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Aust. J. Rural Health (2015) ••, ••–••
Original Research Challenges of working and living in a new cultural environment: A snapshot of international medical graduates in rural Tasmania Daniel R. Terry, MIntlHlth and Quynh Lê, PhD Centre for Rural Health, University of Tasmania, Launceston, Tasmania, Australia
Abstract
Introduction
Objectives: To highlight the experiences and challenges of international medical graduates (IMGs) living and working in rural and remote Tasmania, and how this informs their acculturation and retention in the state. Design: This paper reports the findings from the Tasmanian IMG questionnaire, which was administered both in hardcopy and online format to all known IMGs within the state. A total of 105 questionnaires were returned, representing a response rate of 30.0%. Results: IMGs were from the 30 countries and the majority were under 49 years of age, had migrated in the past 10 years, with over half having worked in the state for less than 2 years. Many IMGs indicated that they were satisfied with their current employment, the medical facilities, the friendliness of their patients and the friendliness of the community where they lived, and would like to stay much longer in Tasmania. Conclusions: Many IMGs have previously lived and worked in rural areas and are reasonably satisfied with their current employment and lifestyle in Tasmania. However, the following factors play an important part in their views and attitudes: employment satisfaction, access to schools, employment for spouse or partner and access to cultural or religious foods and goods. Nevertheless, beyond employment satisfaction, employment itself, coupled with career pathway and training opportunities, were highlighted as contributory factors for leaving Tasmania.
International medical graduates (IMGs) continue to be central to health workforce planning in Australia.1,2 IMG recruitment and compulsory rural schemes remain essential to sustain rural access to health services. This includes the 10-year moratorium, which restricts IMG access to Medicare provider numbers and subsequent cash rebates for up to 10 years until mandatory rural practice has been fulfilled.3 Rural and remote regions experience the lowest levels of health access, the highest levels of medical practitioner maldistribution and the greatest health disadvantage in Australia.4,5 Currently, the medical workforce remains reliant on IMG recruitment; however, their retention in rural and remote areas, once obligations are met, remains problematic.6–8 IMGs have a propensity to relocate into more metropolitan areas once compulsory services obligations are complete.6–8 To date, research concerning IMG rural retention and settlement success has focused primarily on workplace satisfaction and practice support. Little research has examined the quality of life, social needs, and the health and well-being of IMGs and their families.9–14 These crucial factors may have some bearing on IMG retention, length of stay and acculturation – where migrants adopt aspects of a new culture while retaining elements of their original culture.15 Currently, IMGs constitute approximately 30% (n = 350) of all registered medical practitioners in Tasmania, which is higher than the national average of 25.9%.16 This paper provides some insights into the enablers and barriers that IMGs encounter as they live and work in Tasmania.17–19 It highlights a number of motivators explaining why IMGs are staying or leaving rural areas of Tasmania and reflects the needs, desires and challenges encountered by IMGs locally and nationally.
KEY WORDS: acculturation, international medical graduate, medical workforce, retention, satisfaction.
Correspondence: Mr Daniel R. Terry, Centre for Rural Health, University of Tasmania, Locked Bag 1372, Launceston, Tasmania, 7250, Australia. Email: [email protected] Accepted for publication 16 June 2014. © 2015 National Rural Health Alliance Inc.
Methods This paper reports the findings of the Tasmanian IMG questionnaire, which took a ‘snapshot’ of IMGs in doi: 10.1111/ajr.12128
2
D. R. TERRY AND Q. LÊ
What is already known on this subject: • International medical graduate (IMG) recruitment continues to be vital for Australian health workforce planning, particularly in rural areas. • Retention of IMGs in rural and remote areas remains challenging. • Professional support remains critical for IMG integration and retention in rural communities.
Tasmania. The confidential self-administered questionnaire had undergone face and content validation, while psychometric properties were evaluated. The questionnaire was administered between March and July 2012, in hardcopy format, and was also made available online via SurveyMonkey. It was distributed to all know IMGs in the state through third parties such as medical educators, directors of clinical training and IMG recruitment staff. Ethical approval for the study was obtained by the Human Research Ethics Committee (Tasmania) Network prior to commencing the study. Data were cleaned, checked and analysed using SPSS version 20.0 (IBM, Armonk, New York). Descriptive statistics and inferential statistics, such as χ2 tests and Spearman’s correlation, were performed to analyse the data. Results were considered statistically significant at P ≤ 0.05. Lastly, the Wilson procedure was used, as described by Newcombe,20 to calculate the 95% confidence intervals (CI) for percentages of important constructs within the data.
Results A total of 105 questionnaires were returned, representing a response rate of 30.0% and showed that 34.4% of the respondents were working in general practice and 65.6% were working in the acute care sector. This included 26.7% hospital registrars, 21.1% hospital residents including interns and 13.3% specialists. A high proportion of IMGs were working in and around the three major population centres of Hobart, Launceston and Burnie, with 38.8% in the North-West, 33.7% in the Northern and 27.6% working in the Southern region of Tasmania.
Characteristics of participants Questionnaire respondents comprised 57.2% males and 42.8% females while the age ranged from 20 to 60+
What this study adds: • The findings indicate that many IMGs are reasonably satisfied with their current employment and lifestyle in Tasmania that they and their families are experiencing. • Beyond employment and lifestyle satisfaction, employment itself, coupled with career pathway and training opportunities, are highlighted as contributory factors for leaving rural Tasmania. • Strategic recruitment of IMGs needs to benefit all parties involved, while IMG integration and retention is a process of marrying IMGs desires, their training requirements with current and long-term local needs of the community.
years of age. Those aged between 30 and 49 accounted for 69.5% of IMGs, as observed in Table 1. In addition, IMGs originated from 30 different countries across the globe, which included Africa, America, Asia, Europe, Middle East and Oceania. However, IMGs from India represented 31.4% of questionnaire respondents. English was reported to be the first language among 14.5% IMGs, while 80.4% reporting their English skills at the time of migration was ‘good’ to ‘very good’ and 5.1% stated their English at the time of migration was ‘fair’ to ‘poor’.
Migration profile In the past ten years 83.5% of the IMGs arrived in Tasmania with the remaining 16.5% arriving before 2000. In addition, 51.0% arrived on temporary work visas, whereas 9.0%, 7.0% and 6.0% had arrived on family visas, independent skilled and employer visa categories, respectively. The remaining 23.0% had entered Australia on dependent spouse visas, student visas (PhD), student dependent visas, and tourist or visitor visas. Those who migrated directly to Tasmania from their country of origin stated the three most important reasons moving: ‘to accept current medical position’ (64.2%); ‘to gain a better standard of living’ (43.3%); and ‘to join family or friends’ (28.3%).
Registration and employment profile The mean (±SD) length of time an IMG had worked prior to arriving in Australia was 9.37 ± 6.7 years, while 53.3% IMGs had worked in rural areas for a mean length of time of 5.10 ± 4.8 years before © 2015 National Rural Health Alliance Inc.
3
DOCTORS’ PERSPECTIVE OF RURAL TASMANIA
TABLE 1:
Characteristic of participants
Variables Gender (n = 105) Male Female Age (n = 105) 20–29 30–39 40–49 50–59 60+ Marital status (n = 104) Married/de facto Separated/divorced Never married Widowed Total with children (n = 104) Religion (n = 102) Christian Hindu No religion Islam Buddhist Sikh Jewish Total
Number (n/N) Percentage (%)
60/105 (57.2) 45/105 (42.8) 13/105 38/105 35/105 11/105 8/105
(12.4) (36.2) (33.3) (10.5) (7.6)
78/104 16/104 9/104 1/104 68/104
(75.0) (15.3) (8.7) (1.0) (65.4)
29/105 22/105 17/105 16/105 12/105 5/105 1/105 100.0%
(28.4) (21.6) (16.7) (15.7) (11.8) (4.9) (1.0)
migrating to Australia. After migrating to Australia, 57.9% of the IMGs had immediately gained employment through ‘area of need’ or other similar medical positions; however, 11.4% gained employment more than 25 months after arrival. In terms of employment, 82.5% of the IMGs were currently on contracts between 7–24 months. In addition, 50.6% were working between 31 and 40 hours; 24.7% working between 41 and 50 hours; 16.9% working more than 50 hours a week; while the remaining 7.8% were working less than 30 hours a week.
Current time and intention to stay in location 59.0% of IMGs lived in Tasmania for 2 years or less; however, the mean length of time in the state was 2.8 ± 2.9 years. 58.2% (57/98; 95% CI, 47–67) of IMGs further indicated that they would like to stay ‘long term’ in Tasmania, while 56.5% (52/92; 95% CI, 46–66) of the IMGs said that their families would also like to stay in Tasmania ‘long term’. The relationship between an IMG’s desire to stay in Tasmania and their family’s desire to stay in Tasmania was further analysed using Spear© 2015 National Rural Health Alliance Inc.
man’s correlation. The results showed that there was a strong positive correlation between an IMG’s and their family’s desire to stay in Tasmania, r = 0.784, n = 92, P value 0.01 < 0.05. However, when asked how much longer they would like to work in Tasmania, 60.0% (63/105; 95% CI, 50–68) stated that they would work in their current location for a further 1–2 years with a mean of 2.7 ± 3.2 years being indicated.
Employment satisfaction Employment satisfaction has been shown to be one of the most important factors for IMGs retention in rural areas.2,3,10,12,13,21,22 As such, each participant was asked concerning their satisfaction with their current employment. Overall, 86.8% (79/91; 95% CI, 78–92) of IMGs were ‘satisfied’ in their current position, 13.2% (12/91; 95% CI, 7–21) indicated that they were unsure, whereas no IMGs indicated that they were dissatisfied in their current position. In addition, 85.7% (78/91; 95% CI, 77–91) of the IMGs were satisfied with supportive colleagues, and 88.0% (81/92; 95% CI, 79–93) were satisfied with the friendliness of their patients. Conversely, 85.9% (79/92; 95% CI, 77–91) of the IMGs were satisfied with the friendliness of the community in which they were currently working. However, those IMG working in the north-west region, a more rural and regional area of Tasmania, were more satisfied than those IMG respondents working in the more urban regions of Northern and Southern Tasmania (χ2 (6, n = 92) = 12.296, P value = 0.038 < 0.05).
Lifestyle satisfaction In terms of lifestyle satisfaction, IMGs were relatively satisfied with their current location, with 84.9% (79/93; 95% CI, 76–90) being satisfied. In addition, 79.6% (74/93; 95% CI, 70–86) were satisfied with the friendliness of the local people in the community. Nevertheless, the data analysis also showed 64.7% (55/85; 95% CI, 54–74) and 51.2% (42/82; 95% CI, 40–61) were unsatisfied because of the inability to access cultural or religious foods or goods and religious facilities, respectively. Further exploration showed that IMGs from Asia were less satisfied with being able to access religious facilities than those IMG respondents from other countries (χ2 (15, n = 79) = 34.015, P-value = .002 < 0.05).
Future plans of respondents The IMGs were asked to rate the level of importance against 17 characteristics of their current residential location, which would most likely influence future employment. It is reported that 76.1% (70/92; 95% CI, 66–83) rated employment satisfaction as an important
4
aspect of future employment, followed by access to private transport, 65.9% (60/91; 95% CI, 55–74); improved medical facilities and resources, 51.1% (47/ 92; 95% CI, 41–61); access to good schools, 48.9% (44/90; 95% CI, 38–59); and employment for a partner or spouse, 48.4% (44/91; 95% CI, 38–58). In addition, 77.0% (70/91; 95% CI, 67–84) of the IMGs rated settlement near cultural community as unimportant, while 59.8% (55/92; 95% CI, 49–69) indicated that access to cultural community was important. Also, 55.0% (50/91; 95% CI, 44–64) indicated that access to cultural or religious foods and goods was also important. Lastly, 60.9% (56/92; 95% CI, 50–70) of IMGs reported that they would like to stay in their current position for the foreseeable future, whereas 13.0% (12/92; 95% CI, 7–21) wanted to stay in Tasmania but move to an alternative location. In addition, 25.0% (23/92; 95% CI, 17–38) of respondents wanted to move interstate, while 1.1% (1/92; 95% CI, 0.2–5) were planning to move overseas. Also 72.8% (67/92; 95% CI, 62–80) of the IMGs stated that these future plans were based on employment reasons while 15.2% (14/92; 95% CI, 9–23) indicated that their intention to move away from Tasmania was based on community reasons.
Discussion The Tasmanian IMG questionnaire was undertaken to provide an understanding of IMGs in Tasmania. The results demonstrate that many IMGs have previously lived and worked in rural areas and are reasonably satisfied with their current employment and lifestyle in Tasmania. This was particular evident among those from the Asia region, such as India, Sri Lanka and Malaysia, who were satisfied with the medical facilities and resources in Tasmania. Hawthorne and colleagues23 have indicated that IMGs from Commonwealth Asian nations have a propensity to encounter less barriers than IMGs from other countries, which may explain the increased satisfaction among these groups of IMGs within the study. Despite the friendliness of the communities, there was a proportion of IMGs who stated their experiences in rural communities were less satisfactory due to the inability to access religious facilities and cultural or religious goods. This finding shows that access to and settlement near cultural communities can create a greater level of satisfaction for IMGs and their families when living and working in rural settings.12,13 However, IMGs in Tasmania felt access to rather than settlement near cultural community was more important.
Conclusion The findings may be vital for future planning and recruitment of IMGs specifically in Tasmania as the
D. R. TERRY AND Q. LÊ
research was focused on the enablers and barriers of IMGs living and working in rural and remote Tasmania, and how this informs their retention. To address these particular challenges, specific actions may be undertaken by governments and other key organisations and include having specific recruitment strategies, candidate review processes and policies in place. These policies must ensure that the current needs of an employer are met while long-term needs of the state and candidate are at the forefront of the selection process. For example, there may be an immediate need for interns in the acute care sector; however, the selection of applicants may also take into consideration long-term needs of a state or rural area and aspirations of the candidate. In addition, there is a need to develop recruitment policies or selection processes that focus on matching potential candidates, their own or their family’s needs, and characteristics to rural communities. Furthermore, the process needs to focus on developing the awareness IMGs and their families prior to arrival regarding the positives of rural communities. This should include the lifestyle, ease of access to workplaces, proximity to major centres and to culturally and linguistically diverse communities or cultural specific foods. In addition, awareness building must focus on indicating some of the initial and longer term challenges potentially encountered by IMGs, spouses and children, such as spouse employment and education for children. The research shows that IMGs’ integration, settlement and retention in rural areas becomes a process of marrying IMGs’ desires, their training requirements with current and long-term needs. and goals of the community. The processes may be strengthened through strategic recruitment, which benefits the needs of the employer, employee and rural community. This needs to be followed by increased peer and pastoral support for IMGs to gain registration and to navigate the new medical system and social cultural environment.24 Nevertheless, as the questionnaire was conducted specifically among IMGs in Tasmania or because of the low response rate, the findings may be subject to response bias or may not be generalisable to all IMG populations. Despite these limitations, the research does provide some insights regarding IMGs who live and work in rural communities in other areas of Australia, particularly where settlement near cultural community is not always viable.
Acknowledgements We are most grateful to all participants for their invaluable contribution to the study. We would like to express our deep appreciation to the University of Tasmania, Department of Health and Human Services, Tasmanian © 2015 National Rural Health Alliance Inc.
DOCTORS’ PERSPECTIVE OF RURAL TASMANIA
Medical Local, General Practice Training Tasmania, Health Recruit Plus and Post Graduate Medical Council of Tasmania for their support.
References 1 Spike NA. International medical graduates: the Australian perspective. Academic Medicine 2006; 81: 842–846. 2 Alexander C, Fraser J. Education, training and support needs of Australian trained doctors and international medical graduates in rural Australia: a case of special needs. Rural and Remote Health 2007; 7: 681. (Online) http://www.rrh.org.au/articles/subviewaust.asp?ArticleID= 681. 3 Rural Health Workforce Australia. Parliamentary inquiry into overseas trained doctors. In: Webber Kim, ed. Submission to the Health Standing Committee. Melbourne, Vic.: Rural Health Workforce Australia, 2011; 1–19. 4 Deloitte Access Economics. Review of the Rural Medical Workforce Distribution Programs and Policies. Sydney, NSW: Deloitte Access Economics Pty Ltd, 2011; 1–61. 5 Scott A, Witt J, Humphreys J et al. Getting doctors into the bush: general practitioners’ preferences for rural location. Melbourne Institute Working Paper. Melbourne: Melbourne Institute of Applied Economic and Social Research, The Univerity of Melbourne, 2012. 6 Harvey K, Faunce TA. Critical analysis of overseas-trained doctor (OTD) factors in the Bundaberg Base Hospital surgical inquiry. Law in Context 2005; 23: 73–90. 7 Lim CKD. Prescribing practices of Australian dispensing doctors. School of Public Health. Perth, WA: Curtin University, 2010; 1–156. 8 Kilpatrick S, Johns S, Vitartas P, Homisan M. Mobile skilled workers: making the most of an untapped rural community resource. Journal of Rural Studies 2011; 27: 181–190. 9 Colic-Peisker V. Visibility, settlement success and life satisfaction in three refugee communities in Australia. Ethnicities 2009; 9: 175–199. 10 Durey A. Settling in: overseas trained GPs and their spouses in rural Western Australia. Rural Society 2005; 15: 38–54. 11 Gilles MT, Wakerman J, Durey A. ‘If it wasn’t for OTDs, there would be no AMS’: overseas-trained doctors working in rural and remote Aboriginal health settings. Australian Health Review: A Publication of the Australian Hospital Association 2008; 32: 655–663.
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5 12 Han GS, Humphreys JS. Overseas trained doctors in Australia: community integration and their intention to stay in a rural community. The Australian Journal of Rural Health 2005; 13: 236–241. 13 Hawthorne L, Birrell B, Young D. The retention of overseas trained doctors in general practice in regional Victoria. Faculty of Medicine DaHS. Melbourne, Vic.: University of Melbourne, 2003; 1–100. 14 Terry DR, Lê Q, Woodroffe J, Ogden K. The quality of life and social needs of International Medical Graduates: Emerging themes in research. International Journal of Innovative Interdisciplinary Research 2011; 1: 59–67. 15 Berry JW. Immigration, acculturation, and adaptation. Applied Psychology 1997; 46: 5–34. 16 Australian Institute of Health and Welfare. Medical Labour Force Survey 2009. Canberra: Australian Institute of Health and Welfare, 2011. 17 Han GS, Humphreys JS. Overseas trained doctors in Australia: community integration and their intention to stay in a rural community. Australian J Rural Health 2005; 13: 236–241. 18 Lê Q, Kilpatrick S. Vietnamese-born health professionals: negotiating work and life in rural Australia. Rural and Remote Health 2008; 8: 1–15. 19 Australian Bureau of Statistics. Census of Population and Housing – Expanded Community Profile. Canberra: Australian Bureau of Statistics, 2011. 20 Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Statistics in Medicine 1998; 17: 857–872. 21 Carlier N, Carlier M, Bisset G. Orientation of IMGs: a rural evaluation. Australian Family Physician 2005; 34: 485–487. 22 Han GS, Humphreys JS. Integration and retention of international medical graduates in rural communities. Journal of Sociology 2006; 42: 189–207. 23 Hawthorne L, Hawthorne G, Crotty B. The registration and training status of overseas trained doctors in Australia: final report. Melbourne: Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, 2007. 24 House of Representatives Standing Committee on Health and Ageing. Lost in the labyrinth: report on the inquiry into registration processes and support for overseas trained doctors. House of Representatives SCoHaA. Canberra: Department of House of Representatives Printing and Publishing Office, 2012; 1–259.
Aust. J. Rural Health (2015) ••, ••–••
Original Research Challenges of working and living in a new cultural environment: A snapshot of international medical graduates in rural Tasmania Daniel R. Terry, MIntlHlth and Quynh Lê, PhD Centre for Rural Health, University of Tasmania, Launceston, Tasmania, Australia
Abstract
Introduction
Objectives: To highlight the experiences and challenges of international medical graduates (IMGs) living and working in rural and remote Tasmania, and how this informs their acculturation and retention in the state. Design: This paper reports the findings from the Tasmanian IMG questionnaire, which was administered both in hardcopy and online format to all known IMGs within the state. A total of 105 questionnaires were returned, representing a response rate of 30.0%. Results: IMGs were from the 30 countries and the majority were under 49 years of age, had migrated in the past 10 years, with over half having worked in the state for less than 2 years. Many IMGs indicated that they were satisfied with their current employment, the medical facilities, the friendliness of their patients and the friendliness of the community where they lived, and would like to stay much longer in Tasmania. Conclusions: Many IMGs have previously lived and worked in rural areas and are reasonably satisfied with their current employment and lifestyle in Tasmania. However, the following factors play an important part in their views and attitudes: employment satisfaction, access to schools, employment for spouse or partner and access to cultural or religious foods and goods. Nevertheless, beyond employment satisfaction, employment itself, coupled with career pathway and training opportunities, were highlighted as contributory factors for leaving Tasmania.
International medical graduates (IMGs) continue to be central to health workforce planning in Australia.1,2 IMG recruitment and compulsory rural schemes remain essential to sustain rural access to health services. This includes the 10-year moratorium, which restricts IMG access to Medicare provider numbers and subsequent cash rebates for up to 10 years until mandatory rural practice has been fulfilled.3 Rural and remote regions experience the lowest levels of health access, the highest levels of medical practitioner maldistribution and the greatest health disadvantage in Australia.4,5 Currently, the medical workforce remains reliant on IMG recruitment; however, their retention in rural and remote areas, once obligations are met, remains problematic.6–8 IMGs have a propensity to relocate into more metropolitan areas once compulsory services obligations are complete.6–8 To date, research concerning IMG rural retention and settlement success has focused primarily on workplace satisfaction and practice support. Little research has examined the quality of life, social needs, and the health and well-being of IMGs and their families.9–14 These crucial factors may have some bearing on IMG retention, length of stay and acculturation – where migrants adopt aspects of a new culture while retaining elements of their original culture.15 Currently, IMGs constitute approximately 30% (n = 350) of all registered medical practitioners in Tasmania, which is higher than the national average of 25.9%.16 This paper provides some insights into the enablers and barriers that IMGs encounter as they live and work in Tasmania.17–19 It highlights a number of motivators explaining why IMGs are staying or leaving rural areas of Tasmania and reflects the needs, desires and challenges encountered by IMGs locally and nationally.
KEY WORDS: acculturation, international medical graduate, medical workforce, retention, satisfaction.
Correspondence: Mr Daniel R. Terry, Centre for Rural Health, University of Tasmania, Locked Bag 1372, Launceston, Tasmania, 7250, Australia. Email: [email protected] Accepted for publication 16 June 2014. © 2015 National Rural Health Alliance Inc.
Methods This paper reports the findings of the Tasmanian IMG questionnaire, which took a ‘snapshot’ of IMGs in doi: 10.1111/ajr.12128
2
D. R. TERRY AND Q. LÊ
What is already known on this subject: • International medical graduate (IMG) recruitment continues to be vital for Australian health workforce planning, particularly in rural areas. • Retention of IMGs in rural and remote areas remains challenging. • Professional support remains critical for IMG integration and retention in rural communities.
Tasmania. The confidential self-administered questionnaire had undergone face and content validation, while psychometric properties were evaluated. The questionnaire was administered between March and July 2012, in hardcopy format, and was also made available online via SurveyMonkey. It was distributed to all know IMGs in the state through third parties such as medical educators, directors of clinical training and IMG recruitment staff. Ethical approval for the study was obtained by the Human Research Ethics Committee (Tasmania) Network prior to commencing the study. Data were cleaned, checked and analysed using SPSS version 20.0 (IBM, Armonk, New York). Descriptive statistics and inferential statistics, such as χ2 tests and Spearman’s correlation, were performed to analyse the data. Results were considered statistically significant at P ≤ 0.05. Lastly, the Wilson procedure was used, as described by Newcombe,20 to calculate the 95% confidence intervals (CI) for percentages of important constructs within the data.
Results A total of 105 questionnaires were returned, representing a response rate of 30.0% and showed that 34.4% of the respondents were working in general practice and 65.6% were working in the acute care sector. This included 26.7% hospital registrars, 21.1% hospital residents including interns and 13.3% specialists. A high proportion of IMGs were working in and around the three major population centres of Hobart, Launceston and Burnie, with 38.8% in the North-West, 33.7% in the Northern and 27.6% working in the Southern region of Tasmania.
Characteristics of participants Questionnaire respondents comprised 57.2% males and 42.8% females while the age ranged from 20 to 60+
What this study adds: • The findings indicate that many IMGs are reasonably satisfied with their current employment and lifestyle in Tasmania that they and their families are experiencing. • Beyond employment and lifestyle satisfaction, employment itself, coupled with career pathway and training opportunities, are highlighted as contributory factors for leaving rural Tasmania. • Strategic recruitment of IMGs needs to benefit all parties involved, while IMG integration and retention is a process of marrying IMGs desires, their training requirements with current and long-term local needs of the community.
years of age. Those aged between 30 and 49 accounted for 69.5% of IMGs, as observed in Table 1. In addition, IMGs originated from 30 different countries across the globe, which included Africa, America, Asia, Europe, Middle East and Oceania. However, IMGs from India represented 31.4% of questionnaire respondents. English was reported to be the first language among 14.5% IMGs, while 80.4% reporting their English skills at the time of migration was ‘good’ to ‘very good’ and 5.1% stated their English at the time of migration was ‘fair’ to ‘poor’.
Migration profile In the past ten years 83.5% of the IMGs arrived in Tasmania with the remaining 16.5% arriving before 2000. In addition, 51.0% arrived on temporary work visas, whereas 9.0%, 7.0% and 6.0% had arrived on family visas, independent skilled and employer visa categories, respectively. The remaining 23.0% had entered Australia on dependent spouse visas, student visas (PhD), student dependent visas, and tourist or visitor visas. Those who migrated directly to Tasmania from their country of origin stated the three most important reasons moving: ‘to accept current medical position’ (64.2%); ‘to gain a better standard of living’ (43.3%); and ‘to join family or friends’ (28.3%).
Registration and employment profile The mean (±SD) length of time an IMG had worked prior to arriving in Australia was 9.37 ± 6.7 years, while 53.3% IMGs had worked in rural areas for a mean length of time of 5.10 ± 4.8 years before © 2015 National Rural Health Alliance Inc.
3
DOCTORS’ PERSPECTIVE OF RURAL TASMANIA
TABLE 1:
Characteristic of participants
Variables Gender (n = 105) Male Female Age (n = 105) 20–29 30–39 40–49 50–59 60+ Marital status (n = 104) Married/de facto Separated/divorced Never married Widowed Total with children (n = 104) Religion (n = 102) Christian Hindu No religion Islam Buddhist Sikh Jewish Total
Number (n/N) Percentage (%)
60/105 (57.2) 45/105 (42.8) 13/105 38/105 35/105 11/105 8/105
(12.4) (36.2) (33.3) (10.5) (7.6)
78/104 16/104 9/104 1/104 68/104
(75.0) (15.3) (8.7) (1.0) (65.4)
29/105 22/105 17/105 16/105 12/105 5/105 1/105 100.0%
(28.4) (21.6) (16.7) (15.7) (11.8) (4.9) (1.0)
migrating to Australia. After migrating to Australia, 57.9% of the IMGs had immediately gained employment through ‘area of need’ or other similar medical positions; however, 11.4% gained employment more than 25 months after arrival. In terms of employment, 82.5% of the IMGs were currently on contracts between 7–24 months. In addition, 50.6% were working between 31 and 40 hours; 24.7% working between 41 and 50 hours; 16.9% working more than 50 hours a week; while the remaining 7.8% were working less than 30 hours a week.
Current time and intention to stay in location 59.0% of IMGs lived in Tasmania for 2 years or less; however, the mean length of time in the state was 2.8 ± 2.9 years. 58.2% (57/98; 95% CI, 47–67) of IMGs further indicated that they would like to stay ‘long term’ in Tasmania, while 56.5% (52/92; 95% CI, 46–66) of the IMGs said that their families would also like to stay in Tasmania ‘long term’. The relationship between an IMG’s desire to stay in Tasmania and their family’s desire to stay in Tasmania was further analysed using Spear© 2015 National Rural Health Alliance Inc.
man’s correlation. The results showed that there was a strong positive correlation between an IMG’s and their family’s desire to stay in Tasmania, r = 0.784, n = 92, P value 0.01 < 0.05. However, when asked how much longer they would like to work in Tasmania, 60.0% (63/105; 95% CI, 50–68) stated that they would work in their current location for a further 1–2 years with a mean of 2.7 ± 3.2 years being indicated.
Employment satisfaction Employment satisfaction has been shown to be one of the most important factors for IMGs retention in rural areas.2,3,10,12,13,21,22 As such, each participant was asked concerning their satisfaction with their current employment. Overall, 86.8% (79/91; 95% CI, 78–92) of IMGs were ‘satisfied’ in their current position, 13.2% (12/91; 95% CI, 7–21) indicated that they were unsure, whereas no IMGs indicated that they were dissatisfied in their current position. In addition, 85.7% (78/91; 95% CI, 77–91) of the IMGs were satisfied with supportive colleagues, and 88.0% (81/92; 95% CI, 79–93) were satisfied with the friendliness of their patients. Conversely, 85.9% (79/92; 95% CI, 77–91) of the IMGs were satisfied with the friendliness of the community in which they were currently working. However, those IMG working in the north-west region, a more rural and regional area of Tasmania, were more satisfied than those IMG respondents working in the more urban regions of Northern and Southern Tasmania (χ2 (6, n = 92) = 12.296, P value = 0.038 < 0.05).
Lifestyle satisfaction In terms of lifestyle satisfaction, IMGs were relatively satisfied with their current location, with 84.9% (79/93; 95% CI, 76–90) being satisfied. In addition, 79.6% (74/93; 95% CI, 70–86) were satisfied with the friendliness of the local people in the community. Nevertheless, the data analysis also showed 64.7% (55/85; 95% CI, 54–74) and 51.2% (42/82; 95% CI, 40–61) were unsatisfied because of the inability to access cultural or religious foods or goods and religious facilities, respectively. Further exploration showed that IMGs from Asia were less satisfied with being able to access religious facilities than those IMG respondents from other countries (χ2 (15, n = 79) = 34.015, P-value = .002 < 0.05).
Future plans of respondents The IMGs were asked to rate the level of importance against 17 characteristics of their current residential location, which would most likely influence future employment. It is reported that 76.1% (70/92; 95% CI, 66–83) rated employment satisfaction as an important
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aspect of future employment, followed by access to private transport, 65.9% (60/91; 95% CI, 55–74); improved medical facilities and resources, 51.1% (47/ 92; 95% CI, 41–61); access to good schools, 48.9% (44/90; 95% CI, 38–59); and employment for a partner or spouse, 48.4% (44/91; 95% CI, 38–58). In addition, 77.0% (70/91; 95% CI, 67–84) of the IMGs rated settlement near cultural community as unimportant, while 59.8% (55/92; 95% CI, 49–69) indicated that access to cultural community was important. Also, 55.0% (50/91; 95% CI, 44–64) indicated that access to cultural or religious foods and goods was also important. Lastly, 60.9% (56/92; 95% CI, 50–70) of IMGs reported that they would like to stay in their current position for the foreseeable future, whereas 13.0% (12/92; 95% CI, 7–21) wanted to stay in Tasmania but move to an alternative location. In addition, 25.0% (23/92; 95% CI, 17–38) of respondents wanted to move interstate, while 1.1% (1/92; 95% CI, 0.2–5) were planning to move overseas. Also 72.8% (67/92; 95% CI, 62–80) of the IMGs stated that these future plans were based on employment reasons while 15.2% (14/92; 95% CI, 9–23) indicated that their intention to move away from Tasmania was based on community reasons.
Discussion The Tasmanian IMG questionnaire was undertaken to provide an understanding of IMGs in Tasmania. The results demonstrate that many IMGs have previously lived and worked in rural areas and are reasonably satisfied with their current employment and lifestyle in Tasmania. This was particular evident among those from the Asia region, such as India, Sri Lanka and Malaysia, who were satisfied with the medical facilities and resources in Tasmania. Hawthorne and colleagues23 have indicated that IMGs from Commonwealth Asian nations have a propensity to encounter less barriers than IMGs from other countries, which may explain the increased satisfaction among these groups of IMGs within the study. Despite the friendliness of the communities, there was a proportion of IMGs who stated their experiences in rural communities were less satisfactory due to the inability to access religious facilities and cultural or religious goods. This finding shows that access to and settlement near cultural communities can create a greater level of satisfaction for IMGs and their families when living and working in rural settings.12,13 However, IMGs in Tasmania felt access to rather than settlement near cultural community was more important.
Conclusion The findings may be vital for future planning and recruitment of IMGs specifically in Tasmania as the
D. R. TERRY AND Q. LÊ
research was focused on the enablers and barriers of IMGs living and working in rural and remote Tasmania, and how this informs their retention. To address these particular challenges, specific actions may be undertaken by governments and other key organisations and include having specific recruitment strategies, candidate review processes and policies in place. These policies must ensure that the current needs of an employer are met while long-term needs of the state and candidate are at the forefront of the selection process. For example, there may be an immediate need for interns in the acute care sector; however, the selection of applicants may also take into consideration long-term needs of a state or rural area and aspirations of the candidate. In addition, there is a need to develop recruitment policies or selection processes that focus on matching potential candidates, their own or their family’s needs, and characteristics to rural communities. Furthermore, the process needs to focus on developing the awareness IMGs and their families prior to arrival regarding the positives of rural communities. This should include the lifestyle, ease of access to workplaces, proximity to major centres and to culturally and linguistically diverse communities or cultural specific foods. In addition, awareness building must focus on indicating some of the initial and longer term challenges potentially encountered by IMGs, spouses and children, such as spouse employment and education for children. The research shows that IMGs’ integration, settlement and retention in rural areas becomes a process of marrying IMGs’ desires, their training requirements with current and long-term needs. and goals of the community. The processes may be strengthened through strategic recruitment, which benefits the needs of the employer, employee and rural community. This needs to be followed by increased peer and pastoral support for IMGs to gain registration and to navigate the new medical system and social cultural environment.24 Nevertheless, as the questionnaire was conducted specifically among IMGs in Tasmania or because of the low response rate, the findings may be subject to response bias or may not be generalisable to all IMG populations. Despite these limitations, the research does provide some insights regarding IMGs who live and work in rural communities in other areas of Australia, particularly where settlement near cultural community is not always viable.
Acknowledgements We are most grateful to all participants for their invaluable contribution to the study. We would like to express our deep appreciation to the University of Tasmania, Department of Health and Human Services, Tasmanian © 2015 National Rural Health Alliance Inc.
DOCTORS’ PERSPECTIVE OF RURAL TASMANIA
Medical Local, General Practice Training Tasmania, Health Recruit Plus and Post Graduate Medical Council of Tasmania for their support.
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