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Dear Editor
A recent quality improvement project in a remote Australian clinic highlighted the negative impact transient and short-term staff can have on quality in health care.
The project sought to improve the quality of diabetes care in a small primary healthcare clinic in a remote Indigenous community in Australia's Northern Territory. The project followed quality improvement methodology over a 9 month period and obtained ethical approval from the Central Australian Human Research Ethics Committee. It involved clinical and administrative staff of varying employment contracts - fly in/fly out (FIFO), agency locums and other short-term employees, as well as permanent staff.
As is the norm in quality improvement projects there were a number of barriers to improvement, though many of these could be anticipated and overcome. However, the most significant barrier was the considerable extent of staff turnover. Each departing staff member took with them any new knowledge and skills, and new arrivals had varying experience necessitating induction and training and the requirement for ongoing interventions by permanent employees that were, ultimately, unsustainable.
Within remote and Indigenous health care there are significant numbers of agency staff employed on FIFO contracts and other forms of short-term and temporary arrangements. This is in response to difficulties in recruiting and retaining permanent employees. The use of such contracts is often viewed positively as they plug gaps in rosters and work cover, and address some of the issues that have been identified as inhibiting staff retention, for example, isolation, stress and burn-out. As a result, many clinics are now staffed with an ever-changing mix of temporary, agency, and part-time nurses and doctors.
Temporary staff address the immediate walk-in health and emergency needs of remote communities. However, by the nature of their short-term contracts they may be less able to engage in ongoing quality improvement initiatives, indeed the use of large numbers of transient staff can work against quality. Evidence on the impact of staff turnover shows that staff stability provides better outcomes1 whereas staff discontinuity and turnover is linked to a fall in healthcare quality2,3. Within remote Australia, there is strong anecdotal evidence that high staff turnover decreases the effectiveness of clinics4, and retention of staff is the most significant challenge facing the QAAMS quality program on point-of-care testing5.
Our own project found that, with continuous attention from permanent supportive clinicians, quality improvement can be accomplished. However, with transient staff and high staff turnover, securing quality becomes very difficult to achieve and to sustain. Though our project has been small, the clinic situation is not unique and an increasing number of remote Indigenous health clinics have a constant turnover of staff. The current high level of FIFO or other short-term and transient contracts may provide solutions to some problems, but it should be recognised that such employment models can have an adverse impact on healthcare quality.
Matthew Justin Busbridge, MSc
Remote Area Nurse, Central Australia
Dr Annetta Smith, PhD
Associate Head of School, Highlands and Western Isles
University of Stirling School of Nursing, Midwifery and Health, Scotland
References
1. Hickey EC, Young GJ, Parker VA, Czarnowski EJ, Saliba D, Berlowitz DR. The effects of changes in nursing home staffing on pressure ulcer rates. Journal of the American Medical Directors Association 2005; 6(1): 50-3.
2. Bar-Zeev SJ, Kruske SG, Barclay LM, Bar-Zeev N, Kildea SV. Adherence to management guidelines for growth faltering and anaemia in remote dwelling Australian Aboriginal infants and barriers to health service delivery. BMC Health Services Research 2013; 13(1): 250.
3. Bar-Zeev S, Barclay L, Kruske S, Kildea S. Factors affecting the quality of antenatal care provided to remote dwelling Aboriginal women in northern Australia. Midwifery 2013; 30(3): 289-96.
4. Wakerman J, Curry R, McEldowney R. Fly in/fly out health services: the panacea or the problem? Rural and Remote Health 2012; 12: 2268. Available: www.rrh.org.au (Accessed 9 March 2014).
5. Shephard MD, Spaeth B, Mazzachi BC, Auld M, Schatz S, Loudon J, et al. Design, implementation and initial assessment of the NT POCT program. Australian Journal of Rural Health 2012; 20: 16-21.