- Research article
- Open Access
- Open Peer Review
Views of Australian dental practitioners towards rural recruitment and retention: a descriptive study
© The Author(s). 2016
- Received: 13 January 2016
- Accepted: 24 May 2016
- Published: 1 June 2016
Despite an increase in the supply of dental practitioners in Australia in recent years, there remains an unequal distribution of dental practitioners with more dental practitioners working in city areas. This is in part due to difficulties in attracting and retaining dental practitioners to rural practice. The aim of this study was to investigate the attitudes of Australian dental practitioners towards what may attract them to rural areas and why they may remain in them.
A descriptive study, utilising telephone, semi-structured interviews with dental practitioners across Australia. Dental practitioners were recruited through their professional associations. Data were analysed using content and thematic analysis.
Fifty participants; 34 dentists, eight oral health therapists, and eight dental prosthetists working in rural and urban areas of Australia. Four main themes were identified: Business Case: concerns related to income and employment security, Differences in Clinical Practices: differences in clinical treatments and professional work, Community: fitting in and belonging in the area in which you live and work, and Individual Factors: local area provision for lifestyle choices and circumstances. The most influential of these themes were business case and individual factors. Smaller rural areas, due to low populations and being unable to provide individuals with their lifestyle needs were considered unappealing for dental practitioners to live. Previous experience of rural areas was highly influential.
The main factors influencing rural recruitment and retention were income sustainability and employment security, and individual factors. Dental practitioners felt that it was harder to earn a sustainable income and provide quality lifestyles for their family in rural areas. Previous experience of rural areas was influential towards long-term rural retention. These factors should be considered in order to develop effective strategies to address the unequal distribution of dental practitioners.
- Dental practitioners
- Oral health
- Rural health workforce
Australia is one of the most sparsely populated countries in the world. People residing outside capital cities have poorer oral health and less favourable dental visiting patterns than their city counterparts . The differences in visiting patterns may be due to difficulties with access as a result of an unbalanced distribution of dental practitioners between urban and rural areas in Australia . Previous literature has investigated factors which influence rural recruitment and retention of the oral health workforce from Australia and around the world. Working rurally has been linked with desire for a rural lifestyle [2–5], more challenging job opportunities [2, 6], wider range of patients and clinical exposures [2–4, 6], administrative and clinical experience [3, 4, 6], an enjoyable patient base , financial incentives [6, 7], personal and professional supportive networks [2, 5, 6, 8, 9], and a sense of belonging to a community [2, 3, 8–10]. However, rural practitioners also experienced a range of negative factors which influenced their decisions to leave rural areas. These included professional and social isolation [2, 4–6, 11–13], limited access to facilities and social activities [2, 4, 13], increased workload and inadequate time off duty [2, 3, 7], limited access to continuing professional development [6, 7], poor access to education services for children [2, 13], limited job opportunities for their partner [2, 3, 8, 11], their own or their family’s dissatisfaction with rural lifestyle and failure to integrate into the rural community [2–5, 7, 8, 14]. Previous studies have found that the most commonly identified indicator of rural practice was prior rural exposure [3, 9, 15].
There have been strategies put in place aimed towards increasing recruitment of both private and public dental practitioners into the rural health workforce. They have included the use of foreign-trained dentists , student loan repayment schemes [5, 8, 10, 14] and financial incentives [2, 3, 11]. Strategies aimed at increasing retention of rural dental practitioners included increasing the number of dental students at universities with rural upbringings [11, 16], rural clinical placement programs during undergraduate training [4, 13, 16], and locating dental schools in rural areas [10, 16].
Despite many previous studies focusing on rural recruitment and retention of dental practitioners, a systematic review suggested that more comprehensive research could better investigate the issue by including all types of dental practitioners and excluding other health disciplines such as medicine . Moreover, the literature mostly focused on the views and experiences of rural dental practitioners. As one of the strategies is to encourage non-rural dental practitioners to move to and stay in rural areas, their views should also be explored. The aim of this study was to describe the opinions of Australian dental practitioners towards living and working in rural areas as a part of a further exploratory design research project.
In this study, the term dental practitioner follows the Australian Dental Board’s general registration categories of dentists, dental prosthetists, and dental therapists, dental hygienists, and oral health therapists . Therapist, hygienist and oral health therapist participants were combined into one OHT group due to their similarities in provided services. The term urban refers to the Australian Standard Geographical Classification (ASGC) categories , major city and inner regional, and the term rural refers to outer regional, remote, and very remote. This study included dental practitioners operating in the private sector, and those working for government clinics in the public sector.
This is a descriptive study  utilising semi-structured interviews. Ethics approval was obtained from the Tasmania Social Sciences Human Research Ethics Committee (H0013194). Purposive sampling was used to ensure that the sample was representative of the mentioned categories of Australian of dental practitioners, across urban and rural areas, male and female, different age groups and across different states.
Invitation letters and information about the study were sent to the presidents of the four dental associations (Australian Dental Association, Dental Hygienist Association of Australia, Australian Dental and Oral Health Therapist Association, and Australian Dental Prosthetists’ Association) to ask for their support for the study. These four associations agreed to participate in the study. With their approval and support, advertisements to recruit participants were placed in the organisations’ websites and newsletters. Participants were asked to contact the researchers via email or phone if they were interested in participating in the study, they were then asked to use a snowball sampling technique to recruit others . Phone interviews were used because dental practitioners are busy clinicians and were in various locations across the nation. Written consent forms were emailed to each participant. The forms were emailed, faxed or posted back to the researcher prior to the interview.
The interview guide was developed using findings from our systematic review  and discussion among the research team to investigate knowledge gaps in the existing literature. It was then piloted with five dental practitioners to make sure that the questions in the guide were appropriate and easy to understand. The interviews were divided into three parts: (i) participant background and training information, (ii) participant views/experiences of why they would or would not practice in rural areas, (iii) participant views on strategies to recruit and retain rural dental practitioners.
The interviews were developed to act as a hypotheses generating tool describing the opinions of dental professionals towards rural practice. All interviews were audio recorded and transcribed verbatim. Each of the interviews were listened back to alongside reading of their full transcriptions for quality assurance purposes. All data were anonymised prior to analysis. Participants are identified only by their professional category, gender, and age. The data were then imported into QSR-NVivo V.10.0 software  which assists researchers to store, code, classify and sort qualitative data. Two authors (DG and HH) analysed the data using content and thematic analysis . DG and HH conducted the analysis independently, which involved coding the transcripts, categorising the codes and the generation of themes.
The research team met regularly during data collection and analysis to discuss the process of coding and theme assignment and any disagreements were solved by discussion. The study reached thematic saturation when the researchers identified the content of new interviews repeated that of previous interviews. The researchers used this, as it is a common method of determining if sufficient data has been collected in qualitative research .
Characteristics of participants
(N = 34)
(N = 8)
(N = 8)
(N = 50)
Location of practice
Classification of practice
Prior rural exposure
When talking about working as a rural practitioner, the majority of the participants expressed their concerns about the long-term sustainability of rural practices, an oversupply of dental practitioners and their views on financial incentives to encourage dental practitioners to work in rural areas.
Sustainability of a rural practice
There are more issues than just the money to build a clinic. Um… such as how big is the patient base actually going to be and how sustainable is a dental practice going to be in a particular area. (Dentist, female, 40 yo, urban practitioner-has previous rural experience)
That’s an issue for rural areas in particular, in that they either don’t have the income to pay for a full time dentist in the area and because it costs so much to set up a dental practice, you need to make sure it’s going to be viable in that area. And that there might not be the population size to afford a rural practice. (Dentist, male, 31 yo, urban practice-has previous rural experience)
You go up there, and if you were to broke, nobody cares. You’ve gone broke. You’ve lost money, well that’s hard luck for you. (Dentist, male, 66yo, rural practitioner)
I think population, the number, just having the amount of work required to maintain a practice. (Prosthetist, male, 49 yo, urban practitioner-has previous rural experience)
The other thing is that whilst we can talk about shortages and numbers of people, there's still a lot of people who are not choosing to access care so, not all of these small communities can actually realistically sustain a full time practitioner there. (Dentist, female, 52 yo, urban practitioner-no previous rural experience)
…And in agricultural areas like this, people compare the price of a crown to the price of an acre of land, and they say well I can make more money out of an acre of land than I can by putting a crown on a tooth [laughs] so they opt for the cheaper options. (Dentist, male, 59 yo, rural practitioner)
I recognised a need in those areas so, um yeah, I’m filling that need, and also a commercial thing. Um, while sometimes it’s not the best commercial decision it does return fairly well, but, fine. (Prosthetist, male, 56 yo, rural practitioner)
I wonder whether, you know, it’s financially viable, and for dentists it’s more viable to stay in a central area and have people to come to you. To locate outside a central area, it’s a little bit like a reverse economy. You don’t get as much exposure and you don’t, yeah, you don’t get the same financial return. (Dentist, male, 44 yo, rural practitioner)
Employment scarcity and security
… you know that there's going to be an oversupply of graduates, which I think you're going to find its going to be a lot easier to get people to go and do country service, just because, they're going to have to because there's going to be too many unemployed ones in the city. (Dentist, male, 62 yo, urban practitioner-has previous rural experience)
I think it is becoming less of an issue with the oversupply of dentists in the metropolitan areas, that people finding, feeling the pressure that they don’t have the options of work in the city. Um, so they're being forced out into country areas anyway. (Dentist, female, 32 yo, urban practitioner-has previous rural experience)
…I, for 30 years used to struggle, I would advertise and I would get absolutely no interest. …[now] I was inundated with applications, you'd only just got to throw, the smallest amount of bait out and there are just kids everywhere just wanting a job. (Dentist, male, 59 yo, rural practitioner)
Oh, yeah it would certainly, certainly play into it, it would contribute to a positive decision to work in a rural area, but I think there are other intangibles which are, in my particular… which are more important than the financial incentives. (Dentist, male, 35 yo)
… they are important, that’s why we go to work that’s why we do what we do, that’s part of the reason why we do what we do. …but that’s also, it’s a trade-off between lifestyle and the financial benefits. I would rather have less of a financial benefit but enjoy the lifestyle that I have. (Prosthetist, female, 49 yo, rural practitioner)
I don’t think money brings people to um, you know to areas. It certainly, it doesn’t retain them. I've employed you know various people over the years and paid them exceptionally well, but you know, you see them heading back to the city every second weekend to meet up with their mates and so on, and you know that they're not going to stay. So, you’ve really got to get somebody whose heart is in, in being where they want to be. (Dentist, male, 64 yo, rural practitioner)
I think it’s important that you know rural areas that we least have the same earning capacity as metropolitan… I've worked in practices that I've had to go down almost $20 an hour and then in some cases I've moved states where I've had to go down nearly $30 an hour. OHT, female, 49 yo, urban practitioner-has previous rural experience)
Differences in clinical practices
When discussing rural recruitment and retention, 43 participants felt that there were differences in clinical practices between urban and rural practice which in turn influenced their decision to move to and stay in a rural area. This included clinical procedures, job satisfaction and professional progression.
That unfortunately dentistry via its nature is a, is a terminal profession. In that there's um not a lot of um opportunities for upward advancement, and that upward advancement is even less so in a rural area. (Dentist, male, 34 yo, rural practitioner, has previous rural experience)
… the graduates don’t tend to have had as much clinical experience as perhaps they once did. And their anxiety to me was “what if I start to do something and don’t know how I finish it?” because you know there's no one there who can help me.” (Specialist dentist, female, 52 yo, urban practitioner-has previous rural experience)
I guess the experience that I knew I was going to get when I moved out there [a rural area], my mentor, was really nice and really encouraging. (New graduate dentist, female, 25 yo, rural practitioner)
Rural practice was considered a barrier to accessing professional support networks. Rural practitioners used the internet to overcome this isolation. Rural practitioners spoke about the increasing professional and personal support which could be available to rural areas through professional associations, using methods such as phone help services, online help, and electronic network communities of rural practitioners.
I went out to some really tiny Aboriginal communities for a week at a time, and I just had a ball, I really loved it and you can really tell, like you ask somebody in a small community if you're making a difference and I guess, that played a big part in me choosing to go rural. (New graduate dentist, female, 25 yo, rural practitioner)
I found it much more fun to practise in those areas, much more rewarding you’d have people with serious um dental conditions which were affecting their medical health rather than just a simple broken tooth. (Dentist, female, 32 yo, urban practitioner-has previous rural experience)
Rural practice was considered an avenue for requiring increased clinical skills, as there were less available referral pathways to other health practitioners. Rural practice for younger practitioners was considered a fast way to up skill and learn clinical treatments quickly.
I would definitely make sure that there was an education, peer support network for rural practitioners, um, I'd make sure there was some sort of assistance for their greater out of pocket costs. (Dentist, female, 54 yo, urban practitioner-no previous rural experience)
Support from professional associations, professional networking and peer group support was thought to be harder to access in rural areas than urban areas due to a lower number of health professionals.
Fitting into the local community played an important role in dental practitioners’ decisions to move and stay in a rural area. The participants spoke about who they were, what they valued, and how they provided for and were provided for in their social networks and communities.
Social support networks
Lifestyle, I think, and family. I think just know where you like to live, I'd prefer to live in a rural area. (Prosthetist, male, 52 yo)
The lifestyle I think I was sort of itching to get back into the CBD [city area]. Um mainly because of you know being closer to friends and family. (Dentist, male, 59 yo, urban practitioner-has previous rural experience)
Community was mentioned as a negative aspect of rural practice in relation to ethnicity and individuals who were not ‘local’, and as a result felt that they were not accepted by the rural community. However, community engagement was a positive factor for rural practice for dental practitioners, providing social support, networking and social activities.
I live in a small town now and I don’t think I've ever lived somewhere so social in my whole life. It’s a lot more social because you end up making your own fun. (OHT, female, 58 yo, rural practitioner)
Participants were asked about their personal backgrounds. Individual factors such as backgrounds, family needs and quality of life played an important role in dental practitioners’ decisions about working in rural areas.
I've got this bigoted view that rural people want to work in rural areas, and people who grew up in the metropolitan areas probably want to work in metropolitan areas. And the reason I think that is, you couldn’t pay me enough to get me to work in the metropolitan area and yet, yet we sort of, you get people going around saying, “so why won't they move to the country?” and I say oh well the same reason I won't move to the city.” (Dentist, male, 63 yo, rural practitioner)
Participants who self-identified as ‘urban’ felt fearful about rural practice as a result of not having had previous experiences or exposure to rural areas. Urban background practitioners mentioned never having considered rural practice due to already having employment opportunities in their local area.
I think what they're doing at the moment that’s having universities in rural settings. It’s sort of giving the students the opportunity to actually be exposed during that 5 years training. And also that may give them the opportunity to sort of go, look maybe this isn’t that bad after all, it’s actually quite a nice experience personally. (Dentist, female, 33 yo, urban practitioner-has prior rural experience)
…our son’s education, he was getting to 12 years of age and it was a choice either he went to boarding school or we would relocated. And we looked at the alternatives and boarding school was not one that we welcomed so we relocated. (Dentist, male, 70 yo, current urban practitioner-has extensive previous rural experience)
… The big thing that I would emphasis would be the lack of job opportunities for partners, because partners are likely to be educated and you know professionals and so, it’s certainly a major factor for a lot of people. (Dentist, female, 32 yo, urban practitioner, has previous rural experience)
Quality of life
…it’s mainly just lifestyle rather than work, where I, that determines where I live. (Prosthetist, male, 52 yo, urban practitioner-has previous rural experience)
Rural practitioners enjoyed what they called ‘rural lifestyle’ this was considered separate from ‘city lifestyle’. This term referred to feelings of a more relaxing and laid back daily life. Lifestyle rewards were considered in conjunction to all types of financial incentives, and were thought to be more important provided the financial incentives allowed a reasonable income. Lifestyle rewards were considered to be of key importance for rural practitioners to facilitate long-term retention.
These findings confirms some factors from previous studies, and it adds that private practitioners were concerned about the future income security when considering to move to a rural practice. This was not a concern for practitioners in the public sector as they were salaried employees. While other factors such as enjoyment of rural lifestyle [2–5], social isolation [2, 4–6, 11–13], limited access to facilities and social activities [2, 4, 13], limited access to education services for children [2, 13], and limited job opportunities for partners [2, 3, 8, 11]; could be negotiated, ignored or ‘solutions’ found, the failure to reach an appropriate income level to support one’s family was not able to be substituted with other factors. Participants expressed concern that some rural areas did not have large enough population numbers to adequately financially support a full-time private practitioner. Australia is one of the most sparsely populated countries in the world. Nearly 90 % live in urban areas (more than 1000 people) . However; in 2011, 1.8 million people lived in rural areas outside any defined towns or localities . Tennant and colleagues  proposed that there was a minimum population level for communities which is required in order to support a full-time dental practitioner and that many areas in Australia do not fulfil this population requirement. This is further complicated by differences between urban and rural clinical work, including lower routine visiting patterns  and a higher likelihood of emergency treatments . In Australia, dental services are largely provided in the private sector (85 %) , and the burden of payment falls to the individual. The cost of treatment is a common reason for people to avoid dental treatment, leaving a large proportion of the community with untreated dental issues [2, 29]. Given the manner in which dental care is provided, a private dental practitioner requires a larger patient base than a medical practitioner does to financially support their practice and many widely-dispersed rural areas in Australia do not have the population size to support a full-time dental practitioner .
Strategies such as higher salaries and financial remuneration [2, 3, 11] to encourage rural practice would attract public dental practitioners. A recent program in Australia provides relocation incentives and infrastructure support grants to private dentists who relocate to provide general dental services in regional and remote locations . However, for many participants in the current study, there had to be assurance of long-term financial security from the work location before other factors were considered. This is a complex issue which requires flexible, practical and different models tailored for rural oral health care delivery for individual communities , mobile clinics and tele-dental services .
Another important finding from this study was that individual factors played an important role in influencing rural retention [3, 33]. These aspects included the successful formation or pre-existence of strong social bonds to the local community and personal enjoyment of rural lifestyle . This was facilitated by the local rural area being able to ‘provide’ certain lifestyle necessities for the individual and their families. The most important of these ‘provisions’ were family concerns: quality schooling opportunities for children , and sufficient employment opportunities for partners . Furthermore, having prior rural exposure and positive experiences of rural areas for themselves and their partners influenced later work location decisions [9, 34, 35]. This is known as the Rural Background Effect [36, 37]. The strategies which supported this factor were: increasing the number of dental students at universities with rural upbringings [11, 16, 35], rural placement programs during undergraduate training [4, 13, 16], locating dental schools in rural areas [10, 16, 35]. Retention issues are extremely complex and so too would be the solution, with issues to be addressed in the future being avenues to facilitate employment opportunities for the spouses of relocating dental practitioners, sense of belonging in rural communities and social engagement with local populations.
The limitations of this study were due to the nature of volunteer participants, there was a higher than average proportion of rurally experienced dental practitioners donating their time for the interviews. Using snowball sampling could introduce bias as individuals who know each other could share similar characteristics and opinions. The higher number of dentists compared with OHT’s and prosthetists could mean that factors which were influential for dentists in comparison to other dental practitioners may have been overly addressed. Further rural dental practitioner workforce research with a larger sample size is required to assist policy makers plan for more equitable access to oral health care for rural Australians.
The main factor influencing rural recruitment and retention was financial sustainability. Dental practitioners felt that it was harder to earn a sustainable income and provide quality lifestyles for their family in some rural areas. Previous experience of rural areas was considered to be highly influential towards long-term rural retention.
The authors would like to acknowledge the support of our funders the Australian Primary Health Care Research Institute (APHCRI). We acknowledge participants and colleagues who support our research in many ways.
The research reported in this review is a project of the Australian Primary Health Care Research Institute (APHCRI), which is supported under the Australian Government’s Primary Health Care Research, Evaluation and Development Strategy. The information and opinions contained in it do not necessarily reflect the views or policy of the Australian Primary Health Care Research Institute or the Department of Health and Ageing.
The authors would also like to acknowledge the late Associate Professor Erica Bell for her guidance in the initial stages of the research.
DG carried out the interviews, transcribed and analysed the data, and drafted the manuscript. HH analysed the data and helped to draft the manuscript. LC participated in the analysis of the data and edited the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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