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What Professional Educational Training and Support Have Been Shown to Improve Retention Strategies for Nurses and Midwives in Remote Parts of Australia?

Table of Contents

Table of Contents.

Introduction. 

Literature review..

Workplace culture and its effect on the retention.

Existing workforce.

Reason for low retention and recruitment

Retention strategies.

Research methodology.

The rationale for conducting a scoping review..

Formulation of the research question.

Definition of key terms.

Identification of relevant studies.

Selection of studies to be included in the scoping review..

Charting of data.

Collating, summarizing and reporting of the results.

Additional information.

Ethical consideration.

Funding.

Timeline.

Research question formulation.

Definition of key terms.

Scheduling and publication.

Limitations.

Conclusion.

References.

Introduction

The profession of healthcare is a dynamic one and the healthcare professional require continuous training and have to enhance their education in such a way that they can cater best to the needs of their consumers (Ortega et al. 2015). This depends on the technical and ethical professional action which affects the quality of work in terms of material and human resources. The planning and management education curriculum are made based on the relationship between various factors like higher education, society and labour market (Yates Usher and Kelly 2011). The professional education training is in such a way that it is appropriate for the social, economic and cultural development and from a bio-psycho-social point of view caters to the needs of the clientele. Healthcare workforce has nurses and midwives as their integral part that caters to the needs of the clients at primary, secondary and tertiary levels of healthcare. They work in various kinds of settings per the requirements like in acute care setting, elderly care setting or community and even in a rural care setting (Hayes et al. 2012).

The healthcare task force is divided for the urban and rural population who work for the wellbeing of the people living in a particular geographic setting. There has been a demographic shift from younger age group to older age which is not only in the people requiring care but also the people working are in the same age group. This is not a localized phenomenon but it is seen across the globe as the demographic shift towards the older generation is attributed to the success of healthcare which has extended the life span of humans. This is an era of population explosion and it is seen that the care-seeking population is increasing but there is no proportionate increase in the task force.

The major proportions of the existing nurses are either nearing retirement, retired or will be closer to retirement by the end of the coming decade (Finlayson et al. 2002). This is not a localized scenario as this is faced by the healthcare system across the world like European nations, the United States, the United Kingdom and even the developing nations are facing it. There is more proportion of people living in rural or remote areas compared to urban areas but the healthcare workforce and facilities are concentrated in the latter. This maldistribution accounts for health disparity among the people living in various geographic locations. According to the principle of equitable distribution of the healthcare, there should equitable distribution of healthcare which is including the manpower.

Due to various reasons, it is seen that there is less retention of the nurses in a rural setting like lack of resources, underpaid and better opportunities have rendered nurses and midwives to quit or shift the workability (Atitsogbui and Amponsah-Tawiah 2019). To make sure that the manpower in remote areas is adequate there is a requirement of support and proper education and training and there is no adequate literature for the same in the Australian context. 

Research question: What professional educational training and support have been shown to improve retention strategies for nurses and midwives in remote parts of Australia?

Literature Review

Workplace culture and its effect on the retention

Workplace culture is important for the people working to increase their experience which ultimately increases the productivity of employees and in case of healthcare as a positive impact on the patients as well. A study was conducted to understand the perceptions of midwives about the workplace culture and its subsequent effect on their retention (Catling and Rossiter 2019). The policy and procedural changes take place often and the culture of the workplace change accordingly which might have a negative or positive influence on the workforce as well as the wellbeing of the patient. The practise of midwifery has always known to adapt themselves towards the change in technology and new evidence, adopt the changes in the government directives and hospital into the culture of the workplace.

When there is an addition to the workforce they are acclimatized to the work culture either by practice and experience or by observation as to what needs to be done and what is expected of them (Catling and Rossiter 2019). This culture is seen by the employees as well as the consumers in the way of interaction that happens between staff. This influences the practice of midwifery and the ability of the students in learning. The study conducted was a mixed-methods study in which 23 midwives were interviewed later questionnaire was developed for the collection of data regarding their perception across Australia. There was a low response rate the tool used was pre-tested and validated (Catling and Rossiter 2019).

The results reflected that the workplace culture consisted of available support; their ability to be a midwife; and the presence of unacceptable behaviour and bullying. According to the study participants, the factors that are responsible for them to leave the work is dependent on management, powerlessness and lack of engagement at the workplace. Midwives want their patients’ wellbeing as being of utmost importance and bullying is responsible for the sub-optimal level of care for the patients and it is one of the driving factors for less retention. As the response rate was low the external validity and generalizability of the study results are questionable for the quantitative aspect. There was an underrepresentation of midwives from remote and rural areas of Australia and it cannot be said that the same factors are responsible for fewer retentions (Catling and Rossiter 2019).

Existing workforce

In an attempt to explore the existing workforce that is present in the remote and rural areas a study was conducted by Russell et al. (2017) where turnover and retention of the workforce in remote communities of the northern territory was Australia was done. Maldistribution of the health workforce according to the geographical location is a global issue and it is related to the inequitable distribution of healthcare. For curbing this maldistribution it is required that the planners and policymakers can understand the transitions of the workforce in and out of rural areas. In the present study, it was seen that healthcare provided to patients in primary healthcare is majorly by the nurses and midwives in a primary care setting and remote areas of the northern territory there were care facilities where there were no nurses and midwives.

Personnel Information and Payroll Systems reflected that the nurses and midwives recruited are done on a temporary or casual basis. The results of the present study reflected that nurses and midwives in the northern territory of Australia have a high turnover rate while the retention rate was extremely low. This was in comparison to the Aboriginal health practitioner though the reasons were not explored in the present study it can be attributed that Aboriginal health practitioners’ retention is related to the location which was closer to their traditional land and extended family.

The result reflected that shorter the intended time nurse or midwife is spending in a remote clinic more is the balance shift towards provision of healthcare and return on investment for the short-term staff is small and is not desirable (Russell et al. 2017). There is sub-optimal continuity of care which compromise health outcomes due to poor level of staffing and governments of territory and federal which works towards implementing and adequate delegation of the workforce so that the primary care workforce is stabilized (Russell et al. 2017).

Another study was conducted to evaluate the effective utilization of resource and capabilities of the rural communities for recruitment and retention of nurses. The study utilized a nursing community Apgar questionnaire for the same purpose (Prengaman et al. 2017). The study participants included were nursing administrators, senior nurses and other nurses in health facilities with the background knowledge of recruitment and retention history. The background reflected that the existing workforce is ageing which causes a difference in health access and health disadvantage to people living in remote areas. Sustainable access to health services has improved but the retention remains an issue which affects the health outcomes of people living in a particular geographic location (Adams 2016).

The results of the study reflected that community practice support has advantages like lifestyle, hospital management, the emphasis placed on the quality of care, reciprocity between the nurses and community, availability of resources, perception of quality, obtaining positive feedback, independence in decision making and ethical practice. Challenges identified were spousal satisfaction, community engagement, social life, allowance for making the move, fewer opportunities for recreation, a hindrance to electronic medical records, absence of flexibility and less professional development. Similar trends of factors were identified in Victoria where professional factors like autonomy, respect for the nurses remain a key factor in nurses’ job satisfaction and further their retention (Prengaman et al. 2017).

Reason for low retention and recruitment

Remote areas in Australia harbour less population, are far from large dwellings and have harsh geographic and climatic conditions which have cultural variation from the population the nurses are usually used to treating. A study was conducted to understand the problems of recruitment and retention of allied healthcare professionals in remote areas of Australia using a mixed-methods design using case studies from urban and rural areas (Campbell, Eley and McAllister 2016).

Allied healthcare professionals cover a wide range of professionals including nurses and midwives which were explored in the current study. Personality measure and repertory grid interviews were used to assess then remote success and four case studies were explored in the study. The results reflected that being from a rural background and remote area along with family or partner preference was a major influence on the recruitment and retention of the nurses and other allied health professionals in remote areas. The major limitation of the present study was that the sample size was extremely limited (Campbell et al. 2016).

Another study which was conducted for exploring the factor that acts as a barrier to the retention of the nurses in remote areas of Australia. The background reveals that there is a shortage of workforce which is indigenous in origin is underrepresented in the workforce of the healthcare system (Lai et al. 2018). This reduced workforce places the exiting workforce of indigenous health professionals under pressure. The study conducted was a systematic review where the barrier to retention was identified. The barriers were the environment of work, work pressure, absence of well-documented roles and responsibilities of the nurses, feeling of being underpaid and perception of income disparity, the influence of the community being worked for, and not being able to maintain a work-life balance (Taylor et al. 2018). The authors have recommended strategies for the improvement of retention like the building of supportive and culturally safe workplaces, definitive job roles, and scope of practice and responsibilities creation of substantial and stable workforce.

A scoping review was conducted by Cosgrave et al. (2019) where the social determinants affecting the rural health workforce retention was evaluated. The authors stated that the populations living in remote and rural areas enjoy poorer health compared to people living in urban cities and this was attributed to a shortage of workforce that exists outside the metropolitan area and this is a global phenomenon. The results of the study were obtained by thematic analysis and the themes obtained were interest or familiarity with the rural area; social connection and place integration; community participation and satisfaction and fulfilment of life aspirations.

To reduce the health workforce gap, these professionals are in direct attention of government and political agenda which is directed towards the retention of the workforce which are directed towards individual nurses and their families (Cosgrave, Malatzky and Gillespie 2019). Involvement of local health services, businesses and local communities can be done to support the nurses and their families. The strategies for retention and recruiting cannot be focused on each healthcare professional individually and rural context is to be considered. The authors concluded that further research is required for the evaluation of retention strategies (Cosgrave et al. 2019).

Retention strategies

A review was conducted to summarize the retention strategies which are in place so that the retention of healthcare professionals in rural areas and this is done so that the existing primary healthcare is more cost-effective (Wakerman et al. 2019). The main reason that was stated by the authors was that the healthcare professionals recruited in rural areas are on temporary and the turnover rate makes it a costly affair (Zhao et al. 2018). The result of the review reflected upon three themes which were derived for the retention of the healthcare professionals.

The themes were: targeted enrolment into training and appropriate education which would create a workforce which is competent, accessible, and acceptable to the community and fit-for-purpose; addressing the issue of the safe and supportive work environment for the nurses and midwives; the individual and family of the nurses and midwives are provided with local support. The educational intervention required is to make sure that there is the prioritization of students from the remote origin and indigenous background at the time of university entry. Followed by maximizing the training in remote areas, curriculum which is contextualized, providing financial support, pedagogical and pastoral support, and support for professional and personal development (Wakerman et al. 2019).

Another study was conducted for exploring the interventions that can be used to support the nurses' retention in rural and remote areas. It was an umbrella review which was an overview of existing systematic reviews (Mbemba et al. 2013). The background reflected the same reasons and barriers to retention are similar to what has been discussed by the articles that have been discussed above. The recruitment and retention of nurses in rural areas are difficult compared to metropolitan areas. The barriers to retention were being in remote areas, not having safe work environment, lack of resources for personal life, professional stagnation and isolation and presence of better professional opportunities elsewhere which is the reason for increased turnover rate (Mbemba et al. 2013).

The first strategy that was identified in the study was to provide a financial incentive of nurses or midwives return to service in remote areas. The second strategy was to provide a supportive relationship to the nurses. The third strategy was to provide mentoring to the nurses as it can give a personal experience on an individual level, reciprocal, and vertical professional growth. Clinical supervision was the fourth strategy that was found which as a support mechanism for the nurses and midwives. The fifth strategy was precepting in which fresh graduate nurses are supervised by faculty staff. The sixth strategy was to provide the support of information and technology for the nurses and other strategies included career pathway for rural health (Mbemba et al. 2013).

From the literature review, it is seen that there are various factors which affect the recruitment and retention of nurses and midwives in rural areas. These factors mainly were related to lack personal and professional development and support, lack of resources, isolation and not having a safe workplace along with geographic and climatic conditions. Few intervention strategies have been identified for improving retention but the success of the same is not proven. The present research proposal is formulated for a scoping review for the research question ‘What professional educational training and support have been shown to improve retention strategies for nurses and midwives in remote parts of Australia?’

Research Methodology

From the literature review, it can be seen that there are scarce scoping reviews for the present formulated research question regarding the professional educational training and support provided to the nurses and midwives who work in remote areas. The information that is collected as a part of scoping review can be used to gather data which can provide valuable insight for the gap of the knowledge that is identified as the end of literature review (Egan et al. 2017). The gap currently exists which cause the sub-optimal level of health to the population living in rural and remote areas of Australia. The high turnover rate of the nurses and low retention in not cost-effective and hurts the health and safety of the patient which is linked to the job satisfaction and retention of the workforce.

The outcomes of this scoping review in the future can be used for a full systematic review but that decision will be made depending on the findings of the current scoping review (Bazzano et al. 2017). From the research question, the research objective identified is: to conduct a comprehensive scoping review of the related literature to map the identified evidence to evaluate the effectiveness of professional education and support strategies that increase retention for nurses and midwives working in rural and remote areas. The intervention aims to make sure that the nurses and midwives have job satisfaction working and are retained more in remote conditions of Australia.

The rationale for conducting a scoping review

A review is conducted mostly for primary research and it is a common practice for the basis of evidence-based practice as it is the benchmark for recognition of the care and in the recent time of information explosion there is increased access to primary researches (Munn et al. 2018). As the conduction of research has been made mandatory for the healthcare professionals for the continued professional education more number of primary researches is being conducted. There are various types of reviews and scoping review is one of them and the first framework for scoping review was published in 2005 but it is a newer method. It is also called mapping review as it is used for mapping the evidence that is present in a particular field in terms of nature, features and volume. The main aim behind the conduction of a scoping review is to clarify the definitions of various concepts in a particular field and understand conceptual boundaries (Morris, Boruff and Gore 2016).

Scoping review is more useful when there has been less review regarding a particular topic and the literature available on the topic is heterogeneous. The framework for scoping review has been updated since the first time they have been published by Levac, Colquhoun & O’Brien (2010) and further have been expanded and explained by Joanna Briggs Institute (as cited in Peters et al. 2015). The present research proposal also follows the steps as described by Joanna Briggs Institute (as cited in Peters et al. 2015). The steps include: identifying the research question; identifying the relevant studies; selection of studies to be included in the study; charting of the data; collating, summarize and reporting of the results and last step is optional which is consultation (Peters et al. 2015).

Formulation of the research question

Formulation of the research question is an important part of the scoping review as the identification and selection of research question will depend on the research question. Peters et al. (2017) gave the idea of PCC and the expansion stands for population, concept and context which are helpful in the identification and it helps in the establishment of a clear research purpose. The research question can be modified into the formation of the title of the scoping review and that also follows the concept of population, concept and context (Pham et al. 2014). Based on the research question formulated a concise background which is comprehensive. This is done so that the main topics of the scoping review are covered. This should include the main definitions and the knowledge which exists in the given field.

The introduction and the literature review made above give a brief background context the existing knowledge regarding the educational training and the intervention strategies regarding the retention of nurses and midwives in remote areas of Australia (Khalil et al. 2016). This is an important step as after this only the deficiency in the literature can be identified such that the future requirement of the scoping review is established and based on this research questions and objectives are made. The research question is a broad aspect by the use of which literature will be searched for the review while the objectives are the one which will help in the achieving the research question (Doody and Bailey 2016).

It is important that before the review is commenced the review objective and the research questions are clearly stated. They act as guiding statements for the development of inclusion and exclusion criteria which will help in the identification and selection of articles to be included in the review. From the broad research questions following objective or specific questions are formulated to aid in the selection process and they are:

  • What are the issues that nurses and midwives encounter and the effect of these issues in their retention in remote areas?
  • What are the supports that exist in the system for the improvement of the nurses and midwives in the remote areas of Australia?
  • What are the specific interventions and strategies that can be used to increase the retention of nursing and midwifery workforce in remote areas of Australia?

Definition of key terms

Before the literature search can begin the terms must be defined so that appropriate articles are selected. The first definition required is that of retention “it can be defined as the length of the time that is calculated from the time of commencement of the employment till the cessation with a particular employer”. Retention can also be measured by the rate of the turnover rate of the workforce of nurses and midwives (Cosgrave et al. 2019). The second definition is required is for the remote area which can be defined as the areas which are far from metropolitan areas and have fewer amenities including that of healthcare and have harsh geographic and climatic conditions (Jegasothy et al. 2017). For the current research proposal for scoping review, the terms rural and remote can be used interchangeably. The workforce working in remote and rural areas who are from local areas and non-locals both are included for the nurses and midwives other allied health professionals are not taken into consideration.

Identification of relevant studies

For the search strategy, the PICOS framework can be used so that the selected articles should match the PICO of the research question of the current scoping review.

Participants or population involved: Nurses and midwives

Intervention: Professional educational training and provision of support

Comparator: none

Outcome: retention of the nurses and midwifery workforce

Setting: remote Australia

From the research questions and the objectives, search terms or keywords are identified. These are the words which are synonyms to the PICO terms which have been identified. These keywords should be in such a way that they have MeSH representation that is when searched these terminologies will give the article or the review as one of the search results. The keywords and the subsequent MeSH representation that will be used in the mapping of the review articles are mentioned in table 1.

Table 1: Keywords and MeSH terms for the selection of articles

 

Population or participants (P)

Intervention (I)

Comparator (C)

Outcomes (O)

Setting (S)

Keywords

Nur* (Nurses, nurse, nursing staff) and midwi* (midwife, midwives)

Professional educational training and provision of support

-

Retention of the nur* and midwi* workforce

Remote Australia

Medical subject headings (MeSH)

Nurses, nurse, nursing staff, midwife, midwives, midwifery

Professional educational training, professional support, personal support, community support, social support, university training,

 

Retention of nurses/ nursing staff/ nurse, retention of workforce, retention of midwife/ midwives/ midwifes, turnover

Remote Australia, rural Australia.

The terms nurse and midwife can be used in a lot of variations so that a wide range of terms should be included in the search strategy. Truncation is used for both the terms nurse and midwife, that is, nur* and midwi* so that the last parts variation can be searched and mapped in the search strategy. For the formulation of a search string for the databases, there will be the utilization of Boolean Operators AND, OR and NOT in various combinations with the keywords so that the search can be blasted and mapped. Boolean operators as it is mentioned above are simple words which are used as conjunctions that are used for combining or excluding keywords and are used in research which gives the results in a more refined form which is more productive. For the current scoping review the keywords along with Boolean operators will be used in combinations as mentioned in table 2.

Table 2: Boolean operators and their combinations

Boolean operators

Combinations

AND

Nur* retention AND educational training, midwi*retention AND professional educational training, Nur* retention AND support, midwi*retention AND support, workforce retention AND professional educational training, workforce retention AND support, Nur* retention AND educational training AND remote areas, Nur* retention AND professional educational training AND rural areas, midwi*retention AND professional educational training AND remote areas, midwi*retention AND professional educational training AND rural areas, Nur* retention AND support AND remote areas, Nur* retention AND support AND rural areas, workforce retention AND professional educational training AND remote areas, workforce retention AND professional educational training AND rural areas, workforce retention AND support AND remote areas, workforce retention AND support AND rural areas.

OR

Professional educational training OR support, professional support OR personal support, professional educational training OR university training, professional support OR personal support OR community support OR social support, remote areas OR rural areas, remote areas of Australia OR rural areas of Australia, retention OR turnover

NOT

Nur* NOT general practitioner, Nur* NOT GPs, Nur* NOT doctors, Nur* NOT physicians, Nur* NOT allied health professional, Nur* NOT health professionals, Nur* NOT health personnel, Nur* NOT allied health personnel, Midwi* NOT general practitioner, Midwi * NOT GPs, Midwi * NOT doctors, Midwi * NOT physicians, Midwi * NOT allied health professional, Midwi * NOT health professionals, Midwi * NOT health personnel, Midwi * NOT allied health personnel

Combined

Professional educational training AND support OR university training OR professional support OR personal support OR community support OR social support AND nur* AND midwi* NOT general practitioner NOT GPs, NOT doctors NOT allied health professional NOT health professionals NOT health personnel NOT allied health personnel AND retention OR turnover AND remote areas OR rural

When search strategy is created the search limits must be placed to make sure that the information that is obtained is appropriate and relevant to the search requirements. In case of any review including a scoping review, it is important that articles are current and the authority of the articles are good so that the data obtained is reliable as it might determine the validity of the results obtained from the scoping review. For this purpose, search limiter will be used for limiting a few aspects of the search results which will be obtained from the databases that will be based on the geographic location. Search limiters are used for managing the large volumes of the literature that which is not possible to go through and form a review (Havill et al. 2014). Use of the keywords with truncation and Boolean operators long with search limiters can help with the formation of search strings which are used for advanced data search in the selected databases. Search strings may use alphanumeric variables which can help in the searching of the files.

This search strategy will be used to obtain results from various medical and nursing databases and those included PubMed, BioMed Central, Medline (Ovid), CINAHL, Emcare and Embase. These are databases which are related specifically for the research conducted in the field of nursing and medicine which can help to get the literature required for the current scoping review and the research question that has been formulated.

Selection of studies to be included in the scoping review

The articles which are obtained as a result of the search will be checked for the eligibility criteria for it to be included in the literature for the scoping review. An eligibility criterion is different from inclusion and exclusion criteria former is the one in which a particular study is to be taken in the scoping review or not while inclusion and exclusion criteria are used for better refining of the articles. The eligibility criteria for the articles to be included in the scoping review are that all the kinds of study design are included, that is, qualitative, quantitative, randomized control trial and other kinds of reviews. The articles from the search list will be screened by two independent researchers who will screen the search output for the title and abstract such that it can be included in the further review process.

Inclusion criteria in a scoping review will act as a guide as to what has been proposed by the reviewers and also help in guiding the reviewers as to what should and should not be included in the review.

  1. Articles only in English will be included in the study as it is the native language of both the researchers.
  2. The research design that will be included in the scoping review is- primary qualitative research, primary quantitative research, systematic reviews, meta-analysis, randomized controlled trial, literature review, scoping review and other types of reviews.
  3. The articles will also be checked for the participants, context and concept of the studies and will be included in the scoping review and they should conform to the PICOS guidelines.

Participants- the participants in the selected articles should have the study participants as nurses, midwives, nursing staff, nursing healthcare workforce, excluding aboriginal health workers, allied health professionals, doctors and other healthcare staff. Adults, irrespective of age, gender and race or ethnicity will be included in the study.

Concept- the review will take the articles which are based on professional educational training or opportunities to advance the career prospects of nurses and midwives. The role of the support strategies for critical thinking and self-reflection will be considered in the articles chosen for the scoping review. The outcomes that are considered in the articles that are selected in the current scoping review are the retention of nursing and midwives workforce in rural or remote areas of Australia. The articles were not limited to just the retention but also decrease in the turnover rate of the nurses and midwives and attrition.

Context- only the articles which will be included are the ones which are about the remote and rural areas in Australia.

Exclusion criteria:

  1. Articles which are regarding the retention of the healthcare professionals other than nurses and midwives.
  2. The articles which are conducted for areas which are not remote or rural Australia.

All the conflicts if there is any between the researchers will be dissolved by face-to-face discussion. The articles included will be done unanimously by the researchers. A search will be conducted for unpublished articles and a grey literature search will be performed. Search will be conducted as per the three step-protocol which is indorsed by Joanna Briggs Institute (2015). Step 1: A search in MEDLINE and CINAHL will be carried out, afterwards an examination of the title and abstract passage, likewise a search on the index phrases used to define articles. Step 2: Endeavour to undertake a second search on the keywords and index phrases within the included databases. Step 3: Search the reference lists of all the identified articles will be screened to pinpoint supplementary studies. The scoping review process will be conducted by the modified preferred reporting items for systemic reviews and meta-analyses (PRISMA) as depicted in figure 1 (Aromataris and Riitano 2014). This will be helpful in the extraction of data.

PRISMA flow diagram for the scoping review process

Figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for the scoping review process (Aromataris and Riitano 2014)

Charting of data

Extraction of data is also called as charting of results which is done in a logical and descriptive to form summary of the results that are aligned as per the objectives and research questions of the scoping review formulated for in the current research proposal. As articles of various research designs are included in the present scoping review the data will be extracted using the CASP checklist. CASP checklist is available for all the research designs like for qualitative, quantitative, systematic review, meta-analyses and others (Buccheri and Sharifi 2017). The checklists consist of simple questions which can help the researcher in the extraction of data as per the research question (Zuzelo 2019). This should be done in the form of a table where the data found can be easily seen and it would consist of source of the article, CASP, description of the article, key findings, relevance, strengths and limitations of the studies selected (table 3).

S. No.

Source of the article

CASP

Description

Key findings

Relevance

Strengths and limitations

             

Collating, summarizing and reporting of the results

A thematic analysis of the key findings and relevance that has been obtained as a part of charting of the data that can be used in summarizing the data that is found in the charting of the results will be done. The similar results will be grouped under the same clusters and these clusters will be categorized as similar categories and the major category will be named theme. A coding tree will be given this will be derived independently and then the researchers will compare the results and the difference will be resolved by the discussion will be done to arrive at a solution.

As the results are taken from the articles which have been published earlier which does not include the collection of information from human participants and there is no requirement for consent. Before the commencement of the review proposal will be approved from the institutional review board. There is no external funding for the review and it is a self-funded project.

Additional Information

Ethical consideration

The data or the information that is collected in the process of obtaining the data for the present scoping review is secondary as the primary researches which have been conducted in the context of the research question were searched. There is no human interaction with the participants in the current scoping review and the data collected is secondary from the studies which have already been published. In medical research, there are different kinds of consents that the researchers need to obtain from the study participants while recruiting them into the study (Pratt et al. 2017). If the study participants are involved in the study and information is required from them which will help in the collection of data or intervention if there is any provided to the participant's informed consent must be obtained before the commencement of the study.

There are instances when informed consent can be waived off and in an instance when a review is conducted the information taken is from secondary resources and informed consent is not required in cases like these (Cumyn et al. 2019). The information given by the study participants is in the original study is usually after consent for the research and as this is a secondary source it can be used as it is usually implied that the information can be used for future research purposes. The main ethical consideration that is to be taken care of in scoping review is that there is a chance of plagiarism. In the current scoping review all the sources of the literature that will be included in the review will be appropriately cited using proper referencing style and appropriate proofreading will be done to make sure that the no source remains unreferenced. Before the review process is started the approval for the scoping review will be obtained from the institutional review board.

Funding

For the present scoping review, no funding was obtained from any external source and the if there was the requirement of any source of funding like for example to gain access to some articles were completely self-funded.

Timeline

Setting up of the timeline for all the parts and stage of a scoping review is extremely important so that the review process is commenced and is completed within the given stipulated time. Though the scoping review is different from a systematic review the time taken for both the kinds of the reviews are almost the same. The first stage is to get the approval from the institutional review board and the time is counted from the formation of the research proposal. The next stage is to get both the independent researchers trained and calibrated so that the level and the quality of the literature that is obtained is similar from both the researchers and the difference between them is less so that the data collected and collated individually will obtain similar charting.

The next stage is the formulation of the research question and the definitions of the context and concept that are to be included in the present study. This part is already covered in the current research proposal of the scoping review. The next stage is the identification and the selection of the articles which will be included in the scoping review and this the part which takes more time as the literature search and the articles selected should be appropriate to the participants, concept and context of the research question and the objectives that are developed in the preceding step. The next stage is the discussion between the researchers to make sure that if there is any conflict can be resolved by this discussion.

The next step is the extraction of the data which the researchers will be conducted independently by the use of preferred reporting items for systematic review and meta-analyses. This stage can be further divided into the screening of the articles as per their titles and abstract; followed by screening for articles from other sources like grey literature and cross-referencing of the selected articles; removal of the duplicates; applying inclusion and exclusion criteria; full-text articles are screened as per the participants, concept and context and PICOS as developed; the full text of the listed final articles will be screened and analyzed as per the CASP checklist relevant for the study design.

The next stage is charting of the results which are allotted the most time after or equivalent to identification and selection of the articles which is done by the researchers independently. The next stage is a thematic analysis of the result which is also done by the researchers independently after which the researchers will discuss if there is any variation and a consensus is reached. The next stage is to form the write-up and hand over the thesis for the scoping review. The complete and concise Gantt chart is given in the appendix.

Research question formulation

The introduction and the literature review made above give a brief background context the existing knowledge regarding the educational training and the intervention strategies regarding the retention of nurses and midwives in remote areas of Australia (Khalil et al. 2016). This is an important step as after this only the deficiency in the literature can be identified such that the future requirement of the scoping review is established and based on this research questions and objectives are made. The research question is a broad aspect by the use of which literature will be searched for the review while the objectives are the one which will help in achieving the research question.

From the broad research questions following objective or specific questions are formulated to aid in the selection process and they are:

  • What are the issues that nurses and midwives encounter and the effect of these issues in their retention in remote areas?
  • What are the supports that exist in the system for the improvement of the nurses and midwives in the remote areas of Australia?
  • What are the specific interventions and strategies that can be used to increase the retention of nursing and midwifery workforce in remote areas of Australia?

Definition of key terms

Before the literature search can begin the terms must be defined so that appropriate articles are selected. The first definition required is that of retention "it can be defined as the length of the time that is calculated from the time of commencement of the employment till the cessation with a particular employer". Retention can also be measured by the rate of the turnover rate of the workforce of nurses and midwives. The second definition is required is for the remote area which can be defined as the areas which are far from metropolitan areas and have fewer amenities including that of healthcare and have harsh geographic and climatic conditions. For the current research proposal for scoping review, the terms rural and remote can be used interchangeably. The workforce working in remote and rural areas who are from local areas and non-locals both are included for the nurses and midwives other allied health professionals are not taken into consideration.

Scheduling and publication

The result that is obtained after the conduction of scoping review can be used to conduct a complete systematic review. The result that is obtained as a part of the scoping review is valuable information that can be used for the betterment of the healthcare workforce consisting of nurses and midwives. The strategies that are identified can be included in the policy-making at national, educational and community level. 

Limitations

Scoping review can have a few limitations which are not specific to the current scoping review but can be seen. There are more citations to screen in a scoping review and the screening is different compared to a systematic review. The review process is extensive and requires multiple structured searches and the search will obtain a large volume of literature.

Conclusion

The profession of healthcare is a dynamic one and the healthcare professional require continuous training and have to enhance their education in such a way that they can cater best to the needs of their consumers. There is more proportion of people living in rural or remote areas compared to urban areas but the healthcare workforce and facilities are concentrated in the latter. This maldistribution accounts for health disparity among the people living in various geographic locations. According to the principle of equitable distribution of the healthcare, there should equitable distribution of healthcare which is including the manpower. Due to various reasons, it is seen that there is less retention of the nurses in a rural setting like lack of resources, underpaid and better opportunities have rendered nurses and midwives to quit or shift the workability. To make sure that the manpower in remote areas is adequate there is the requirement of support and proper education and training and there is no adequate literature for the same in the Australian context. To address this gap in the literature current scoping review’s proposal is undertaken.

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