturally safe and holistic approach to health care [
2]. IHW’s play an essential and unique role in Indigenous PHC services. Their roles encompass a range of comprehensive PHC activities including assessment, intervention, health promotion, disease prevention and chronic disease management, with IHW roles often adapted to local needs and contexts. IHW’s are also play a crucial role in providing culturally safe care to clients through advocating for clients, explaining their cultural needs and educating other healthcare professionals. Indigenous health professionals support non-Indigenous health professionals to provide culturally appropriate care through providing cultural, social and community mentorship and education, acting as cultural brokers, helping to increase patient trust and safety and therefore improving care [
8,
9,
12,
13,
20].
However, Indigenous Australians in general are under-represented in the health workforce, and IHWs, in particular, have high turnover rates [
8]. While there has been an overall growth in the number of IHWs between 2006 and 2016, this growth has not matched the population growth of Aboriginal and Torres Strait Islander peoples leading to concerns that little is being done to increase recruitment and retention of this workforce [
21]. IHW career development pathways have also been limited by significant variation in IHW roles, scopes of practice, education and career pathways [
14].
The engagement and retention of Indigenous health professionals has been supported by co-worker support and peer mentorship; inclusiveness and cultural safety in the workplace and culturally competent human resources policy and practice; access to clinical and cultural supervision; clear definition of roles and enhanced role recognition; job security and adequate remuneration; and support for expanded roles and strong career pathways [
8,
9,
11]. Career pathways have been enhanced through explicit and appropriate training and education pathways and strategies that allow for a combination of formal education and training as well as cultural guidance and support, or learning through mentoring and work shadowing [
8,
9,
11]. For non-Indigenous professionals in Indigenous PHC in particular, additional factors which impact on their longevity and effectiveness in rural Indigenous PHC include cultural competence, clinical experience, qualifications and skills and perceived connection with the local community and Aboriginal colleagues [
9].
This paper reports a qualitative exploration of the workforce strengths and challenges of one ACCHS. An ACCHS is defined by the National Aboriginal Community Controlled Health Organisation (NACCHO) as an incorporated Aboriginal organisation, initiated by and based in a local Aboriginal community, governed by an Aboriginal body which is elected by the local Aboriginal community and delivering an holistic and culturally appropriate health service to the Community which controls it (NACCHO, 2012 in [
22]). Established as advocacy services in the 1960s and 1970s in response to the poor health of Indigenous people and communities and failure of mainstream services to provide adequate health care, and enabled by government policies and funding, ACCHSs are an essential part of the Indigenous PHC sector and are considered crucial in driving efforts to close the gap in Indigenous health outcomes in Australia [
22,
23]. ACCHSs address health inequalities by providing a culturally appropriate alternative to mainstream medical services [
24] and reducing healthcare access barriers for Indigenous people [
3]. ACCHSs have been pioneers in comprehensive PHC [
25] and have demonstrated superior performance to mainstream services on a range of healthcare quality, performance and delivery outcomes [
3,
25,
26]. ACCHSs also play an important role in training and developing the health workforce, with approximately 50% of the ACHHS health workforce being Indigenous [
3].
The current study was undertaken in Gurriny Yealamucka Health Service (Gurriny), located in Yarrabah, North Queensland. Yarrabah is the largest discrete Aboriginal community in Australia. In 2014, management and accountability for PHC services in Yarrabah were transferred from Queensland Health (QH) to community control through Gurriny. In the 4 years post-transition, Gurriny grew employment of local people by more than 75% to improve culturally safe healthcare to Yarrabah’s 3472 clients, and achieved optimal practitioner to client ratios and workforce stability in some areas [
27,
28]. However, multiple funding sources with separate agendas and accountabilities created disjointed workforce planning [
29]. Gurriny management considered that further improvements were required in: Indigenous leadership, strengths, career development, wellbeing, competencies, roles/ professions, responsibility, control, accountability, liability, performance/contribution, retention, progression, and underpinning systems and processes. Such issues were the subject of this study. The key research question was: what are the enabling conditions and strategies for a best practice workforce model for one ACCHS. The findings from this study are discussed in the context of broader literature on workforce enhancement for Indigenous PHC and Indigenous health professionals.
Discussion
The strategies to strengthen the Indigenous PHC workforce found in this study reflect many of those established in the literature [
8‐
11].
Strengthening Workforce Stability, Having Strong Leadership, Growing Capacity, and
Working Well Together are broadly similar to the three multifaceted strategies found in our recent literature review: 1) enhancing recruitment and retention; 2) improving supervision, mentoring and support; and 3) strengthening roles, capacity and teamwork [
11]. They are also supported by the six priority areas of the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework 2016–2023 [
6]. In addition, this study identified several novel strategies to strengthen the Indigenous PHC workforce including ensuring profession specific leadership and providing opportunities for Indigenous PHC staff to have input into decision making. Workforce needs and challenges unique to the ACCHS sector are also discussed. This study outlined many positive and innovative strategies being implemented in Indigenous PHC to support staff professional development. It also reiterates the identified need for further efforts to build IHW capacity across these key areas.
Workforce stability is closely associated with workforce conditions. Inadequate remuneration is a systemic issue in Indigenous PHC where low salaries result from low, short-term and non-recurrent funding, especially in the non-government sector [
8]. Remuneration levels are a sensitive indicator of employee mobility in rural and remote health in general, therefore maintaining realistic and competitive remuneration is an important retention strategy [
10]. Adequate remuneration is a major issue particularly for IHWs who are more likely to have lower wages than other occupational groups [
8], with pay inequality noted as one of IHWs major frustrations [
35]. Suggestions to address this issue include IHWs organising together across Australia to increase award wages as well as organisations reviewing staff salaries and negotiating with funding bodies to ensure budgets provide appropriate remuneration [
8]. Other important strategies to support the stability of the Indigenous health workforce include culturally appropriate human resources management practices such as adequate leave provision for cultural commitments and those which support professional development such as subsidising study costs or allocating work time to study purposes [
8].
Strong leadership, expressed through clear communication and strong management and supervision, has also been identified as important for fostering effective and sustainable workplaces in rural and remote healthcare [
10]. Research on factors affecting workplace motivation for health and human services professionals has identified the importance of honest, open, appropriate and timely communication; a sense of being respected and valued; positive, regular, timely and specific feedback; and a clear direction from leadership [
36,
37]. Indigenous PHC leaders need to find ways to effectively communicate with staff about complex issues related to the Indigenous PHC and ACCHS sectors as well as ensure transparency and consistent and effective information sharing.
The importance of profession-specific leadership was a novel finding of this study. A lack of such leadership which understands the professional context, needs, experience and skills of groups of Indigenous PHC professionals can leave staff feeling unsupported in their roles and in the organisation. This study also emphasised the significance of Indigenous PHC leaders consulting staff and providing opportunities to have input into decision making. Involvement in decision making, has been shown to increase organisational commitment [
38]. This may be of particular importance for local staff who feel a sense of ownership in the ACCHS context which prioritises Indigenous self-determination.
Professional development opportunities in the form of training and education are important for growing the Indigenous PHC workforce capacity by developing both clinical and non-clinical skills and competencies [
8,
11,
39]. Innovative implementation of key strategies to support the development of staff capacity demonstrated in this study include the provision of on-the-job training and education through the employment of staff educators and providing internal in-service courses and training through a full afternoon dedicated to professional development weekly. Other studies have found that it is important that Indigenous PHC services support diverse training pathways by providing opportunities for both formal education and training as well as the more informal mentoring and work shadowing which may be more appropriate for Indigenous practitioners [
11]. Furthermore, professional development opportunities should be tailored to the need of the local health workforce [
39], supporting the development of specific skills and knowledge related to health programs and the needs of the intended patient group [
9], while also being relevant to career advancement for health professionals [
11]. This can be achieved through CPD plans which clearly establish professional development needs and goals [
8].
Professional development opportunities for IHWs may have improved over the last few decades [
35], however, this study identified ongoing issues such as IHWs not having opportunities to implement new learning in the workplace after the completion of training [
8,
35] and feeling underutilised in the workplace [
8]. Strategies to address these issues include enhancing IHW roles, providing greater opportunities to apply skills in practice, improving IHW training, and ensuring that IHWs have opportunities to work to their full scope of practice [
11,
39]. This is complicated by the substantial variation that exists in IHW roles, definitions, scopes of practice, education standards and career pathways [
14]. There is a need for clearer definition of roles and enhanced role recognition among IHWs to better support their professional development and career progression [
11,
14].
Another important area for Indigenous PHC workforce enhancement, particularly in ACCHSs, is in relation to career progression pathways for local staff [
8,
11,
39]. In rural and remote healthcare in general, opportunity for career advancement is an important catalyst for retention [
10]. The frustration experienced by IHWs in regard to lack of opportunities for career progression in both government and ACCHS sectors is well established [
35], with such limited career pathways causing some IHWs to look for work outside the health sector [
8]. This issue can be addressed through the development and implementation of succession plans and strong, clear career pathways [
8,
11,
39]. Providing recognition for increased qualifications by changing role descriptions and providing appropriate remuneration are also important strategies [
8].
In addition to strengthened career progression pathways for Indigenous staff, there is an identified need to provide opportunities for the development of leadership capability among the Indigenous workforce at all levels; from entry to leadership positions [
11,
39]. This study identified a strong sentiment in ACCHSs regarding the need to have more locals in leadership positions, particularly in senior management. One strategy to support this is mentoring. Yet, despite the recognised importance of mentoring [
8,
39] there is a limited literature documenting formal mentoring strategies in Indigenous PHC [
11]. Strategies to support local career progression and leadership capacity development at Gurriny were in the pipeline during this study, such as creating team leader positions. Overtime, the implementation of such initiatives could see a positive impact on this issue.
Working well together through a positive work environment, with friendly people and strong team was the final strategy to support a strong workforce [
36,
37]. Informal structures to support team work, such as debriefs and meetings, as well as strong team cohesion have been identified as critical factors in building a strong Indigenous PHC workforce [
11]. Mentoring and support from colleagues are particularly important for retention among Indigenous health professionals [
8]. Successful efforts to create a strong and cohesive work culture demonstrated in this study include those targeting the whole organisation through all in staff meetings and bonding days, as well as those to improve communication and cohesion targeting senior and operational management.
Literature on human resources management (HRM) perspectives can contribute to our understanding on workforce challenges facing Indigenous PHC [
40]. For example, HRM literature on psychological contracts offers a useful perspective to help understand why staff in Indigenous PHC services, and ACCHSs in particular, may feel frustrated or disappointed by the paucity of career progression and leadership opportunities for local staff. A psychological contract can be defined as “a set of individual beliefs or perceptions regarding reciprocal obligation between the employee and the organisation” (p. 57) [
41]. While some of these are formally recorded in a written contract, they are mostly implied and not openly discussed. Psychological contract violation occurs when there is a perceived failure to fulfil obligations or promises in the workplace [
41]. Such violation can lead to feelings of anger, distress, betrayal, resentment and a sense of injustice, which in turn can lead to job dissatisfaction and reduced organisational commitment, as well as negative impacts on role performance, and increased staff turnover [
36,
41]. The concept of psychological contract violation is a potentially powerful explanatory theory which can help to understand several of the workforce issues raised in this study, including: professional development opportunities; career progression; pay rates; and the ability to include decision making. For example, as one important area of potential psychological contract violation, participants suggested an expectation by some local staff that they would be promoted to leadership positions within the ACCHS [
41].
To overcome such violations, it is important that the perceptions of obligations and promises are shared between management and employees [
41]. There needs to be clear and honest communication of expectations and obligations of the employee, as well as the organisation, starting from recruitment and orientation. Regular performance reviews provide opportunities to dispel false beliefs regarding expectations as well as to agree upon future strategies for professional development [
41]. In the ACCHS context there needs to be clarity from the outset about what the organisation can do and what staff will need to do in order to progress to leadership roles, ie. minimum education or skill requirements for senior management roles. Further research into psychological contracts and psychological contract violations among Indigenous Health Professionals in Indigenous PHC, particularly for ACCHSs in discreet Aboriginal communities where there is an expectation of local leadership is needed.
The findings of this study largely reflect what is identified in the established literature on the workforce strengths and challenges faced by Indigenous PHC [
8‐
11] and therefore can be of value to other Indigenous PHC services looking to strengthen their workforce. They also provide insight into workforce needs and issues which may be unique and/or be of particular importance in ACCHS contexts. Further research into the workforce experiences and needs of ACCHSs in varied organisational and community contexts is required to understand if the findings of this study are relevant to other ACCHSs. Finally, considering that there are many similarities between the workforce needs and challenges of Indigenous PHC services and mainstream PHC services [
10] the findings of this study may be relevant to non-Indigenous PHC services providing healthcare to Indigenous Australians.
Limitations
While the findings of this study may hold relevance for other Indigenous PHC services, ACCHSs and the broader Australian PHC service sector, this study was undertaken with only one ACCHS therefore caution should be exercised when applying these findings to other contexts. Considering the important differences that exist in geographical, community and organisational contexts between different Indigenous PHC services, the results of this study may need to be tailored for relevance to other ACCHSs/IPHC services. Only 17 of Gurriny’s 76 staff were interviewed; however, they were representative of the diversity of the workforce Indigeneity, professions and roles. We acknowledge that there can never be complete analysis of data or that our explanatory theory or conceptual models can ever be absolute [
42] but consider that the rich data provided has led to a conceptually robust identification of the core strategies that support a strong Indigenous PHC workforce development.
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