Some of Australia’s most severe and protracted workforce shortages are in public sector community mental health (CMH) services. Research identifying the factors affecting staff turnover of this workforce has been limited. The purpose of this paper is to identify work factors negatively affecting the job satisfaction of early career health professionals working in rural Australia’s public sector CMH services.
In total, 25 health professionals working in rural and remote CMH services in New South Wales (NSW), Australia, for NSW Health participated in in-depth, semi-structured interviews.
The study identified five work-related challenges negatively affecting job satisfaction: developing a profession-specific identity; providing quality multidisciplinary care; working in a resource-constrained service environment; working with a demanding client group; and managing personal and professional boundaries.
These findings highlight the need to provide time-critical supports to address the challenges facing rural-based CMH professionals in their early career years in order to maximise job satisfaction and reduce avoidable turnover.
Overall, the study found that the factors negatively affecting the job satisfaction of early career rural-based CMH professionals affects all professionals working in rural CMH, and these negative effects increase with service remoteness. For those in early career, having to simultaneously deal with significant rural health and sector-specific constraints and professional challenges has a negative multiplier effect on their job satisfaction. It is this phenomenon that likely explains the high levels of job dissatisfaction and turnover found among Australia’s rural-based early career CMH professionals. By understanding these multiple and simultaneous pressures on rural-based early career CMH professionals, public health services and governments involved in addressing rural mental health workforce issues will be better able to identify and implement time-critical supports for this cohort of workers. These findings and proposed strategies potentially have relevance beyond Australia’s rural CMH workforce to Australia’s broader early career nursing and allied health rural workforce as well as internationally for other countries that have a similar physical geography and health system.
Cosgrave, C., Maple, M. and Hussain, R. (2018), "Work challenges negatively affecting the job satisfaction of early career community mental health professionals working in rural Australia: findings from a qualitative study", The Journal of Mental Health Training, Education and Practice, Vol. 13 No. 3, pp. 173-186. https://doi.org/10.1108/JMHTEP-02-2017-0008Download as .RIS
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Copyright © 2018, Emerald Publishing Limited
Health workforce shortages in rural areas are a global phenomenon (World Health Organisation, 2010). In countries like Australia and Canada, with large land masses and many small, widely dispersed rural communities, governments face significant challenges in providing adequate rural health services. A major contributing factor is chronic rural health workforce shortages arising from both recruitment and retention problems. With respect to workforce retention, job dissatisfaction is widely reported as a key influence on the turnover of professionals working in health and human services (Barak et al., 2001). This manuscript focusses on job satisfaction of health professionals working in public health services operating in rural and remote Australia. Cranny et al. (1992) defined job satisfaction as an individual’s positive emotional reaction to their job based on a comparison of the actual outcomes of the job with their desired or expected outcomes.
Health professionals working in Australia’s rural public health services face particular work challenges negatively affecting their job satisfaction (Buykx et al., 2010; Keane et al., 2012; WHO, 2010). Resourcing constraints are one of the major challenges – in particular, staffing shortages in allied health and nursing – as well as the operation of small teams that further reduce in size with increasing remoteness (Australian Institute of Health and Welfare, 2013a, 2013b; Buykx et al., 2010; Ceramidas, 2010; O’Toole et al., 2010). The effects of these resourcing challenges on Australia’s rural-based public sector health professionals relate to managing large workloads, handling high levels of responsibility and having to develop a broad-based set of clinical skills to cope with the diversity and acuity of client/patient presentations (Drury et al., 2005; Keane et al., 2012; Perkins et al., 2007). Managing these additional work demands and responsibilities can be very challenging, especially for less experienced health professionals and, in particular, for new graduates (Lea and Cruickshank, 2015). Compared to health professionals working in Australia’s major cities, widespread rural staffing shortages and budgetary constraints impose challenges on rural staff for attending continuing professional development (CPD) courses and career progression (Buykx et al., 2010; Crowther and Ragusa, 2011; Keane et al., 2012; Perkins et al., 2007).
Some of rural Australia’s most severe and protracted workforce shortages are in public sector mental health. Since the early 1990s, mental health service reform has been a major focus of Australia’s states, territories and federal governments, and they have been working together as the Council of Australian Governments (COAG) to implement changes under the National Mental Health Strategy (Australian Government, 2010). In 2011, COAG established Health Workforce Australia, which had as one of its strategic objectives mental health workforce reform (Health Workforce Australia, 2013). In more recent times, a national review of mental health programs and services has been undertaken by Australia’s National Mental Health Commission to help guide the major reform currently being implemented on the Australian mental health system (National Mental Health Commission, n.d.). The review found that access to mental health care in rural and regional communities was inequitable and attributed this to the skewed distribution of registered health professionals to metropolitan areas (National Mental Health Commission, n.d.). Within the mental health service sector, community mental health (CMH) services experience both critical staffing shortages and a high staff turnover (Health Workforce Australia, 2013; Moore et al., 2010). In rural Australia, public CMH services operate in both small and regional towns and are heavily relied on by those living with a serious and/or persistent mental illness (Perkins et al., 2013). Perkins et al. (2007, p. 9) argued that “excessive workforce turnover” in rural CMH teams has thwarted “improvements in access, quality and continuity of services”. Despite the importance of CMH services for Australia’s regional, rural and remote communities, to date, research identifying the factors affecting the retention of this workforce has been limited (Cosgrave et al., 2015a).
Australia’s public sector CMH workforce is multidisciplinary, and its non-medical workforce includes registered and psychiatric nurses as well as a mix of allied health professionals (Health Workforce Australia, 2013). Almost all CMH positions are case management roles with clients being individually case managed. The range of supports and activities provided by CMH professionals to clients is typically generic, rather than discipline-specific (Lloyd et al., 2004). The sharing of profession-specific skills tends to occur in client case conference team meetings (Fox, 2013). In an earlier related pilot study, undertaken by the authors with rural-based CMH service managers (Cosgrave et al. (2015b), the retention of early career staff was discussed as being a major workforce issue. For this study, “early career” has been defined as the first five years of working in health after completing tertiary level qualifications (Eley et al., 2012).
Retention-focussed CMH workforce studies have identified that work-related factors positively or negatively affect health professionals’ job satisfaction. These factors include: the therapeutic relationship with clients (Wilson and Crowe, 2008), feeling clinically effective (Onyett et al., 1995), team work and the multidisciplinary approach (Onyett et al., 1995), being given a comprehensive orientation (Buykx et al., 2010) and receiving regular clinical supervision (Ashby et al., 2013; Buykx et al., 2010; Perkins et al., 2007). Factors negatively affecting job satisfaction include: additional workload pressures arising from higher levels of client acuity and caseload complexity (Drury et al., 2005; Perkins et al., 2007), reduced numbers and types of community services available to support clients (Crowther and Ragusa, 2011), additional travel to see clients and/or to run outreach clinics (Perkins et al., 2007) and needing to provide mental health skills and expertise to other hospital departments (Drury et al., 2005). Gibb et al. (2003) and Drury et al. (2005) identified that unlimited or excessive caseloads had a negative impact on job satisfaction of rural-based CMH professionals. Managing personal and professional boundaries, particularly for health professionals who are long-term residents of the town they are working in, has also been identified as negatively affecting the job satisfaction of mental health workers (Gillespie and Redivo, 2012). These work challenges are mitigated for those rural-based CMH professionals who feel well supported by their colleagues, perceive their team as being cohesive and functional, and who feel well supported by their line manager and senior management, and that management understands the job challenges faced (Buykx et al., 2010; Moore et al., 2010; Onnis and Dyer, 2017; Perkins et al., 2007; Ragusa and Crowther, 2012).
CMH workforce research also identifies that for job satisfaction, forming and maintaining a discipline-specific identity is important (Ashby et al., 2013; Lloyd et al., 2002). This accords with broader health workforce research that identifies that health professionals tend to strongly define themselves by their profession and identifying their professional differences from other disciplines (McNeil et al., 2013). The formation of a professional identity usually begins at the university, as part of undertaking a profession-specific health course, and, after graduation, is reinforced through the provision of discipline-specific supervision and attending CPD courses, as well as profession-specific networking meetings and social events (Duckett, 2005). Allied health professionals working in rural mental health services, given their proportionally smaller workforce numbers compared to nurses, tend to have less access to discipline-specific role models, including the availability of on-site clinical supervisors (Lloyd et al., 2002).
This study aims to complement and extend the current understanding of health workforce retention in Australia’s rurally located CMH public services. It investigates the work factors affecting the job satisfaction of early career nursing and allied health professionals working in rural CMH services in the State of New South Wales (NSW). This manuscript is a component of a larger doctoral study investigating work and rural-living factors influencing turnover intention. The larger study adopted a constructivist grounded theory methodology and, through a coding process, developed a substantive theory explaining the turnover intention of rural-based early career CMH professionals (Charmaz, 2014; Cosgrave, Maple and Maple, 2018). For this manuscript, the grounded theory analytical approach ceased once categories and sub-categories had been identified.
The recruitment of participants occurred using a criterion sampling strategy. The participant inclusion criteria were: currently works in, or has recently worked in an NSW Health, CMH service operating in north-western NSW; meets the eligibility criteria set by NSW Health to work as a mental health professional; and has between one- and ten-year CMH work experience. NSW Health’s position description for a “mental health professional” was used to determine “eligible” health professions. This included: registered nurses, psychologists, occupational therapists, social workers and Aboriginal mental health workers (AMHWs). While the minimum level of professional qualification is usually completion of a Bachelor degree and registration or membership of a professional body, AMHWs are the exception. AMHWs are recruited as trainees under the NSW Aboriginal Mental Health Worker Training Programme and undertake embedded training over three years while in the workplace (Watson and Harrison, 2009). The study aimed to recruit participants from all the “eligible” health professions working as CMH professionals.
The study’s focus was on the experiences of early career CMH professionals; however, those with up to ten years CMH work experience were also included because of anticipated difficulties finding sufficient participants to meet the “early career” criteria, given the findings of the earlier pilot study (Cosgrave et al., 2015b). Participants who had five years’ plus CMH work experience were asked to reflect on their work experiences in their first five years. For this manuscript, participants with over five years’ experience have been termed “experienced”, while those with one to five years’ work experience have been defined as “early career”. AMHWs undertaking a three-year traineeship are classified as “early career”, and their first year of work after completing their traineeship is treated as their fourth year of working in CMH.
In the earlier pilot study, with increased service remoteness, greater staffing challenges were identified (Cosgrave et al., 2015b). As a result, this study aimed to include health professionals working in CMH services located in towns of differing sizes and varying degrees of remoteness. A town type classification system was developed using town population data from Australia’s 2011 census and the “Australian Standard Geographical Classification – Remoteness Area” (ASGC-RA). The ASGC-RA is based on the nearest road distance to an urban centre and includes five classifications: major cities (RA1), inner regional (RA2), outer regional (RA3), remote (RA4) and very remote (RA5) (Australian Bureau of Statistics, 2006). Small towns were classified as having populations of less than 20,000; medium towns from 20,000 to 30,000; and large towns between 30,0000 and 50,000 people.
University ethics approval for this research was gained from the University of New England Human Research Ethics Committee as well the two rurally located LHD Human Research Committees from which the participants were recruited. In total, 26 participants were recruited after group presentations were made by the first author at CMH team meetings. Two remote (RA4) towns were included in the study. These two services experienced chronic staffing shortages and had very few CMH staff, and hardly any staff who met all of the inclusion criteria. As it was a key aim of the study to include the experiences of health professionals working in smaller services in remote areas, it was decided that it was more important to collect data from these services than for the participants to meet all of the criteria. As a result, some loosening of the criteria was made. This resulted in the inclusion of a worker outside of the eligible professions (participant (P24) was an Aboriginal support worker), as well as participants with work experience outside the 1-10 year range (P25 had over 20 years working in his CMH position, and P26 was an “experienced” health professional, but had only worked a few months in her current position). For this manuscript, given its focus on CMH professionals’ job satisfaction, P24’s response has been excluded from the results.
Semi-structured face-to-face interviews were conducted by the first author over an 11-month period (July 2013-June 2014). On average, interviews lasted 1¼ hours. After each interview, the first author immediately transcribed the interview verbatim and applied pseudonyms. In line with grounded theory methods, a constant comparative method of data collection and analysis was used (Charmaz, 2014). NVivo 10 software (QSR International) was used to assist in the analysis process and to manage data. All three authors designed the study and the second and third authors validated the first author’s coding.
Participant and CMH service profiles
This manuscript includes 25 participants drawn from the full range of eligible CMH professions, 15 of whom were in “early career” and 10 who were “experienced” (see Tables I and II).
The participants worked in CMH services operating in nine rural towns located across north-western NSW (two large towns, one medium, six small). These nine towns covered three of the five remoteness area (RA) classifications: three inner regionals (RA2), four outer regionals (RA3) and two remote (RA4) (see Table III).
During coding of the interviews, the major categories affecting turnover were identified as “managing the job” and “adapting to the workplace”. The factors included under these two categories were: the job role, workplace relationships, access to CPD and availability of career-building opportunities. Given the broad range of factors associated with job satisfaction, it was considered an appropriate measure for discussing these factors.
The study identified five challenges negatively affecting the job satisfaction of early career rural-based CMH professionals. These were: developing a profession-specific identity; providing quality multidisciplinary care; working in a resource-constrained service environment; working with a demanding client group; and managing personal and professional boundaries. The challenges were found to be on a continuum and often heightened for workers in their early career years and/or working in small, more remote towns. This is discussed under each specific challenge (and summarised in Table IV).
Developing a profession-specific identity
Most participants spoke of strongly identifying with their particular profession and discussed the importance of continuing to develop their professional identity despite working in generic case management roles. Some participants described feeling pressured from management and/or from their team members to view themselves primarily as CMH professionals and to give up, or significantly lessen, their attachment to their profession-specific identity upon starting work in CMH, as P20 explains:
There was […] a social worker who started at the same time. […] she was probably only here a year if that. [She had] major personality clashes with the two senior nurses. I think you fit in or you don’t […]. I think, coming in as allied health [professional], I think it’s something you have to leave at the door. Yes, you do really and just walk in as a clinician. I think as a new grad, you come out with all these ideals about your discipline and what your discipline contributes and all of that. That was where she was coming from, and she was really fighting it at every team meeting, and she was just exhausted, and they were exhausted. I think of myself as a mental health worker. I think I’ve lost the OT
(occupational therapy) tag.
Many participants discussed the importance of developing a professional identity, and the significance of having access to regular profession-specific opportunities for networking and exchanging ideas. This was discussed as being particularly important in the early career years, as P12, in his second year of working, discussed:
Yep. I took that opportunity [to undertake professional training courses in a capital city]. The good thing about it was, at these trainings, there was usually a lot of other RNs, who worked in CAMHs [Child and Adolescent Mental Health]. And so, it was my only chance to meet other RNs who worked in CAMHs. Because there simply was none here.
In the larger, more centralised services operating in the inner regional areas (RA2), informal and formal mentoring (including clinical supervision from discipline-specific senior health professionals), most commonly occurred on-site, as P13, explains:
So here in X [an inner regional large town], I guess one of the positive factors in my retention would be that I’ve always had someone with whom I can physically walk two steps to get to their office and say: “This just happened”. Or even times, when I’ve had a client with me, I’ve left and just walked out and ran something by someone. And I’ve also had access to other social workers like Y and Z, like people in this actual building and I could just walk to their office.
In the smaller teams operating in the more remote areas (RA3 and 4), on-site discipline-specific support was uncommon, especially for the allied health professionals. For these participants, profession-specific support was usually provided by health professionals who resided out of the town, and clinical supervision mostly took place over the phone. In all the service sites, both allied health and nursing participants discussed experiencing delays in being assigned a suitable supervisor and their supervision sessions occurring less regularly than required, especially in their first year of work. The NSW Health (2007) supervision policy proposes that new graduates receive one hour per week and more experienced staff one hour per month. P7’s experience as a new graduate, early career staff member highlights some of these supervision issues:
Unfortunately, the person who was selected as my clinical supervisor initially was based in X [another town], and she didn’t have the same value or idea about how clinical supervision should work as I did. And so, for my first twelve months that I was there, I might have had supervision three times.
Allied health professionals working in the smaller teams operating in the more remote towns commonly discussed relying on profession-specific meetings or attending CPD courses to network with other discipline-specific health professionals. Experiencing significant impediments to attending CPD courses was discussed by nearly all the participants, and this was explained as relating to service-level budget constraints or cuts, requiring the participants to partially or fully self-fund their CPD training. As CPD courses are mostly run in Australia’s major cities, training costs tended to be high as they included course fees as well as transport and accommodation costs. P4 discussed her inability to attend CPD due to staffing shortages, as there were no staff available to back-fill her job. This situation was commonplace especially in the more remote towns, where CMH was often the only public sector mental health service available, and staffing the service was essential:
I know we keep talking about [a] lack of training and the funding and lack of resources and all that kind of stuff and that’s a built-in thing with us; it’s something we deal with every single day. But if you were to live in X [a major city], you would be able to take the afternoon off and go to training and it not cost you anything. And not have to worry about that this client is in crisis because they’d go to the crisis care team, not CMH.
Providing quality multidisciplinary care
Most participants were supportive of CMH’s multidisciplinary care approach and believed it offered, at least in theory, holistic mental health care. The usual way that multidisciplinary care happened was through weekly clinical review meetings at which clients were case conferenced. Less formal approaches, such as drawing on the expertise of other team members from different professions as and when required, were also mentioned.
To be able to provide effective multidisciplinary care, team sizes had to be large enough for there to be an adequate mix of professions. In some services, the mix of professions was described as being very limited, and this was nearly always the case in the smaller teams operating in the more remote towns. In these teams, the team size tended to be less than ten people and, in some services, fewer than five. Participants working in these small teams often described their team as comprising a mix of primarily early career allied health professionals, generally in their first or second years of working, as well as one or two long-term staff members, typically hospital-trained psychiatric nurses. Participants working in these teams described the medical model as tending to dominate the care approach, as P2 explains:
Starting in a workplace where you are working with nurses who have an idea that everybody does the same job. There were three fulltime RNs that I was working with at the time […]. It was quite challenging – well it still is challenging – trying to find out where I fitted as a social worker […]. On one of my first days, I said to one of the nurses: “So, is every client here on medication?” She looked at me kind of weirdly and said, “Well yeah!” And I’m thinking, “What do you mean?” Those kinds of ideas of a really strong medical model were really challenging. I felt this pressure to kind of conform to that.
A team’s ability to provide effective multidisciplinary care was also affected by relational issues and a lack of professional respect between team members. P7 discussed the negative impact that working in a small team of just two people had on client care, where the other team member did not support a multidisciplinary approach:
The nurse, […] she was very closed, [so] in those cases, in those mental health client’s care, there was no real multidisciplinary input, apart from the nurse and the doctor.
Some participants considered the ability to provide quality multidisciplinary care as being made difficult due to the constraints and demands facing rural-based CMH services. These included staffing shortages and a high demand for services, which usually meant that client allocation was determined on current caseloads and attempting to share the client load equally rather than matching clients’ needs to the most appropriate team member, as P7 explains:
There’s a big crossover, in the rural environment, between disciplines I guess, or the functions of clinicians. If someone specifically needed a type of psychological therapy, they would ideally be allocated to X, because she’s the psychologist. […]. But, if at those times when, you know, if I have 30 clients, and someone else only had 10, that person that needed a social work service might be allocated to the person with the smaller caseload. In which case, that person might consult with me about things, but would essentially perform a pseudo social work function with the client.
P4 described feeling frustrated because she only got to use her discipline-specific skills with her own allocated clients and not more broadly across the team. She described this as being a huge downfall of working in a rural service and believed it was something particular to rural practice and not something that occurred in the CMH services operating in the major cities:
I’ve talked to my supervisor in X [a major city] and other colleagues as well, and we talk about the psychologists working in teams outside of this area. Whilst they still work in multi-disciplinary teams too, within them it’s very clear what the role of an OT, social worker, or psychologist is within that team rather than being seen as being just like everybody else and doing the same work as everyone.
Working in a resource-constrained service environment
Most participants discussed the challenges of working in a resource-constrained environment. Budgetary and staffing constraints were discussed as negatively impacting workload and, in turn, job satisfaction. Some participants talked about feeling their workloads were much larger than of those working in CMH positions in the major cities, as their rural positions often involved having to provide additional services, with limited support. These additional services included such activities as providing mental health assessments for the hospital’s emergency department and/or running outreach clinics. These additional activities were discussed as taking up substantial amounts of time. Several participants spoke of having to manage large caseloads resulting from other team members leaving or long-term staff vacancies. Several participants discussed having caseloads that were, at times, over 40 adult or child/adolescent clients. P6, working in a CMH service situated in a small remote town, discussed commonly having a caseload of around 45 child or adolescent clients and described her workload as ridiculous. Affected participants’ described their workloads as unmanageable, feeling overworked and stressed, and this having a very negative effect on job satisfaction, as P9’s response highlights:
I was very stressed, that’s why I was looking for other jobs [laughs]. I wasn’t really looking for other jobs though, I think I was looking for distractions, just something to kind of take the pain away [laughs] […]. I think it was just the time management, you know, doing all of the groups, as well as the paper work, like all the computer work and the stats and seeing clients and fitting everything into a really limited kind of time frame. [As well as having] at one point […] 40 clients.
Working with a demanding client group
Most participants spoke of their CMH clients as having high levels of mental illness acuity, challenging behaviours and complex life situations. Supporting these clients was described as being difficult and stressful at times. However, notably, many of the same participants also spoke of drawing considerable job satisfaction from working with this client group. These participants discussed being strongly committed to trying to improve their clients’ well-being. The predominance of high acuity clients was also attributed to a general reluctance to arrange involuntary admissions under the NSW Mental Health Act (2007). This reluctance was especially so if the client would have to leave their home town, which was commonly the case for clients living in the small remote towns, as P25 explains:
We try to keep them out of hospital […]. To get a client from here, X to Y is traumatic for them and traumatic for us. Often the ambulances won’t take them, and they have to be “specialled”  overnight. And they [the hospital] are [usually] short-staffed, so they bring in Health’s security assistants.
Clients on community treatment orders (CTOs) were also described by some participants as being very demanding and significantly adding to workloads, as P4 relates:
Our CTO clients, obviously, the majority of them are non-compliant with medication. So according to the Mental Health Act, we have to follow certain procedures and protocols with that. And on a day when they are overdue with their medication, we would liaise with the police and ambulance to come with us to find this client out in the community somewhere. That could take six–seven hours of an eight-hour day and you’ve still got to fit in everybody else in that day as well.
The stress of working with a client group who often experienced poor outcomes such as self-harm, suicide attempts and inpatient admissions was frequently described by participants as taking an ever-increasing toll, both personally and professionally, and was associated with burnout, both actual and anticipated, as P18 explains:
Those complex cases affect us. If we have done a counselling session, and the next day we are hearing from the mother that he did self-harming or he tried to kill himself […]. One of the first things that would be going through our mind is that I’m not a good enough clinician, it must be my fault. […] There is always this guilty feeling we are worrying about it. Did I document that properly, does the documentation protect me? All these thoughts. […] So, we are carrying all of this into our personal lives, and if you have three or four complex cases, then you won’t be happy on weekends [laughs].
Managing personal and professional boundaries
An important responsibility for all CMH professionals is to protect client privacy and confidentiality and to maintain professional and personal boundaries. Most participants spoke of finding this challenging, given that personal relationships and professional roles tended to overlap living and working in rural towns. These challenges increased the smaller the town and/or the better-known, the health professional in the community, as P21 explained:
It’s harder to maintain the privacy, and confidentiality like in terms of people go: “Oh how do you know him?” or “How do you know that person?” or “Do you know them?” Because it is a small town everyone kind of knows everyone, so people kind of figure it out.
While personal and professional boundary issues were something all CMH workers spoke of having to learn to manage, boundary setting was found to pose additional difficulties for the AMHWs, as P8 explained it was not the cultural norm in Australian Aboriginal culture:
As Aboriginal mental health workers […] we just don’t knock off at 4.30-5 o’clock at the end of the day. If we see a community member, we can’t say, “No sorry, it’s five o’clock”. That stuff doesn’t fly in Aboriginal communities, you don’t say no to people and expect them to be okay about it. You’ve got to give them something, you know, or help in some way.
While protecting client privacy and maintaining personal and professional boundary issues were ongoing concerns, participants spoke of these being much more problematic at the start of their employment, and that over time, it got easier as they found ways to manage. This involved having strategies in place for handling the allocation of clients who were known to them personally or when meeting their clients on the street or in social situations.
These findings identify the key factors negatively affecting the job satisfaction of rural-based, early career CMH professionals, and provides a more nuanced, in-depth understanding of these factors. Developing a professional identity was found to be very important for all CMH staff, regardless of their discipline, but of particular concern in the initial years of early career (Ashby et al., 2013; Lloyd et al., 2002). Given this, having regular opportunities to participate in discipline-specific networking and/or CPD activities with other early career professionals was identified as being extremely important for job satisfaction (Crowther and Ragusa, 2011). In line with previous reports, a lack of respect and understanding between staff members from different disciplines sometimes resulted in early career staff being the targets of workplace hostility and bullying from longer serving staff members (Ashby et al., 2013; Lea and Cruickshank, 2007; Lloyd, King, et al., 2002). Widespread staffing constraints commonly resulted in there being little capacity to match clients’ needs to the most appropriately skilled team member, thus limiting the opportunities for rural-based staff to use their discipline-specific skills. Allied health participants were observed to experience additional challenges relating to the development of their professional identity and in providing multidisciplinary care, particularly if working in small remote towns.
Working in a rural CMH service was confirmed as being stressful and demanding due to the heightened mental health acuity of clients and limited availability of other service supports. This had a cumulative negative effect on job satisfaction, which supports previous findings (Drury et al., 2005; Perkins et al., 2007). In this study, the major factor negatively affecting job satisfaction was large caseloads (Drury et al., 2005; Gibb et al., 2003). While accepting that client numbers are a crude indicator of workload, it is still considered valuable to discuss caseload sizes. A number of participants had caseloads that were well above the recognised average adult caseload size of 20 clients (King, 2009), and these resulted from a high staff turnover and/or long-term staffing vacancies (Ceramidas, 2010; Ragusa and Crowther, 2012). Personal and professional boundary issues were confirmed as being a service-specific challenge experienced by all rural-based CMH staff but posing greater challenges for those working in the small, more remote towns and who were strongly connected to community. This usually concerned early career staff who were working in their hometowns (Gillespie and Redivo, 2012). In rural CMH services, AMHWs were found to experience the greatest personal and professional boundary challenges, given this clashed with Australian Aboriginal cultural norms (Cosgrave, Maple and Hussain, 2018).
In summary, many of the factors identified as negatively affecting the job satisfaction of rural-based early career CMH professionals are well recognised in research. The study’s findings suggest that collectively these factors have a negative multiplier effect on job satisfaction for those in early career years. This multiplier effect is a likely explanation for the high levels of job dissatisfaction and turnover experienced by this cohort of CMH workers. While the findings focus on the work challenges experienced in the early career years, the study found that these challenges affect all rural-based CMH professionals, although to a lesser extent among the more “experienced” staff. These challenges were also observed to be heightened for CMH staff working in small towns in the more remote geographical areas (RA3 and RA4).
The findings highlight the need to provide time-critical supports to address the challenges facing rural-based CMH professionals in their early career years in order to maximise job satisfaction and reduce avoidable turnover among this cohort. Having supports in place from the outset is of importance for all early career CMH professionals and especially for those who are working in small, remote towns. Suggested strategies for improving job satisfaction among rural-based CMH professionals in their early career years include: ensuring regular clinical supervision with a discipline-specific supervisor; providing in-house training for learning to manage professional and personal boundary issues; ensuring funds are budgeted to cover CPD training and associated travel costs; enabling back-filling of positions to support staff to undertake training and opportunities for networking; and working to ensure workloads and caseloads are, and remain, reasonable by promptly recruiting vacancies and engaging agency staff until vacancies are filled.
While it is likely that these findings have relevance beyond the scope of this study, some limitations require noting. First, the reliance on the early career reflections of experienced health professionals who had been working in CMH for over five years, rather than only those experiencing their first years in practice is limited by recall bias. This was particularly the situation for the limited participants from RA4, as was the need to loosen the inclusion criteria for RA4 participants.
Overall the study found that the factors negatively affecting the job satisfaction of early career rural-based CMH professionals affect all professionals working in rural CMH, and these negative effects increase with service remoteness. For those in early career, having to simultaneously deal with significant rural health and sector-specific constraints and professional challenges has a negative multiplier effect on their job satisfaction. It is this phenomenon that likely explains the high levels of job dissatisfaction and turnover found among Australia’s rural-based early career CMH professionals. By understanding these multiple and simultaneous pressures on rural-based early career CMH professionals, public health services and governments involved in addressing rural mental health workforce issues will be better able to identify and implement time-critical supports for this cohort of workers. The authors consider the findings and proposed strategies for improving job satisfaction, as potentially having relevance beyond NSW rural CMH services, to the broader early career nursing and allied health workforce in rural Australia, and also, internationally, to rural health workforces in countries with similar physical geography, population distribution, political and health systems, such as Canada. The authors consider testing the generalisability of the findings and effectiveness of the strategies for improving job satisfaction to be important areas for future research.
Participants by profession and career stage
|Participant (P) – profession /career stage||Registered nurses||Social workers||Psychologists||Occupational therapists||AMHWs||Othera||Total|
P12, 14, 22
P1, 2, 7, 13
P16, 23 (trainee)
P3, 8, 11 (graduate)
P9, 19, 21
Notes: aA diversional therapist with a Bachelor of Applied Science had previously worked in a case management position for three years in her early career in the same CMH service she was currently working in. **Two trainees and three graduates
Participant characteristics and town descriptors
|Participant by interview order||Health profession||Experience level||Town descriptor|
|1||Social worker||Early career||RA3, small town|
|2||Social worker||Early career||RA3, small town|
|3||Aboriginal mental health worker||Early career||RA3, small town|
|4||Psychologist||Early career||RA3, small town|
|5||Occupational Therapist||Experienced||RA3, small town|
|6||Psychologist||Early career||RA3, small town|
|7||Social worker||Early career||RA3, small town|
|8||Aboriginal mental health worker||Early career||RA2, large town|
|9||Registered nurse||Experienced||RA2, large town|
|10||Occupational therapist||Experienced||RA2, large town|
|11||Aboriginal mental health worker||Early career||RA2, large town|
|12||Registered nurse||Early career||RA2, large town|
|13||Social worker||Early career||RA2, large town|
|14||Registered nurse||Early career||RA2, large town|
|15||Diversional therapist||Experienced||RA2, large town|
|16||Aboriginal mental health trainee||Early career||RA2, large town|
|17||Psychologist||Early career||RA2, large town|
|18||Social worker||Experienced||RA2, large town|
|19||Registered nurse||Experienced||RA2, large town|
|20||Occupational therapist||Experienced||RA2, medium town|
|21||Registered nurse||Experienced||RA2, medium town|
|22||Registered nurse||Early career||RA2, medium town|
|23||Aboriginal mental health trainee||Early career||RA4, small town|
|24||Aboriginal health worker (no tertiary qualification)||Not included in this study|
|25||Psychologist||Experienced||RA4, small town|
CMH services by remoteness and town size
|CMH services – remoteness area/town type||Inner regional area (RA2)||Outer regional area (RA3)||Remote area (RA4)||Total|
|Large rural town (population over 30,000<50,000)||n=2||2|
|Medium rural town (population between 20,000-30,000)||n=1||1|
|Small town (population < than 20,000)||n=4||n=2||6|
|Total number of town types||3||4||2||9|
Identified categories and sub-categories
|Challenge category||Particular challenges|
|Developing a profession-specific identity||Tension between professional identity and working in generic case management position|
|Limited availability of profession-specific support (especially for allied health professionals)|
|Reduced access to CPD training|
|Providing quality multidisciplinary care||Recruitment and retention issues and small team sizes resulting in insufficient mix of professions and a limited range of clinical experience|
|More experienced staff sometimes set or limit the care approach taken by the team|
|Client allocation determined on staff’s current caseload size not clients’ needs|
|Underutilisation of discipline-specific skills|
|Working in a resource-constrained service environment||Required to provide additional services|
|Larger than average caseloads size arising from chronic staffing shortages|
|Working with a demanding client group||Clients have very high levels of mental illness acuity|
|Workload increased as reluctance to arrange involuntary hospital admissions|
|Workload intensified from having clients on CTOs who are very demanding and time consuming|
|Stress is cumulative from working with clients who experience poor outcomes|
|Managing personal and professional boundaries||Overlapping professional and personal relationships|
|Cultural clash issues for AMHWs|
In 2014, following the election of a new Federal Government, Health Workforce Australia was closed down and its essential functions were transferred over to the federal government’s Department of Health.
In this manuscript, the term “regional, rural and remote” includes any areas outside of Australia’s major cities and use of the term “rural” from herein should be considered to include regional and remote, unless otherwise specified.
NSW is Australia’s most populous state, situated on its eastern seaboard.
NSW Health is responsible for public health care of NSW residents. This occurs through the operation of local health districts (LHDs). There are 15 LHDs operating, and 7 are situated in rural NSW.
The NSW Mental Health Act (MHA) (2007) makes provisions for the mental health care of people who are admitted to hospital voluntarily (informal patient); are admitted to, or detained in hospital against their wishes (involuntary patient); are required to receive treatment under a community treatment order (CTO); and those who have committed a serious offence and are mentally ill (forensic patient). Most clients using CMH services are non-MHA clients, and only a small number of clients are on CTOs.
Assigned an individual staff member to provide one-on-one care.
A CTO is a legal order made by the Mental Health Review Tribunal, providing for community-based treatment as an alternative to involuntary hospitalisation. It requires a person to accept medication, therapy, rehabilitation or other services for up to 12 months.
This and other challenges uniquely affecting the job satisfaction of AMHWs were identified in the broader study, and these have been published in a separate paper (Cosgrave, Maple and Hussain, 2018).
Australian Standard Geographical Classification – Remoteness Structure
Aboriginal mental health worker
Community mental health
Continuing professional development
Community treatment order
Local Health District
Mental Health Act
New South Wales
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The authors acknowledge the CMH professionals who generously gave their time to participate in this study and the NSW rural LHDs that approved its undertaking.
About the authors
Catherine Cosgrave is a Research Fellow at the School of Rural Health, University of Melbourne, Wangaratta, Australia; and School of Health, University of New England, Armidale, Australia.
Myfanwy Maple is based at School of Health, University of New England, Armidale, Australia.
Rafat Hussain is based at Medical School, Australian National University, Canberra, Australia.