Sustaining our rural allied health workforce: Experiences and impacts of the allied health rural generalist pathway

doi:10.21203/rs.3.rs-3577389/v1

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Research Article

Sustaining our rural allied health workforce: Experiences and impacts of the allied health rural generalist pathway

https://doi.org/10.21203/rs.3.rs-3577389/v1

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published 19 Jun, 2024

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Introduction: Rural and remote communities face significant disadvantages accessing health services and have a high risk of poor health outcomes. Workforce challenges in these areas are multifaceted, with allied health professionals requiring broad skills and knowledge to provide vital services to local communities. To develop the expertise for rural and remote practice, the allied health rural generalist pathway (AHRGP) was introduced to develop and recognise specialist skills and knowledge required for rural and remote practice, however the experiences of professionals has not been explored. This study gained the experiences and perceptions of allied health professionals undertaking the pathway as well as their clinical supervisors, line managers, profession leads and consumer representatives.

Methods: A qualitative study was undertaken drawing on pragmatic approaches across four research phases. This study was one component of a larger mixed methods study investigating the experience, impact and outcomes of the AHRGP across six regional Local Health Networks in South Australia. Interviews, surveys and focus groups were conducted to explore the perceptions and experiences of participants. Data was analysed thematically across participant groups and research phases.

Results: A total of 55 participants participated including 15 trainees, 13 line managers, nine clinical supervisors, six profession leads, four program managers and seven consumer representatives. Five themes emerged from the data; gaining broad skills and knowledge for rural practice, finding the time to manage the pathway, implementing learning into practice, the AHRGP impacts the whole team and confident, consistent, skilled allied health professionals positively impact consumers.

Conclusion: The AHRGP is offering allied health professionals the opportunity to develop skills and knowledge for rural and remote practice. It is also having positive impacts on individuals’ ability to manage complexity and solve problems. Findings indicated consumers and organisations benefited through the provision of more accessible, consistent, and high quality services provided by trainees. Trainees’ faced challenges finding the time to manage study and to implement learning into practice. Organisations would benefit from clearer support structures and resourcing to support the pathway into the future. Incentives and career advancement opportunities for graduates would strengthen the overall value of the AHRPG.

People living in rural and remote areas face significant inequalities in access to health care in comparison to metropolitan areas (1, 2). They also have a higher risk of experiencing disease and poorer health outcomes (3, 4). In Australia specifically, rural and remote populations experience wide ranging and complex health conditions over vast geographical areas with limited access to health professionals to support them (1). Previous studies have explored strategies to address workforce challenges in rural and remote areas, but these predominantly address doctors’ needs (5, 6). Medical and allied health professionals face different challenges and opportunities in relation to training, career advancement, supervision, organisational support and personal circumstances and different workforce strategies are required accordingly (7).

Allied health professionals working in rural and remote areas provide vital and wide-ranging services to local communities (8). Until recently there were limited opportunities for allied health to be recognised for advanced skills in rural and remote practice (9), along with career advancement opportunities and adequate retention strategies (10). There is increasing recognition that structured training and professional support assists rural and remote allied health professionals to develop and maintain skills that advance their careers (7, 9, 11). In the Australian context, the state of Queensland’s Health service paved the way for postgraduate training and workforce development initiatives by introducing allied health rural generalist training positions from 2013 to develop and recognise the specialist skills and knowledge required for rural and remote practice (12) and to improve workforce outcomes. Over the following four years, the Allied Health Rural Generalist Pathway (AHRGP) was established which included a formal post graduate training program, workforce structures, supports and the development of rural generalist service models and competencies (13), with other states and jurisdictions subsequently offering the AHRGP.

In 2017, James Cook University, in the state of Queensland Australia, introduced the rural generalist program (RGP) (14) which became a core component of the AHRGP. The RGP is a two level post graduate program. Level 1 is a non-award program designed for early career rural or remote allied health professionals with less than 3 years of experience. It comprises 12 modules that are each 6 weeks in duration requiring approximately 22 hours each to complete. The level 2 program is a graduate diploma qualification, with eight modules requiring approximately 130 hours per module and is designed for rural and remote allied health professionals who have more than 2 years of work experience (14). Both levels offers specialist training and education designed to support clinicians working in rural and remote areas and incorporate online coursework and work-based projects and activities (14). While participating in the AHRGP, trainees are afforded dedicated study time and supervision at work and the opportunity to participate in service development or quality improvement project work.

Research investigating the experience and impact of the AHRGP has identified emerging positive outcomes for trainees undertaking the pathway, employing organisations and communities (12, 13, 15–18). In the first evaluations when the AHRGP was under development, Queensland Health found that allied health professionals in rural generalist training positions’ job satisfaction improved, and they gained relevant skills for practice through their participation (17). Health services with training positions reported their capacity to manage clinical workloads and volume of quality work improvement activities undertaken increased, along with multidisciplinary team communication and coordination improvements. It was also reported that consumers had decreased need to travel, quicker access to health services and improved quality and continuity of care (12, 17). The first cohort of trainees had a 100% completion rate and 78% remained working in rural or remote locations six months after completion of the AHRGP (12, 13). This early research was undertaken prior to the introduction of the RGP and the training positions were supernumerary. A study in another state of Australia, New South Wales, was undertaken after the RGP was established, however the number of participants was small and were all from one discipline with just one completing the RGP. The findings of this study were that the pathway enabled services to recruit and retain physiotherapists into positions that had previously been difficult to fill. This had a positive impact on both service and consumer outcomes (16).

Two recent studies have examined the RGP specifically (15, 18). Through including participants who were enrolled in the training program with JCU, the researchers were able to examine the program impacts across multiple jurisdictions. The study identified a range of benefits and challenges of the program for trainees and employing organisations (15), concluding that the program is assisting in building capacity of allied health professionals working in generalist roles and more broadly, a rural allied health workforce (18). Benefits were also identified for consumers including increasing accessibility and quality of services received (15, 18). The findings of these studies were important in identifying the specific outcomes of participating in the RGP as this was not the focus of the previous studies.

In 2019, Rural Health Workforce Strategy funding provided by the Government of South Australia supported a trial of the AHRGP in SA Health regional local health networks (LHNs). Significant gaps in the research existed in relation to the AHRGP. These included; investigating the impact of the whole pathway including the RGP but also the supports and opportunities provided by the workplace, a synthesis of experience of rural generalist trainees, employing organisations and consumers receiving services, the workforce outcomes and costs of implementing the AHRGP and the contextual factors for successful implementation of the AHRGP.

Addressing these gaps in knowledge provided evidence to inform future implementation of the AHRGP to maximise retention of AH staff in rural health services. The aims of this research were to comprehensively examine the experience, impact and perspectives of the AHRGP for trainees, organisations and consumers as it was introduced in rural South Australia. Specifically, the aims were:

To explore the experience of the allied health professionals participating in the AHRGP and the impact on their skills, abilities and knowledge for practice.

To understand the impact and experiences of the AHRGP from the perspective of clinical supervisors, profession leads, line managers working with rural generalist trainees.

To explore how the AHRGP has impacted employing organisations and consumers receiving allied health services.

A qualitative study was conducted as part of a larger multi-level, multi-phase pragmatic mixed methods research project. The pragmatic approach enabled the researchers to consider both constructivist and positivist perspectives and utilise methods that best addressed the research aims (19). These approaches enabled a comprehensive analysis of the pathway to be undertaken considering multiple layers of participation over four year period. This qualitative component took a constructivist approach enabling the researchers to consider a range of views, perspectives and experiences of the AHRGP (20). Ethics was gained by the Southern Adelaide Clinical Human Research Ethics Committee 21 August, 2019 HREC/19/SAC/170. All methods were performed in accordance with the relevant ethical guidelines and regulations.

Sampling

This research took a purposeful sampling approach to select participants. SA Health provided the researchers with the contact details of all trainees who were participating in the AHRGP as well as their individual clinical supervisors, line managers, profession leads and program management team (herein referred to collectively as service leaders) and consumer representatives who were members of the Local Health Network Advisory Board, in which the trainees were working. All trainees involved in the pathway were invited to participate in the research via an email invitation as well as their associated service leaders, the consumer representatives and the program management team overseeing the pathway introduction. Thus, there were three participant groups. Informed consent was gained prior to data collection.

Data collection methods

This research was undertaken over four research phases, the methods used are outlined in Table 1. Interviews were conducted face to face or via teleconference and were scheduled as each participant reached the associated milestone in the pathway (i.e. the midpoint, endpoint and 6 month follow up). Service leaders’ interviews were scheduled around the same time as their associated trainee. Focus groups were conducted via teleconference and were undertaken in 2019 when trainees were starting the pathway, and in 2022 when the trainees had completed the pathway. INSERT Table 1 HERE

Table 1

Research phases and associate methods
Research phases	Qualitative data collection methods for participant groups
Phase 1 – Pre pathway 2019	Trainee survey and interview Clinical supervisor, line manager, profession lead and program manager interviews (service leaders) Consumer representative focus group
Phase 2 – Mid pathway 2020	Trainee survey and interview Service leader interviews
Phase 3 – End pathway 2020-22	Trainee survey and interview Service leader interviews Consumer representative focus group
Phase 4–6 month post pathway completion 2021-23	Trainee survey

Data Analysis

Interviews and focus groups were transcribed by a third party and checked by the chief investigator for accuracy. The transcripts were coded using Nvivo (Lumivero; https://lumivero.com). Codes were named as close to the actual quote as possible to ensure they were attributed to the actual statements and not misinterpreted later during analysis. The first two interview transcripts were coded by a second researcher (CB) and codes were compared for consistency. A high level of consistency in coding and naming was found and subsequently the remaining transcripts were coded by the primary researcher and reviewed by the team. Once the codes were completed, each participant group was analysed thematically by phase, the codes were synthesised for meaning to form categories.

The categories were compared at each phase to identify themes, similarities and differences across groups (21). Qualitative findings from the phase 4 surveys were also incorporated at this time. At the end of the final phase, the categories and findings from all four phases were brought together to identify patterns. Emerging themes across the phases were discussed amongst the researchers to ensure rigor. Using thematic analysis gave the analysis structure and ensured transparency (22).

This research was conducted between September 2019 and June 2023. A total of 55 participants were involved in the study including: 15 trainees across five allied health professions and six rural regions in South Australia. In addition, 13 line managers, nine clinical supervisors, six profession leads, four program managers and seven consumer representatives participated in this study. Not all service leaders and consumer representatives were involved in all phases due to availability and staffing changes. Nine of the trainees participated in the level 1 RGP and four were in level 2. See Table 2 for details of participant involvement. Of the 15 trainees who participated, seven completed the AHRGP and one was continuing beyond the end of phase 4. Three of the nine level 1 trainees completed the pathway and four of the five level 2 trainees had completed the pathway on the completion of this study with one continuing beyond the end of the research period. INSERT Table 2 HERE

Table 2

Research participant demographics
	Phase 1	Phase 2	Phase 3	Phase 4	Total number of participants
Level 1 trainees	9	8	4*	3	10
Level 2 trainees	4	5	5*	4	5
Occupational therapy trainees	4	3	3	3	4
Physiotherapy trainees	3	3	2	2	3
Podiatry trainees	4	3	3	1	4
Speech pathology trainees	3	2	1	1	3
Social work trainees	1				1
Clinical supervisors	9	9	7		9
Line Managers	7	6	9		13
Clinical leads	4	4	5		7
Consumer representatives	5		4		7
Program managers	3	3	4		4
Total participants	41	35	38	7	55

* Two of the trainees in phase 3 had not completed the pathway but participated in phase 3 as they left between midway and the end.

Five themes emerged from the data:

Gaining broad skills and knowledge for rural practice

Finding the time to manage the pathway

Implementing learning into practice

The AHRGP impacts for the whole team

Confident, consistent, skilled allied health professionals positively impact consumers

Theme 1: Gaining broad skills and knowledge for rural practice

Throughout the four research phases, participants described trainees gaining knowledge, skills and confidence to work as rural generalist allied health professionals. These gains had similarities and differences across the four phases.

In phase 1 as the trainees were beginning the AHRGP they anticipated the learning and skills development they would gain including the development of confidence and skills to work as a rural generalists. They were also hoping to improve service delivery for their organisations and consumers. In phase 2, halfway through the pathway, trainees reported gaining broad and specific skills and knowledge for practice, specifically they discussed the benefits of learning program management skills, understanding how the organisation operated and the scope of rural generalist practice.

“I guess the big thing would be the quality improvement stuff. That’s probably changed my practice just in terms of I think sometimes as a new graduate you’re keen to contribute to things, and you kind of maybe see, like, a gap at your site that you can contribute to. And I definitely probably now understand the process that goes behind that and who to kind of talk to.” Trainee 8 phase 2

“I think I’ve just got more of an awareness that was like all around rural health, so that was a really good one to start with. That just gave me more of an awareness to different strategies to implement within rural health....” Trainee 5 phase 2

In phases 3 and 4 when the trainees had completed the AHRGP, reports of the attainment of confidence in their work roles, taking risks and advancing their career were identified. Trainees also reported broad skills they had gained including evidence based practice, knowledge for generalist practice, leadership skills and operational knowledge.

“I think there’s skills I’ve gained in this that I wouldn’t have otherwise ever gained. And the development and career opportunities that it’s really opened up. Like I couldn’t do the job that I’m in at the moment if I didn’t have (AHRGP), and I probably wouldn’t have gotten, or been prepared for my last role either.” Trainee 12 phase 3

“Most useful was probably just the focus on research evidence and evidence-based practice. That was a consistent theme across most of the subjects … it’s just not something that I’ve used a lot in terms of research evidence, analysing and gathering and that kind of thing.” Trainee 13 phase 3

In phases 2 and 3, service leaders described the ways in which trainees were developing their confidence and skills providing allied health services to across a broad range of service types with more autonomy. In particular, in phase 2, service leaders reported trainees were able make clinical decisions more easily and manage high levels of complexity.

“Both have increased their skills and competences, both have grown in confidence, and so I see them being able to manage more complexities and issues much better. Their tool bag is bigger, so in a sense is when they’re managing issues they are doing really well.” Service leader 19 phase 2

“I think they’ve shown a high level of understanding in some really tricky situations, and I think they just … I don’t think they flinch much around that. They are happy to lay out their understanding and their reasoning and what they would recommend and they’re happy to take on feedback. But all in all, they do a really good job of making those decisions.” Service leader 23 phase 2

Additionally, in phase 3, service leaders described trainees developing system and strategic thinking in the later stages of the AHRGP. They also noted trainees were developing their leadership skill and were advancing their careers.

“I think on a broader scale they have been able to apply the learnings to their overall role and career progression really within their team and leadership progression” Service leader 20 phase 3

“When I listened to (them) talking about, you know, data and activity reports and just worlds away, and understanding actually they’re tools to get, and it’s like oh, safety learning system is your best friend. You know, that understanding of using systems to get things, whereas (before they) had a very clinician approach...” Service leader 17 phase 3

Theme 2: Finding the time to manage the pathway

Time was a theme that emerged from the data in each phase and with all stakeholders. Although the AHRGP was beneficial, trainees found it challenging to find the time to manage the study commitments and to find a work life balance.

While undertaking the AHRGP, trainees were assigned half to one day a week to undertake study related activities at work. In each of the four research phases, trainees reported the challenge of setting this time aside. The challenges related to staff vacancies in teams, heavy workloads, interruptions, unpredictable clinical work, administrative follow up work and the attainment of leadership roles with higher levels of responsibility. Although trainees were given permission to undertake study time at work, this time was not backfilled, and trainees and service leaders reported this to be a barrier.

“Finding the time to study. I’m not sure how everyone else has gone with it, but every time I’ve spoken to you, and every time I seem to speak to (program manager), we don’t have any staff.” Trainee 11 phase 2

“I’d do two days of outreach and then I’d come back, and then I’d have my study day on the Friday, but then I’d be stressing about, I need to write that doctor’s letter, or that person’s going to go in for an amputation, and I want to make sure that we’re covered and stuff.” Trainee 1 phase 3

Work life balance was described as challenging for trainees participating in the AHRGP. Relating to the difficulty of finding time to study at work, there was a need to undertake assignments and coursework in trainees own time.

“I tried everything in the book to try and have a separation between work, study, life, but you get home from work, I’m exhausted, I can’t do study, that leaves the weekend. And when you’ve only got two days in a weekend and I get one day of work to do it, to do two subjects in that time, it barely fits.” Trainee 13 phase 3

Theme 3: Implementing learning into practice

Participants described a range of experiences in terms of implementing learning into practice during the AHRGP. Some trainees were able to easily apply the learning materials to their practice and work roles, while others found it more challenging. This theme related to the relevance of RGP material to their specific context, the time trainees had to implement learning and the resourcing available from organisations to implement project work. Additionally, trainees reported it was challenging to maintain motivation to study over an extended period of time when they were finding it difficult to apply their learning to practice.

The RGP has a combination of mandatory and elective topics. Trainees and supervisors described the wide range of topics that were informative and relevant to their rural allied health context and some that appeared to contain less relevant clinical presentations and assessment tasks for their context. Participants recognised the breadth of content in the RGP impacted on the ability of content always being relevant to individuals and they shared a range of ways in which the education provider had provided a flexible approach to trainee’s learning.

“Probably to find suitable clients was sometimes a little bit difficult because I suppose, in country, your client list is very variable and you’re not like a metro place where you might have a big cluster of one diagnosis or something” Trainee 7 phase 2

“You look at the resources, there’s two for podiatry and one for pharmacy, and then there’s eight for physio … it’s very obviously weighted that way, I think.” Trainee 11 phase 3

Although participants described the attainment of project management and evidence based practice skills positively, the challenge of implementing and evaluating planned projects and other work integrated assessments tasks was also widely reported across phases. Trainees felt the time they had assigned to study at work did not provide enough time to implement their learning into practice and some service leaders described the lack of implementation of projects as reducing the overall impact of the AHRGP.

“So, although you get that time allocated to the rural generalist project, all of that time is kind of spent, for me, actually doing the modules, and I don’t really have a lot of spare time to actually be implementing the projects, if that makes sense.” Trainee 13 phase 2

“I really struggle with this idea that somehow, like you’re in it to learn, and then somehow at the same stage, and I get you’ve got to have outcomes and measurables and stuff like that, like you’re just learning at the same time” Trainee 12 phase 3

The challenge of motivation throughout the AHRGP was raised by trainees in phases 2 and 3. For some, the pathway took more of their time than then had anticipated, while others reported it was difficult to feel motivated to do coursework that didn’t feel directly related to their clinical work or that they couldn’t apply without modification.

“I’m like, I feel like I’m actually, like I get it done but I’m not doing very well. I feel like I don’t really … I just do what I have to, to get it done. I know that sounds really bad, but it’s not very interesting. I think I’ve just got higher priorities with work and whatnot that I just do what I have to, just tick it off. That sounds bad.” Trainee 2 phase 2

“At the start it was all new and interesting and I really enjoyed it as a break from the clinical side of things for the first half of the program, whereas found the second half a lot more challenging to just keep focused and to prioritise it and see it helping me and relating to my practice as a motivator” Trainee 4 phase 3

Theme 4: The AHRGP impacts for the whole team

Service leaders identified a range of positive outcomes for themselves, their teams and the whole organisation. There were also at times, challenges experienced in providing support to trainees.

During phases 2 and 3, service leaders identified a range of ways in which the organisation was impacted by the AHRGP. Trainees were being retained for longer in regions which had positive flow on effects for the whole team. Service leaders felt the pathway was giving trainees a reason to stay in the region, helping them develop their career and demonstrating that the regions had a culture of learning.

“Yeah, I think we get better outcomes for our communities if we’ve got confident, competent staff that are here for the long run, and overall, that helps to build a stronger team, because your team morale and everything increases, if you’ve got happy and confident skilled staff to work with.” Service leader 28 phase 2

The overall skill level of teams improved through trainees gaining skills, being able to manage a broader clinical load which was imperative for rural practice. Service leaders also reported trainees were sharing their knowledge and skills with colleagues within and across regions which resulted in broader organisational benefits.

“We’ve got very junior staff, so how they are able to come in and to being able to guide them, mentor them, and assist them from that generalist point of view is really crucial, because it’s quite difficult when you’re a new AHP, and (name) been able to embed them in really smoothly.” Service leader 19 phase 2

“I don’t believe that when somebody’s involved in the program that it’s just them, often the conversations that they’re actually having within the team or with even other teams, you know, other colleagues, it extends out” Service leader 46 phase 3

Service leaders also recognised that the trainees were demonstrating leadership skills which resulted in them identifying service gaps and implementing quality improvement activities to improve service delivery. They were also moving into supervision and managerial roles as they progressed through the pathway.

“So, it was really, from what I’ve seen, is how they’ve grown not just as a clinician, but as a leader … And how they incorporate the, I guess, the rural generalist skills knowledge into the leadership space, as well as just their own individual practice …they’ve got a really good position to actually really make some definite changes and implement the change … And make it sustainable, as well... ” Service leader 24 phase 2

“I think that’s just going to be so useful for hopefully sustaining these great clinicians working in a rural setting. So, if they can feel like they can progress their career, still be involved clinically but also have a chance to apply their skills in management leadership, project-type roles” Service leader 20 phase 3

Clinical and managerial support was imperative for trainees participating in the AHRGP. Participants described a range of examples where support from a supervisor or line manager had made a difference to the trainees’ experience in the pathway. They felt like they had someone to discuss the pathway with, to get advice and to work through assessment tasks and projects with. Service leaders also benefited from working with trainees as they gained skills themselves and took pride in seeing the trainees grow and develop. In circumstances where there was a disconnect between trainees and service leaders, participants described challenges in terms of trainees feeling adequately supported and service leaders being able to identify benefits of the AHRGP for their organisation. Some service leaders were not sure of their role in supporting trainees, particularly if they had not been in their role when the trainee was selected for the AHRGP.

“Yeah. Just she was a really good resource to be able to find things that I might have not known where to look. But she had a really good insight into that, so yeah, she knew that she’d seen things before so she sort of just followed where logically she would have put it, and found it and sent it all to me, which was good.” Trainee 10 phase 2

“I think that perhaps the, there’s been a few hiccups along the way around supervision, meeting the supervision requirements for the participants … So, I think perhaps it has been difficult for some sites to meet the regularity of supervision because it is more than what is often expected as part of our supervision framework.” Service leader 22 phase 2

“I didn’t have any, any expectations put on me of what I needed to be doing with them. So, I, you know, I haven’t checked in with them and now I’m feeling really bad. But yeah so I think maybe some more organisational stuff around that.” 47 phase 3

Theme 5: Confident, consistent, skilled allied health professionals positively impact consumers

Consumer representatives, service leaders and trainees identified a range of ways in which consumers were impacted by the AHRGP. The improving skills, confidence and knowledge of AHRGP trainees had positive impacts on consumers. Access to more consistent services meant that consumers had better quality care from someone who knew them and could provide more client centred services.

In phase 3, trainees felt they had gained skills to be able to better meet the needs of consumers, they felt more able to manage complexity and solve problems for consumers. They had the opportunity to learn more about specific clinical conditions that were relevant to consumers they were working with to identify new and effective assessment and intervention modalities. Trainees also described the services and projects they had developed that they felt would have indirect benefits for consumers in their regions.

“Perhaps just makes you stop and reflect and clinically reason your way through what you’re doing or whatever else you could do compared to normal practice where you kind of just perhaps a little bit more just keep running.” Trainee 4 phase 3

“Helped increase the sort of efficiency and the consistency, and the longevity of some of our rehab programs. So, that will help some of our community members now and in the future.” Trainee 3 phase 3

Service leaders identified a range of ways in which consumers were impacted by the AHRGP in phases 2 and 3. They felt that trainees were using more evidence based practice with consumers and that they were more confident and skilled in their service provision. Trainees were able to provide a wider range of services to meet consumers’ needs and the quality of care was improving.

“But with the way they’re approaching their clients, they tend to refer to evidence. So, everything that they’re presenting or giving education to clients, it’s more about what evidence suggests.” Service leader 21 phase 2

“If you think about an overall service, I think our quality has gone up, we’re actually meeting the need of the consumer much more effectively than maybe we were before with these staff because they’re able to do whatever we need them to … I think because they’re both advanced in their skills … the quality of service that they’re now being able to supply is increased.” Service leader 18 phase 3

Consumer representatives described rural generalist skills as being imperative for rural practice in South Australia and they felt having more generalists in the region would result in less travel for services for consumers. They also felt more trained staff were more likely to be retained in the region which would have positive impacts on the consistency of service delivery.

“… If you’ve got the higher trained staff in the area, but people don’t have to go then to the city and we can … and that’s what we’re trying to do in our region. Keep as many people in our region as we can because we can provide the services.” Consumer rep 55 phase 3

“That’s it and work it in with the other areas, if you like, of life. Not just looking at it from this isolated point of view but looking at it holistically. Consumer rep 53 phase 3

Consumer representatives felt the AHRGP could potentially benefit communities more if trainees received incentives to participate in the pathway which might improve the retention of trainees further. They also felt it was imperative that feedback from trainees in relation to the relevance of content should be taken on board to ensure the pathway can be as beneficial as possible.

“And I think structurally, you really need to think about incentivising the whole program … I think there needs to be recognition of that in terms of remuneration or the level that those people come in at. I think that if you’re going to do that, we need to make sure that there is an incentive for people to do that. Either that they get promoted to the next level or there’s some kind of other financial incentive.” Consumer rep 54 phase 3

This large study described a wide range of perspectives and experiences of the AHRGP including allied health professionals who were participating in the pathway, clinical supervisors, line managers, profession leads and program managers who were supporting trainees and consumer representatives who experience allied health services.

The results of this qualitative study demonstrate that the AHRGP had a positive impact on allied health professionals’ developing rural generalist skills and knowledge for practice. In particular, the development of evidence based practice and project management skills had positive impacts on practice. The AHRGP facilitated the development of evidence based practice through investigating clinical areas of interest and enabling trainees to use real life examples from their practice to deep dive into the best evidence for allied health assessment and intervention. They developed project management skills by developing quality improvement and service development projects for their workplaces while they learnt. These work integrated approaches are consistent with recent research demonstrating that allied health professionals are more likely to implement their learning from training into practice if they have the opportunity to practice their skills while they learn (23).

Through gaining broad skills and knowledge, trainees felt they were able to manage a higher level of clinical complexity. Service leaders found trainees had developed critical and flexible thinking skills to be able to manage complexity and solve problems. They also felt trainees developed a broader understanding of rural and remote practice through participating in the AHRGP. These skills are imperative for diverse workloads in geographically remote locations. Barker et al. also found trainees undertaking the RGP across Australian jurisdictions knowledge and skill improved in evidence-based practice, managing complexity and problem-solving (15).

Organisations employing allied health professionals can benefit from the AHRGP in a range of ways. Previous studies have identified a range of organisational benefits including improved: efficiencies, effectiveness and accessibility of services (15, 18); workforce outcomes; and support mechanisms for allied health professionals (16). The findings of this research were consistent with previous findings and also found that organisations benefitted from trainees sharing their skills with peers which had a broader impact on the whole team. The pathway had a positive impact on career advancement and the development of leadership skills for trainees. As a result, trainees were able to take on more responsibility and provide support to other staff. Overall, the AHRGP helped to build an effective rural and remote allied health workforce.

Consumers benefitted from working with more skilled, knowledgeable, confident and consistent allied health professionals. The AHRGP assisted trainees to develop skills and knowledge relevant to their clinical practice. Previous studies have considered the impact of the AHRGP on consumer experiences (18) and outcomes (16), but this study was the first to involve consumer representatives. This study found that consumer representatives thought the AHRPG was generating relevant outcomes for consumers and that organisations should continue to invest in the pathway.

Challenges for trainees identified in this research are comparable with those found in previous studies examining allied workforce strategies. These include protecting study time at work, workload pressures (16), higher than expected study load, irrelevant learning activities and time taken away from clinical work to study (15). This research also identified additional challenges that had not arisen in previous studies. Some trainees experienced difficulties accessing adequate clinical and managerial support whilst undertaking the pathway. This had a negative impact on their experience in rural areas and contributed to trainees discontinuing the pathway. The impact the AHRGP had on work-life balance and overall wellbeing was also widely reported in this study. Achieving a balance was especially challenging in the second half of the pathway when trainees were facing difficulties maintaining motivation to study. As trainees were promoted to different roles during the pathway their priorities changed, and they found it more difficult to protect their study time. This new knowledge will be particularly helpful for organisations and allied health professionals considering the AHRGP as they establish study and support structures and routines to facilitate success.

To date, the AHRGP is offered in Australia and the authors did not identify any equivalent training program offered in other countries. Rural generalist medical pathways are offered internationally (24) with a range of favourable outcomes for rural based doctors, organisations and communities (25). These pathways have allowed rural doctors to specialise in rural and remote practice with associated specialisation and career advancement opportunities (24). Unfortunately, the current rural generalist pathway for allied health professionals is not directly associated with career advancement opportunities or the recognition of specialist skills. Trainees and consumer representatives in this study recommended the AHRGP have tangible completion incentives and appropriate remuneration for graduates to increase the value of the pathway.

One of the downsides of the AHRGP identified in this study concerned the limited opportunities to implement service development and quality improvement projects beyond the planning phase required for the RGP. Limited time and organisational support and resourcing resulted in trainees feeling disappointed that their projects were not implemented or evaluated. Benefits for organisations were also diminished when designed projects did not progress beyond the planning phase. Early research investigating the AHRGP described wide ranging benefits of trainees implementing service development projects, however the completion of the RGP was not as strong a focus (16, 17). Consideration of organisations in reducing barriers for the implementation of projects, could improve the overall outcomes of the AHRGP and satisfaction for all stakeholders.

This research has comprehensively examined the experience and outcomes of the AHRGP across multiple levels of stakeholders and over four distinct phases, which brings new knowledge and understanding for allied health professionals and employing organisations. The AHRGP has had a positive impact on allied health professionals’ knowledge and skill for rural and remote practice. Organisations and consumers benefited from allied health professionals being able to solve problems, work across clinical areas and apply evidence based practice to their work. Trainees found it challenging to find time to study and motivation was challenging to maintain especially in the second half of the pathway. Although service leaders found the AHRPG to be worthwhile, at times they were unclear about their roles and responsibilities in supporting a trainee. The value of the AHRGP could be improved through the development of associated workforce structures that recognise and reward the successful completion of the pathway and opportunities to implement projects and learning into practice. Future research is required to explore the implementation of allied health rural generalist pathways in different contexts and internationally.

Ethics approval and consent to participate

Ethics approval for the project was obtained from Southern Adelaide Clinical Human Resource Ethics Committee HREC/19/SAC/170. The research was undertaken with appropriate informed consent of participants.

Consent for publication

Consent to publish data was received by SA Health

Ethical guidelines

All methods were performed in accordance with the relevant ethical guidelines and regulations.

Availability of data and materials

The data that support this study were obtained from SA Health by permission cannot be publicly shared due to ethical and privacy reasons. Data may be shared upon reasonable request to the corresponding author if appropriate with permission from SA Health.

Funding

The authors wish to acknowledge funding support provided by the Rural Health Workforce Strategy, SA Health, Government of South Australia to undertake this research

Competing interest

The Flinders University researchers AD, CB, SG and NC received funding from SA Health to undertake the research.

Author’s contribution

The study was conceptualised and designed by all authors. AD conducted the interviews and surveys. AD and CB conducted the focus groups. All authors were involved in the analysis of data and interpretation of findings. AD drafted the manuscript and all authors critically reviewed and contributed to the final version.

Acknowledgements

We would like to acknowledge the Rural Support Service, SA Government who provided support for this study to be undertaken. Especially, Jodie May, Julianne O’Connor, Silvana Poklar, Narelle Sarakinis and Robyn Gill who provided feedback, guidance and advice on the research design. We would also like to acknowledge the research participants who gave up their time to participate in the study.

Authors information

AD is Academic Lead, Rural Allied health, Lecturer and Researcher at Flinders University, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University

SG is Professor, Healthy Ageing Support and Care, Caring Futures Institute, College of Nursing and Health Sciences, Flinders University

NC is Associate Professor, Flinders University Northern Territory, College of Medicine and Public Health, Flinders University

CB is Pro Vice Chancellor (Curriculum Impact), Caring Futures Institute, Flinders University

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No competing interests reported.

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Sustaining our rural allied health workforce: Experiences and impacts of the allied health rural generalist pathway

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