A sustainable remote health workforce: translating HRM policy into practice

This thesis examined the influence of management practices on Human Resource Management (HRM) policy choices that support the sustainability of health workforces in remote tropical northern Australia. This was achieved by answering four research questions: RQ1) What are the espoused HRM policies and how do they influence remote health workforce sustainability?; RQ2) What is a sustainable remote health workforce?: RQ3) How do HRM policy choices and management practices influence health workforce sustainability for health professionals working in remote regions of northern Australia?; and RQ4) How can management practices support the sustainability of remote health workforces? This thesis commences with an introduction to the Australian health system, health workforces and geographical remoteness, and more particularly, the remote workforce, the remote environment and remote health services, highlighting the high rates of turnover experienced in some geographically remote regions of Australia. HRM policies and practices offer solutions for health workforce challenges, particularly in regard to overcoming workforce shortages. This thesis focused on the influence of management practices on the translation of HRM policies that support the sustainability of remote health workforces. This HRM approach complements those currently used in the health domain for analysing remote workforce challenges. Evidence-based HRM theories relevant to the workforce challenges experienced by remote health professionals build on current knowledge supporting more effective management of remote health workforces, so that Australian's living in remote regions receive consistent continuity of care and can experience better health outcomes through access to stable, reliable and sustainable health services. Two separate but complementary literature reviews were conducted. The first reviewed the literature from the health domain using an HRM approach to examine the challenges identified by health professionals working in remote regions. The second examined the literature from the management domain using the Harvard Analytical Framework for HRM to guide data analysis and identified the overarching theories this thesis: Psychological Contract Theory and Social Exchange Theory. The synthesis of the findings from these two complementary bodies of literature, led to the development of the Theoretical Integrated HRM Framework (TI-HRM), the theoretical framework that guided data analyses for this thesis. A Mixed Methods Research (MMR) methodology and the pragmatism paradigm's philosophical approach shaped the research design for this thesis. Both qualitative and quantitative data were collected through three data sources – semi-formal interviews; an online questionnaire and recruitment advertisements. Five chapters consecutively answer the research questions. Chapter four examines the espoused HRM policies in the recruitment advertisements and the reasons why current health professionals chose to work in remote regions, including, whether the experience met their expectations. Chapter four answered RQ1 revealing that the espoused HRM policies appear to influence workforce sustainability in three ways: attracting health professionals; psychological contract formation; and localised management practices. Chapter five answered RQ2 through examining how current remote health professionals described a sustainable remote health workforce, identifying three extant themes - people, practice and place. It concludes by revealing that the current remote health workforce believes that a SRHW is achievable; and that management practices influence the outcomes of many of the HRM policy choices that provide opportunities to improve retention. Chapter six examines the qualitative interview data to identify HRM policy choices and management practices that could improve health workforce sustainability, through the employment experiences of health professionals currently working in remote regions of northern Australia. Four key areas of management practice linked to HRM policy choices were identified: recruitment; remuneration; resourcing; and relationships. Chapter seven, used the quantitative questionnaire data to examine how management practices influence workforce sustainability for health professionals working in remote regions of northern Australia. The findings revealed that where effective management practices exist, particular HR outcomes (professional isolation, empowerment and remuneration), together with work engagement, moderate for the achievement of a sustainable remote health workforce. Chapter six and seven contributed to answering RQ3, with chapter six concluding that the implementation of HRM policies in remote regions influences workforce sustainability as each manager applies their own policy interpretation into their management practices; and chapter seven concluding that without effective management practices, HRM policies and Human Resources (HR) outcomes are less likely to support workforce sustainability. Chapter eight compared and contrasted the qualitative and quantitative findings discussed in chapters four to seven, using a mixed methods research methodology to answer RQ4. The chapter concluded with an examination of the framework developed through this thesis, the Integrated HRM Framework for sustainable remote health workforces, and how it addresses the key challenges for remote health workforce sustainability identified through both the literature and the empirical evidence contained in this thesis. Finally, chapter nine explains the contribution this thesis has made, including areas where research gaps were identified, limitations, and recommendations arising from this thesis, including areas for future research. The research aim for this thesis was achieved through answering the research questions providing empirical evidence to support the argument that the management practices influence the translation of HRM policies into practices that support sustainable remote health workforces. This thesis reports four significant findings: 1) HR outcomes do not significantly influence the achievement of a sustainable remote health workforce (SRHW) without effective management practices (LMX and POS); 2) Management practices (LMX and POS) influence the achievement of a SRHW, where HR outcomes (professional isolation, empowerment, remuneration and work engagement) are present; 3) Occupational commitment may be more influential in improving retention than organisational commitment; and 4) The measure of a SRHW is better represented through Herzberg's motivation-hygiene theory than through job satisfaction and work engagement. In conclusion, this thesis provides evidence that management practices are crucial for the achievement of sustainable remote health workforces where sustainable workforces contribute to improving access to health services for remote populations. In remote regions where voluntary turnover is high, integrating HRM and health sector research was important for examining the influence of management practices on the translation of HRM policy choices into practices that support the achievement of sustainable remote health workforces