Analyses of interview data revealed a range of supportive workforce strategies that were already being implemented, and strategies for additional potential workforce improvements at the study site. We also briefly outline the enabling conditions which supported the implementation of these strategies.
Strategies
All identified strategies fall under the overarching categories of Strengthening Workforce Stability, Having Strong Leadership, Growing Capacity, and Working Well Together. These strategies can be built on into the future to help maintain and strengthen the workforce.
Strengthening Workforce Stability
Whilst the ACCHS had a stable General Practitioner (GP), IHW and senior management workforce, it experienced a high turnover among nursing staff, and a need for additional male IHWs. To address nurse workforce turnover, participants suggested improved Continuing Professional Development (CDP) planning and opportunities and appropriate leadership for nurses.
“one of the difficulties over that time is being able to establish enough of an RN (registered nurse) support workforce… that’s probably the area where there’s been more attrition.”
To achieve workforce stability, participants also cited a need for staff to understand and agree with the values and philosophies of community control and comprehensive primary health care (PHC) and to have the right skills and experience.
“I think that we’ve gotta be really careful for what we shop for… because I think we’ve for too long put bums on seats and that’s cost us greatly… I think that that person needs to be infused with our way… and really get the philosophy of community control”
Stability in the workforce was supported through the work conditions provided to staff. Positive work conditions included generous flexibility in roles and responsibilities, study support and training opportunities, leave conditions, and work schedules to account for changes in personal circumstances.
“I undertook my diploma… I done it here based in Yarrabah… luckily Gurriny has… Thursday afternoons (for professional training and professional development) and luckily my training fell on Thursdays so it just worked out well over that year”
Staff also identified supportive benefits such as extra paid leave over the Christmas break, more paid study leave than industry standards, additional paid funeral leave and a paid day off on birthdays.
“even though you get so sick, you use up all your sick leave, you use up all your holidays, they still support you”
Participants suggested improvements to work conditions such as assuring that pay rates were consistent with roles, responsibilities and award rates, providing annual salary increases, and reconsidering the award wages for Health Workers and Nurses.
“a lot of them are still sitting on the same wages as before”
Also suggested were strategies to further enhance work conditions such as through ensuring that all staff had support in their daily responsibilities from a team or other staff member; increasing the regularity of Rostered Days Off (RDO’s), defined as an additional day in a roster period that an employee does not have to work [34], to once a fortnight as previously allowed, to support staff wellbeing, motivation and energy levels; and sharing responsibilities among staff to reduce work pressure.
“R-D-O’s, we have it once a month and I think that has kind of impacted on some of our staff. Myself, I am starting to get really tired… at least when we had (RDO’s) once a fortnight, you know you had time.”
While improvements in work conditions was an important theme, a number of participants identified a lack of awareness among some staff members of the relatively positive work conditions provided by Gurriny in comparison with conditions frequently provided in the health care sector. This suggested a need for greater understanding and appreciation of comparative conditions in the sector.
“I don’t think the workforce actually… appreciate how lucky they are. The… conditions that they have, that they’re offered here are out of this world compared to mainstream.”
Having Strong Leadership
Strong leadership is essential for a strong and stable workforce. Strong leadership was demonstrated at the service through clarity and direction provided by stable leaders. Strategic vision and direction has steered the service forward via understanding of the broader Indigenous PHC funding and policy contexts. The service has also had stable clinical leadership with an understanding of the needs and challenges of the medical workforce and has provided the support and guidance needed.
“the Senior Medical Officer role is not just to be in clinical governance, but is absolutely supporting that medical workforce and putting all the enablers around that so that they can practice efficiently… to mentor and supervise the group of doctors”
The clarity and direction of organisational leadership could be strengthened by creating profession-specific leadership positions for both nurses and IHWs to ensure these roles are supported by leaders with the appropriate knowledge, skills and experience.
“just like we have a Senior Medical Officer for the doctors, I think the nurses need like a Nursing Manager or a Team Leader”
More clearly distinguished lines of leadership and greater clarity in leadership responsibilities and role boundaries could be achieved by creating team leader positions to simplify chains of command and address the issue of managers’ managing too large or multiple teams. Also, participants cited a need to clearly define the boundaries of senior management roles and responsibilities.
“some roles go outside of where they should be sitting as well. The S-M-T (Senior Management Team) should be more defined in their responsibilities.”
Strategies supporting strong leadership included senior managers have an open-door policy and middle managers being very responsive. There is also a formal system for responding to staff conflicts. However, participants suggested that further formal processes and opportunities could be created, and greater efforts put into creating a workforce culture that encouraged staff input into decisions and strategic direction.
"there’s lots of great things going on, but there’s no consultation. Like with the whole organisation, to be a great leader you’ve gotta include your staff in decision making and feedback”
Strong leadership is also about bringing staff along on the journey of organisational growth and improvement by communicating about and including staff in the strategic direction and decision making of the organisation. This is supported through the organisations operational management forum, which is designed to include operational managers in the broader strategic direction so they can better understand and share that understanding with their teams.
“the middle managers… they’re able to be a part of understanding the strategic direction of the Board, filtered down to them from the Senior Management Team… then at least could share back with their team members, where we’re heading and why some of the decisions were being made, what directions were happening.”
Participants suggested that leaders could support staff to better understand the broader Indigenous PHC and ACCHS sector contexts, as well as policy, funding and regulation contexts and how these impact on and limit what an individual service can do. For instance, some staff expressed a tension between the drive for local leadership and the need for professionals with the knowledge, skills and experience to understand that broader context. Staff members’ understanding of comprehensive, holistic primary health care and the role of Social and Emotional Wellbeing services in this model of care could also be strengthened.
“my understanding was okay, well it’s community-controlled, community-driven, a hundred per cent local staff. But no… so when community heard about Gurriny’s going into community control, they didn’t make it clear what is community control”
Finally, participants said that leadership is supportive by being available and approachable, providing encouragement and positive feedback to staff, and having rewards and incentives.
“whoever worked well… that team will get a certificate for working well... so that inspires us to keep up the good work… That sort of really boost us up and help us”
Leaders also encourage innovation and flexibility among staff by encouraging change positivity as well as promoting creativity and innovation in program design and delivery.
“the beauty of working here was the creativity. They said basically, this is it. You can go for it... we could be free to reinvent what Queensland Health had just said, ‘this is how your care’s going to look.’”
However, leaders could do more to encourage staff members to share and implement ideas and solutions, and to provide encouragement and positive feedback in both formal and informal ways to ensure that staff feel valued.
“I think that we can then sit down and say, ‘well how about let’s jump out of the box. Let’s just take this to a whole new level.’”
A member of the senior management team reflected at the research feedback session that Gurriny’s leaders could do more to enhance communication mechanisms with staff. Suggestions included an open email circulation of the findings of the research, and an active notice board for two-way communication of issues and suggestions.
Growing Capability
To strengthen the workforce there is a need to build the capability and capacity of staff. Strategies already being implemented to grow up the local health workforce are focused on providing opportunities to build the knowledge, skills, experience and capacity of local staff. These strategies include: supporting IHWs to gain qualifications; providing scholarships to support professional development and paid study leave; allowing trainee entry points; supporting staff to present at and attend conferences nationally and internationally; providing mentorship and staff education; and supporting leadership building opportunities.
"I think Gurriny is very big on professional development… Thursday’s we have professional development day, so there’s always something happening for us around professional development."
However, a strong desire was expressed by participants for further strategies to support strengthened local leadership, in particular, to increase the number of local Indigenous people in senior management positions. Suggestions included career progression pathways for local staff by creating more middle management and team leader positions, giving local staff a chance to move into leadership positions, and increasing wages with increased qualifications, experience and responsibility. Recognising and rewarding staff effort, determination and ambition is important to raise up the next generation of leaders. Also, strong succession planning was an identified need, including clear career progression pathways and systematic processes for staff to follow.
“We’ve been asking, ‘where’s the succession plan for this organisation?’… you’ve got young ones there that are energetic. That want to be in that leadership position, and they can do it as well. You know, these are local people… they should’ve identified… what skill-sets do they have? Are they able to work at that level now or how can we build their capacity say in the next five years?”
Local leadership could also be strengthened through enhancing health worker capacity. Suggested strategies included improving health worker training by situating the skills needed in their broader context and providing opportunities to apply the knowledge and skills learnt in training, or by supporting IHWs to become Health Practitioners. Finally, participants identified a need for greater clarity about the role of non-Indigenous staff in supporting local staff career progression and leadership capacity development. This could be achieved by establishing mentoring/role shadowing systems and building these into contracts and key performance indicators (KPI's).
"that’s why I sort of always advocate and say you know when we’re doing health checks and assessments, let the Health Workers do it to build their clinical skills up too. Because if they don’t, they’re gonna lose it"
Support for general development of staff capacity, both local Indigenous and non-Indigenous, is provided through having accessible in house and external training and education opportunities in Yarrabah and Cairns as well as paid or unpaid study leave; the creation of middle management positions to support career progression pathways; and developing senior and operational management skills and capacity.
“So these training were offered in Yarrabah which was made accessible and easy to attend”
Strategies to better support the development of staff capacity included ensuring that the approval of training and professional development requests were fair and equal and supporting nurses to maintain clinical skills and professional requirements through sufficient CDP planning and activities.
“I feel that my skill set has definitely deteriorated since I’ve been here.”
Working Well Together
Finally, a strong and stable workforce requires strategies that support a positive work culture where staff members work well together, and feel good in the workforce. Staff members were supported to work well together through clear communication and information sharing systems and processes such as regular team and all of staff meetings, having team plans with matching KPI’s, effective email communication, and utilising the Operational Management Forum to communicate and share information across the organisation.
“each Monday, we come to work, eight o’clock we have our meeting with everyone, all Health Workers, all doctors, all nurses… and then when we come away, then the doctors and the nurses stay behind for their meeting. And our team- the Care Coordination team, we have our meeting down at the back… then at least we will know what each one is doing”
However, there is a need for improved information sharing between staff, teams and management about services, work conditions and benefits, others’ roles and responsibilities, and professional development and training opportunities. Suggested strategies included the provision of clear guidelines and instructions; longer, more in-depth induction training to teach the ACCHS philosophy and model of care; and clarifying staff expectations around roles and responsibilities as well as benefits and entitlements, such as training, leave and registered days off. These strategies could be facilitated by increasing transparency from senior and operational management and having regular meetings with an open agenda focused on giving staff the opportunity to raise and discuss workplace issues. A staff member present at the research feedback session also suggested that staff understandings of the philosophy of community control could also be usefully enhanced by incorporating within the staff induction process a history of what motivated Gurriny’s transition to community control, the process entailed in that transition, and the outcomes.
“our induction processes… I think it’s over a day. And I think it just needs to be over a week and I think that that person needs to be infused with our way… and really get the philosophy of community control”
Staff work well together when there is cohesive team culture in which people get along. Participants noted that Gurriny staff are there for one another, help each other out, are kind to one another and are understanding of personal context. They get past personal differences and maintain respect and professionalism. In multidisciplinary teams, staff from all different positions and programs, Indigenous and non-Indigenous, share knowledge, skills and experience. The ACCHS supports this process through creating opportunities for cross-organisational bonding, including formal and informal whole of organisation and team/program specific team building events.
“I really think that everyone has respect for one another. I think everyone, they do well to come to work and put their differences aside. Everyone always works towards positive outcomes, regardless of whatever issue”
The ACCHS workforce could be further supported to work well together by clarifying expectations and understandings of the impacts of personal circumstances, as well as creating processes to work through and overcome personal differences. There could also be improvements in encouraging and facilitating staff members to work outside of role and program boundaries and to better integrate clinical and social and emotional wellbeing (SEWB) programs and services, as well as efforts to create further opportunities for cross-organisational bonding.
“you’ve gotta kind of have a sense of… how other people operate in your space. When you assume that a person maybe is not doing their job properly or is undermining you, it’s not at all, it’s just that they’re coming from it from a completely different angle.”
Enablers
Enabling conditions were also identified for implementing the four strategies 1) Strengthening Workforce Stability; 2) Having Strong Leadership; 3) Growing Capacity; and 4) Working Well Together. Briefly, the key enabling conditions for developing a strong ACCHS workforce occurred at macro, community, organisational and individual levels. Macro-level enabling conditions include national and international movements and discourses of Indigenous self-determination and community control as well as government commitment and support for the transition to community control. Enabling conditions at the community level include local ownership and control of PHC service and social and cultural dynamics, norms and systems.
“at the Senior Management level… (Gurriny has) six and three of them are Indigenous. Plus you’ve got your Board as well. And then the Operational Management level, at this point in time, every Manager is Indigenous.”
At the organisational level, enabling conditions include Gurriny’s process of organisational growth from before, during and after transition to community control; strong local governance; holistic, comprehensive trauma-informed and family-centered model of care; flexibility in service delivery; as well as increases in senior and middle management positions to support organisational growth.
“our model of care, we’re looking at it being culturally appropriate. We’re looking at it being a preventative right through to acute. It’s counselling services, it’s Mental Health, it’s Child Maternal health etcetera, but also, we’re trying to broaden out the model of care to describe how the interaction between the staff operates”
Finally, on the individual level, enabling conditions included strong professional boundaries, change positivity, staff motivation and commitment, strong local leadership and a large percentage of local, Indigenous staff who are motivated by a strong responsibility to improve the health and wellbeing of the Yarrabah community.
“It’s not just about being paid… it’s about these people. The rest of our mob out there. We have close family members that we need to help”.
Enablers at all four levels were required to optimise implementation of the strategies outlined above.