Work challenges negatively affecting the job satisfaction of early career community mental health professionals working in rural Australia: Findings from a qualitative study.

Abstract

Purpose
Some of Australia’s most severe and protracted workforce shortages are in public sector community mental health (CMH) services. Research identifying the factors affecting staff turnover of this workforce has been limited. The purpose of this paper is to identify work factors negatively affecting the job satisfaction of early career health professionals working in rural Australia’s public sector CMH services.

Design/methodology/approach
In total, 25 health professionals working in rural and remote CMH services in New South Wales (NSW), Australia, for NSW Health participated in in-depth, semi-structured interviews.

Findings
The study identified five work-related challenges negatively affecting job satisfaction: developing a profession-specific identity; providing quality multidisciplinary care; working in a resource-constrained service environment; working with a demanding client group; and managing personal and professional boundaries.

Practical implications
These findings highlight the need to provide time-critical supports to address the challenges facing rural-based CMH professionals in their early career years in order to maximise job satisfaction and reduce avoidable turnover.

Originality/value
Overall, the study found that the factors negatively affecting the job satisfaction of early career rural-based CMH professionals affects all professionals working in rural CMH, and these negative effects increase with service remoteness. For those in early career, having to simultaneously deal with significant rural health and sector-specific constraints and professional challenges has a negative multiplier effect on their job satisfaction. It is this phenomenon that likely explains the high levels of job dissatisfaction and turnover found among Australia’s rural-based early career CMH professionals. By understanding these multiple and simultaneous pressures on rural-based early career CMH professionals, public health services and governments involved in addressing rural mental health workforce issues will be better able to identify and implement time-critical supports for this cohort of workers. These findings and proposed strategies potentially have relevance beyond Australia’s rural CMH workforce to Australia’s broader early career nursing and allied health rural workforce as well as internationally for other countries that have a similar physical geography and health system.

Full text

The Journal of Mental Health Training, Education and Practice
Work challenges negatively affecting the job satisfaction of early career community mental health
professionals working in rural Australia: findings from a qualitative study
Catherine Cosgrave, Myfanwy Maple, Rafat Hussain,
Article information:
To cite this document:
Catherine Cosgrave, Myfanwy Maple, Rafat Hussain, (2018) "Work challenges negatively affecting the job satisfaction of
early career community mental health professionals working in rural Australia: findings from a qualitative study", The Journal
of Mental Health Training, Education and Practice, https://doi.org/10.1108/JMHTEP-02-2017-0008
Permanent link to this document:
https://doi.org/10.1108/JMHTEP-02-2017-0008
Downloaded on: 18 April 2018, At: 21:51 (PT)
References: this document contains references to 42 other documents.
To copy this document: permissions@emeraldinsight.com
Access to this document was granted through an Emerald subscription provided by
Token:Eprints:FJ3NY2GV4K3UF2HTMEKD:
For Authors
If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service
information about how to choose which publication to write for and submission guidelines are available for all. Please visit
www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of
more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online
products and additional customer resources and services.
Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication
Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation.
*Related content and download information correct at time of download.
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

Work challenges negatively affecting the
job satisfaction of early career community
mental health professionals working
in rural Australia: findings from a
qualitative study
Catherine Cosgrave, Myfanwy Maple and Rafat Hussain
Abstract
Purpose –Some of Australia’s most severe and protracted workforce shortages are in public sector
community mental health (CMH) services. Research identifying the factors affecting staff turnover of this
workforce has been limited. The purpose of this paper is to identify work factors negatively affecting the job
satisfaction of early career health professionals working in rural Australia’s public sector CMH services.
Design/methodology/approach –In total, 25 health professionals working in rural and remote CMH services
in New South Wales (NSW), Australia, for NSW Health participated in in-depth, semi-structured interviews.
Findings –The study identified five work-related challenges negatively affecting job satisfaction: developing a
profession-specific identity; providing quality multidisciplinary care; working in a resource-constrained service
environment; working with a demanding client group; and managing personal and professional boundaries.
Practical implications –These findings highlight the need to provide time-critical supports to address the
challenges facing rural-based CMH professionals in their early career years in order to maximise job
satisfaction and reduce avoidable turnover.
Originality/value –Overall, the study found that the factors negatively affecting the job satisfaction of early
career rural-based CMH professionals affects all professionals working in rural CMH, and these negative
effects increase with service remoteness. For those in early career, having to simultaneously deal with
significant rural health and sector-specific constraints and professional challenges has a negative multiplier
effect on their job satisfaction. It is this phenomenon that likely explains the high levels of job dissatisfaction
and turnover found among Australia’s rural-based early career CMH professionals. By understanding these
multiple and simultaneous pressures on rural-based early career CMH professionals, public health services
and governments involved in addressing rural mental health workforce issues will be better able to identify
and implement time-critical supports for this cohort of workers. These findings and proposed strategies
potentially have relevance beyond Australia’s rural CMH workforce to Australia’s broader early career nursing
and allied health rural workforce as well as internationally for other countries that have a similar physical
geography and health system.
Keywords Australia, Public health, Community mental health, Early career health workforce,
Rural and remote health
Paper type Research paper
Background
Health workforce shortages in rural areas are a global phenomenon (World Health Organisation,
2010). In countries like Australia and Canada, with large land masses and many small, widely
dispersed rural communities, governments face significant challenges in providing adequate rural
health services. A major contributing factor is chronic rural health workforce shortages arising from
Received 15 February 2017
Revised 5 May 2017
4 July 2017
14 August 2017
5 October 2017
Accepted 5 October 2017
The authors acknowledge the
CMH professionals who
generously gave their time to
participate in this study and the
NSW rural LHDs that approved its
undertaking.
Catherine Cosgrave is a
Research Fellow at the School
of Rural Health, University of
Melbourne, Wangaratta,
Australia; and School of Health,
University of New England,
Armidale, Australia.
Myfanwy Maple is based at
School of Health,
University of New England,
Armidale, Australia.
Rafat Hussain is based at
Medical School,
Australian National University,
Canberra, Australia.
DOI 10.1108/JMHTEP-02-2017-0008 © Emerald Publishing Limited, ISSN 1755-6228
j
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

both recruitment and retention problems. With respect to workforce retention, job dissatisfaction is
widely reported as a key influence on the turnover of professionals working in health and human
services (Barak et al., 2001). This manuscript focusses on job satisfaction of health professionals
working in public health services operating in rural and remote Australia. Cranny et al. (1992)
defined job satisfaction as an individual’s positive emotional reaction to their job based on a
comparison of the actual outcomes of the job with their desired or expected outcomes.
Health professionals working in Australia’s rural public health services face particular work
challenges negatively affecting their job satisfaction (Buykx et al., 2010; Keane et al.,2012;WHO,
2010). Resourcing constraints are one of the major challenges –in particular, staffing shortages in
allied health and nursing –as well as the operation of small teams that further reduce in size with
increasing remoteness (Australian Institute of Health and Welfare, 2013a, 2013b; Buykx et al.,
2010; Ceramidas, 2010; O’Toole et al., 2010). The effects of these resourcing challenges on
Australia’s rural-based public sector health professionals relate to managing large workloads,
handling high levels of responsibility and having to develop a broad-based set of clinical skills to
cope with the diversity and acuity of client/patient presentations (Drury et al., 2005; Keane et al.,
2012; Perkins et al., 2007). Managing these additional work demands and responsibilities can be
very challenging, especially for less experienced health professionals and, in particular, for new
graduates (Lea and Cruickshank, 2015). Compared to health professionals working in Australia’s
major cities, widespread rural staffing shortages and budgetary constraints impose challenges on
rural staff for attending continuing professional development (CPD) courses and career progression
(Buykx et al., 2010; Crowther and Ragusa, 2011; Keane et al., 2012; Perkins et al.,2007).
Some of rural Australia’s most severe and protracted workforce shortages are in public sector
mental health. Since the early 1990s, mental health service reform has been a major focus of
Australia’s states, territories and federal governments, and they have been working together as the
Council of Australian Governments (COAG) to implement changes under the National Mental
Health Strategy (Australian Government, 2010). In 2011, COAG established Health Workforce
Australia[1], which had as one of its strategic objectives mental health workforce reform (Health
Workforce Australia, 2013). In more recent times, a national review of mental health programs and
services has been undertaken by Australia’s National Mental Health Commission to help guide the
major reform currently being implemented on the Australian mental health system (National Mental
Health Commission, n.d.). The review found that access to mental health care in rural and regional
communities was inequitable and attributed this to the skewed distribution of registered health
professionals to metropolitan areas (National Mental Health Commission, n.d.). Within the mental
health service sector, community mental health (CMH) services experience both critical staffing
shortages and a high staff turnover (Health Workforce Australia, 2013; Moore et al.,2010).Inrural
Australia, public CMH services operate in both small and regional towns and are heavily relied on by
those living with a serious and/or persistent mental illness (Perkins et al.,2013).Perkinset al. (2007,
p. 9) argued that “excessive workforce turnover”in rural CMH teams has thwarted “improvements
in access, quality and continuity of services”. Despite the importance of CMH services for
Australia’s regional, rural and remote[2] communities, to date, research identifying the factors
affecting the retention of this workforce has been limited (Cosgrave et al.,2015a).
Australia’s public sector CMH workforce is multidisciplinary, and its non-medical workforce
includes registered and psychiatric nurses as well as a mix of allied health professionals (Health
Workforce Australia, 2013). Almost all CMH positions are case management roles with clients
being individually case managed. The range of supports and activities provided by CMH
professionals to clients is typically generic, rather than discipline-specific (Lloyd et al., 2004). The
sharing of profession-specific skills tends to occur in client case conference team meetings (Fox,
2013). In an earlier related pilot study, undertaken by the authors with rural-based CMH service
managers (Cosgrave et al. (2015b), the retention of early career staff was discussed as being a
major workforce issue. For this study, “early career”has been defined as the first five years of
working in health after completing tertiary level qualifications (Eley et al., 2012).
Retention-focussed CMH workforce studies have identified that work-related factors positively or
negatively affect health professionals’job satisfaction. These factors include: the therapeutic
relationship with clients (Wilson and Crowe, 2008), feeling clinically effective (Onyett et al., 1995), team
work and the multidisciplinary approach (Onyett et al., 1995), being given a comprehensive orientation
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

(Buykx et al., 2010) and receiving regular clinical supervision (Ashby et al.,2013;Buykxet al., 2010;
Perkins et al., 2007). Factors negatively affecting job satisfaction include: additional workload
pressures arising from higher levels of client acuity and caseload complexity (Drury et al., 2005; Perkins
et al., 2007), reduced numbers and types of community services available to support clients (Crowther
and Ragusa, 2011), additional travel to see clients and/or to run outreach clinics (Perkins et al., 2007)
and needing to provide mental health skills and expertise to other hospital departments (Drury et al.,
2005). Gibb et al. (2003) and Drury et al. (2005) identified that unlimited or excessive caseloads had a
negative impact on job satisfaction of rural-based CMH professionals. Managing personal and
professional boundaries, particularly for health professionals who are long-term residents of the town
they are working in, has also been identified as negatively affecting the job satisfaction of mental health
workers (Gillespie and Redivo, 2012). These work challenges are mitigated for those rural-based CMH
professionals who feel well supported by their colleagues, perceive their team as being cohesive and
functional, and who feel well supported by their line manager and senior management, and that
management understands the job challenges faced (Buykx et al., 2010; Moore et al., 2010; Onnis and
Dyer, 2017; Perkins et al., 2007; Ragusa and Crowther, 2012).
CMH workforce research also identifies that for job satisfaction, forming and maintaining a
discipline-specific identity is important (Ashby et al., 2013; Lloyd et al., 2002). This accords with
broader health workforce research that identifies that health professionals tend to strongly define
themselves by their profession and identifying their professional differences from other disciplines
(McNeil et al., 2013). The formation of a professional identity usually begins at the university,
as part of undertaking a profession-specific health course, and, after graduation, is reinforced
through the provision of discipline-specific supervision and attending CPD courses, as well as
profession-specific networking meetings and social events (Duckett, 2005). Allied health
professionals working in rural mental health services, given their proportionally smaller workforce
numbers compared to nurses, tend to have less access to discipline-specific role models,
including the availability of on-site clinical supervisors (Lloyd et al., 2002).
This study aims to complement and extend the current understanding of health workforce retention
in Australia’s rurally located CMH public services. It investigates the work factors affecting the job
satisfaction of early career nursing and allied health professionals working in rural CMH services in
the State of New South Wales (NSW)[3]. This manuscript is a component of a larger doctoral study
investigating work and rural-living factors influencing turnover intention. The larger study adopted
a constructivist grounded theory methodology and, through a coding process, developed a
substantive theory explaining the turnover intention of rural-based early career CMH professionals
(Charmaz, 2014; Cosgrave, Maple and Maple, 2018). For this manuscript, the grounded theory
analytical approach ceased once categories and sub-categories had been identified.
Methodology
The recruitment of participants occurred using a criterion sampling strategy. The participant
inclusion criteria were: currently works in, or has recently worked in an NSW Health[4], CMH
service operating in north-western NSW; meets the eligibility criteria set by NSW Health to work
as a mental health professional; and has between one- and ten-year CMH work experience. NSW
Health’s position description for a “mental health professional”was used to determine “eligible”
health professions. This included: registered nurses, psychologists, occupational therapists,
social workers and Aboriginal mental health workers (AMHWs). While the minimum level of
professional qualification is usually completion of a Bachelor degree and registration or
membership of a professional body, AMHWs are the exception. AMHWs are recruited as trainees
under the NSW Aboriginal Mental Health Worker Training Programme and undertake embedded
training over three years while in the workplace (Watson and Harrison, 2009). The study aimed to
recruit participants from all the “eligible”health professions working as CMH professionals.
The study’s focus was on the experiences of early career CMH professionals; however, those
with up to ten years CMH work experience were also included because of anticipated difficulties
finding sufficient participants to meet the “early career”criteria, given the findings of the earlier
pilot study (Cosgrave et al., 2015b). Participants who had five years’plus CMH work experience
were asked to reflect on their work experiences in their first five years. For this manuscript,
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

participants with over five years’experience have been termed “experienced”, while those with
one to five years’work experience have been defined as “early career”. AMHWs undertaking a
three-year traineeship are classified as “early career”, and their first year of work after completing
their traineeship is treated as their fourth year of working in CMH.
In the earlier pilot study, with increased service remoteness, greater staffing challenges were identified
(Cosgrave et al., 2015b). As a result, this study aimed to include health professionals working in CMH
services located in towns of differing sizes and varying degrees of remoteness. A town type
classification system was developed using town population data from Australia’s 2011 census and
the “Australian Standard Geographical Classification –Remoteness Area”(ASGC-RA). The ASGC-RA
is based on the nearest road distance to an urban centre and includes five classifications: major cities
(RA1), inner regional (RA2), outer regional (RA3), remote (RA4) and very remote (RA5) (Australian
Bureau of Statistics, 2006). Small towns were classified as having populations of less than 20,000;
medium towns from 20,000 to 30,000; and large towns between 30,0000 and 50,000 people.
University ethics approval for this research was gained from the University of New England Human
Research Ethics Committee as well the two rurally located LHD Human Research Committees from
which the participants were recruited. In total, 26 participants were recruited after group
presentations were made by the first author at CMH team meetings. Two remote (RA4) towns were
included in the study. These two services experienced chronic staffing shortages and had very few
CMH staff, and hardly any staff who met all of the inclusion criteria. As it was a key aim of the study
to include the experiences of health professionals working in smaller services in remote areas, it was
decided that it was more important to collect data from these services than for the participants to
meet all of the criteria. As a result, some loosening of the criteria was made. This resulted in the
inclusion of a worker outside of the eligible professions (participant (P24) was an Aboriginal support
worker), as well as participants with work experience outside the 1-10 year range (P25 had over
20 years working in his CMH position, and P26 was an “experienced”health professional, but had
only worked a few months in her current position). For this manuscript, given its focus on CMH
professionals’job satisfaction, P24’s response has been excluded from the results.
Semi-structured face-to-face interviews were conducted by the first author over an 11-month
period ( July 2013-June 2014). On average, interviews lasted 1¼ hours. After each interview, the
first author immediately transcribed the interview verbatim and applied pseudonyms. In line with
grounded theory methods, a constant comparative method of data collection and analysis was
used (Charmaz, 2014). NVivo 10 software (QSR International) was used to assist in the analysis
process and to manage data. All three authors designed the study and the second and third
authors validated the first author’s coding.
Findings
Participant and CMH service profiles
This manuscript includes 25 participants drawn from the full range of eligible CMH professions,
15 of whom were in “early career”and 10 who were “experienced”(see Tables I and II).
Table I Participants by profession and career stage
Participant (P) –profession /career stage Registered nurses Social workers Psychologists
Occupational
therapists AMHWs Other
a
Total
Early career n¼3
P12, 14, 22
n¼4
P1, 2, 7, 13
n¼3
P4, 6,17
n¼5**
P16, 23 (trainee)
P3, 8, 11 (graduate)
n¼15
60%
Experienced n¼3
P9, 19, 21
n¼2
P18, 26
n¼1
P25
n¼3
P5,10, 20
n¼1
P16
n¼10
40%
Totals n¼6
24%
n¼6
24%
n¼4
16%
n¼3
12%
n¼5
20%
n¼1
4%
n¼25
100%
Notes:
a
A diversional therapist with a Bachelor of Applied Science had previously worked in a case management position for three years in her early
career in the same CMH service she was currently working in. **Two trainees and three graduates
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

The participants worked in CMH services operating in nine rural towns located across
north-western NSW (two large towns, one medium, six small). These nine towns covered three of
the five remoteness area (RA) classifications: three inner regionals (RA2), four outer regionals
(RA3) and two remote (RA4) (see Table III).
Interview findings
During coding of the interviews, the major categories affecting turnover were identified as
“managing the job”and “adapting to the workplace”. The factors included under these two
categories were: the job role, workplace relationships, access to CPD and availability of
career-building opportunities. Given the broad range of factors associated with job satisfaction, it
was considered an appropriate measure for discussing these factors.
The study identified five challenges negatively affecting the job satisfaction of early career
rural-based CMH professionals. These were: developing a profession-specific identity; providing
quality multidisciplinary care; working in a resource-constrained service environment; working
with a demanding client group; and managing personal and professional boundaries.
The challenges were found to be on a continuum and often heightened for workers in their
early career years and/or working in small, more remote towns. This is discussed under each
specific challenge (and summarised in Table IV ).
Table II Participant characteristics and town descriptors
Participant by interview order Health profession Experience level Town descriptor
1 Social worker Early career RA3, small town
2 Social worker Early career RA3, small town
3 Aboriginal mental health worker Early career RA3, small town
4 Psychologist Early career RA3, small town
5 Occupational Therapist Experienced RA3, small town
6 Psychologist Early career RA3, small town
7 Social worker Early career RA3, small town
8 Aboriginal mental health worker Early career RA2, large town
9 Registered nurse Experienced RA2, large town
10 Occupational therapist Experienced RA2, large town
11 Aboriginal mental health worker Early career RA2, large town
12 Registered nurse Early career RA2, large town
13 Social worker Early career RA2, large town
14 Registered nurse Early career RA2, large town
15 Diversional therapist Experienced RA2, large town
16 Aboriginal mental health trainee Early career RA2, large town
17 Psychologist Early career RA2, large town
18 Social worker Experienced RA2, large town
19 Registered nurse Experienced RA2, large town
20 Occupational therapist Experienced RA2, medium town
21 Registered nurse Experienced RA2, medium town
22 Registered nurse Early career RA2, medium town
23 Aboriginal mental health trainee Early career RA4, small town
24 Aboriginal health worker (no tertiary qualification) Not included in this study
25 Psychologist Experienced RA4, small town
Table III CMH services by remoteness and town size
CMH services –remoteness area/town type Inner regional area (RA2) Outer regional area (RA3) Remote area (RA4) Total
Large rural town (population over 30,000o50,000) n¼22
Medium rural town (population between 20,000-30,000) n¼11
Small town (population othan 20,000) n¼4n¼26
Total number of town types 3 4 2 9
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

Developing a profession-specific identity
Most participants spoke of strongly identifying with their particular profession and discussed the
importance of continuing to develop their professional identity despite working in generic case
management roles. Some participants described feeling pressured from management and/or
from their team members to view themselves primarily as CMH professionals and to give up, or
significantly lessen, their attachment to their profession-specific identity upon starting work in
CMH, as P20 explains:
There was […] a social worker who started at the same time. […] she was probably only here a yearif
that. [She had] major personality clashes with the two senior nurses. I think you fit in or you don’t[…].
I think, coming in as allied health [professional], I think it’s something you have to leave at the door.
Yes, you do really and just walk in as a clinician. I think as a new grad, you come out with all these
ideals about your discipline and what your discipline contributes and all of that. That was where she
was coming from, and she was really fighting it at every team meeting, and she was just exhausted,
and they were exhausted. I think of myself as a mental health worker. I think I’ve lost the OT
(occupational therapy) tag.
Many participants discussed the importance of developing a professional identity, and the
significance of having access to regular profession-specific opportunities for networking and
exchanging ideas. This was discussed as being particularly important in the early career years, as
P12, in his second year of working, discussed:
Yep. I took that opportunity [to undertake professional training courses in a capital city]. The good thing
about it was, at these trainings, there was usually a lot of other RNs, who worked in CAMHs [Child and
Adolescent Mental Health]. And so, it was my only chance to meet other RNs who worked in CAMHs.
Because there simply was none here.
In the larger, more centralised services operating in the inner regional areas (RA2), informal and
formal mentoring (including clinical supervision from discipline-specific senior health
professionals), most commonly occurred on-site, as P13, explains:
So here in X [an inner regional large town], I guess one of the positive factors in my retention would be
that I’ve always had someone with whom I can physically walk two steps to get to their office and say:
“This just happened”. Or even times, when I’ve had a client with me, I’ve left and just walked out and
ran something by someone. And I’ve also had access to other social workers like Y and Z, like people
in this actual building and I could just walk to their office.
In the smaller teams operating in the more remote areas (RA3 and 4), on-site discipline-specific
support was uncommon, especially for the allied health professionals. For these participants,
profession-specific support was usually provided by health professionals who resided out of
the town, and clinical supervision mostly took place over the phone. In all the service sites, both
Table IV Identified categories and sub-categories
Challenge category Particular challenges
Developing a profession-specific identity Tension between professional identity and working in generic case management position
Limited availability of profession-specific support (especially for allied health professionals)
Reduced access to CPD training
Providing quality multidisciplinary care Recruitment and retention issues and small team sizes resulting in insufficient mix of professions and a
limited range of clinical experience
More experienced staff sometimes set or limit the care approach taken by the team
Client allocation determined on staff’s current caseload size not clients’needs
Underutilisation of discipline-specific skills
Working in a resource-constrained
service environment
Required to provide additional services
Larger than average caseloads size arising from chronic staffing shortages
Working with a demanding client group Clients have very high levels of mental illness acuity
Workload increased as reluctance to arrange involuntary hospital admissions
Workload intensified from having clients on CTOs who are very demanding and time consuming
Stress is cumulative from working with clients who experience poor outcomes
Managing personal and professional
boundaries
Overlapping professional and personal relationships
Cultural clash issues for AMHWs
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

allied health and nursing participants discussed experiencing delays in being assigned a
suitable supervisor and their supervision sessions occurring less regularly than required,
especially in their first year of work. The NSW Health (2007) supervision policy proposes that
new graduates receive one hour per week and more experienced staff one hour per month.
P7’s experience as a new graduate, early career staff member highlights some of these
supervision issues:
Unfortunately, the person who was selected as my clinical supervisor initially was based in X [another
town], and she didn’t have the same value or idea about how clinical supervision should work as I did.
And so, for my first twelve months that I was there, I might have had supervision three times.
Allied health professionals working in the smaller teams operating in the more remote towns
commonly discussed relying on profession-specific meetings or attending CPD courses to
network with other discipline-specific health professionals. Experiencing significant impediments
to attending CPD courses was discussed by nearly all the participants, and this was explained as
relating to service-level budget constraints or cuts, requiring the participants to partially or fully
self-fund their CPD training. As CPD courses are mostly run in Australia’s major cities, training
costs tended to be high as they included course fees as well as transport and accommodation
costs. P4 discussed her inability to attend CPD due to staffing shortages, as there were no staff
available to back-fill her job. This situation was commonplace especially in the more remote
towns, where CMH was often the only public sector mental health service available, and staffing
the service was essential:
I know we keep talking about [a] lack of training and the funding and lack of resources and all that kind
of stuff and that’s a built-in thing with us; it’s something we deal with every single day. But if you were to
live in X [a major city], you would be able to take the afternoon off and go to training and it not cost you
anything. And not have to worry about that this client is in crisis because they’d go to the crisis care
team, not CMH.
Providing quality multidisciplinary care
Most participants were supportive of CMH’s multidisciplinary care approach and believed it
offered, at least in theory, holistic mental health care. The usual way that multidisciplinary care
happened was through weekly clinical review meetings at which clients were case conferenced.
Less formal approaches, such as drawing on the expertise of other team members from different
professions as and when required, were also mentioned.
To be able to provide effective multidisciplinary care, team sizes had to be large enough for there
to be an adequate mix of professions. In some services, the mix of professions was described as
being very limited, and this was nearly always the case in the smaller teams operating in the more
remote towns. In these teams, the team size tended to be less than ten people and, in some
services, fewer than five. Participants working in these small teams often described their team as
comprising a mix of primarily early career allied health professionals, generally in their first or
second years of working, as well as one or two long-term staff members, typically hospital-trained
psychiatric nurses. Participants working in these teams described the medical model as tending
to dominate the care approach, as P2 explains:
Starting in a workplace where you are working with nurses who have an idea that everybody does
the same job. There were three fulltime RNs that I was working with at the time […]. It was quite
challenging –well it still is challenging –trying to find out where I fitted as a social worker […]. On one
of my first days, I said to one of the nurses: “So, is every client here on medication?”She looked at
me kind of weirdly and said, “Well yeah!”And I’mthinking,“What do you mean?”Those kinds
of ideas of a really strong medical model were really challenging. I felt this pressure to kind of conform
to that.
A team’s ability to provide effective multidisciplinary care was also affected by relational issues
and a lack of professional respect between team members. P7 discussed the negative impact
that working in a small team of just two people had on client care, where the other team member
did not support a multidisciplinary approach:
The nurse, […] she was very closed, [so] in those cases, in those mental health client’s care, there was
no real multidisciplinary input, apart from the nurse and the doctor.
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

Some participants considered the ability to provide quality multidisciplinary care as
being made difficult due to the constraints and demands facing rural-based CMH services.
These included staffing shortages and a high demand for services, which usually meant that client
allocation was determined on current caseloads and attempting to share the client load equally
rather than matching clients’needs to the most appropriate team member, as P7 explains:
There’s a big crossover, in the rural environment, between disciplines I guess, or the functions
of clinicians. If someone specifically needed a type of psychological therapy, they would ideally
be allocated to X, because she’s the psychologist. […]. But, if at those times when, you know, if I have
30 clients, and someone else only had 10, that person that needed a social work service might be
allocated to the person with the smaller caseload. In which case, that person might consult with
me about things, but would essentially perform a pseudo social work function with the client.
P4 described feeling frustrated because she only got to use her discipline-specific skills with her
own allocated clients and not more broadly across the team. She described this as being a huge
downfall of working in a rural service and believed it was something particular to rural practice and
not something that occurred in the CMH services operating in the major cities:
I’ve talked to my supervisor in X [a major city] and other colleagues as well, and we talk about the
psychologists working in teams outside of this area. Whilst they still work in multi-disciplinary
teams too, within them it’s very clear what the role of an OT, social worker, or psychologist is within that
team rather than being seen as being just like everybody else and doing the same work as everyone.
Working in a resource-constrained service environment
Most participants discussed the challenges of working in a resource-constrained environment.
Budgetary and staffing constraints were discussed as negatively impacting workload and, in turn,
job satisfaction. Some participants talked about feeling their workloads were much larger than of
those working in CMH positions in the major cities, as their rural positions often involved having to
provide additional services, with limited support. These additional services included such
activities as providing mental health assessments for the hospital’s emergency department and/
or running outreach clinics. These additional activities were discussed as taking up substantial
amounts of time. Several participants spoke of having to manage large caseloads resulting from
other team members leaving or long-term staff vacancies. Several participants discussed having
caseloads that were, at times, over 40 adult or child/adolescent clients. P6, working in a CMH
service situated in a small remote town, discussed commonly having a caseload of around
45 child or adolescent clients and described her workload as ridiculous. Affected participants’
described their workloads as unmanageable, feeling overworked and stressed, and this having a
very negative effect on job satisfaction, as P9’s response highlights:
I was very stressed, that’s why I was looking for other jobs [laughs]. I wasn’t really looking for other jobs
though, I think I was looking for distractions, just something to kind of take the pain away [laughs] […]. I
think it was just the time management, you know, doing all of the groups, as well as the paper work,
like all the computer work and the stats and seeing clients and fitting everything into a really limited kind
of time frame. [As well as having] at one point […] 40 clients.
Working with a demanding client group
Most participants spoke of their CMH clients as having high levels of mental illness acuity,
challenging behaviours and complex life situations. Supporting these clients was described as
being difficult and stressful at times. However, notably, many of the same participants also spoke
of drawing considerable job satisfaction from working with this client group. These participants
discussed being strongly committed to trying to improve their clients’well-being.
The predominance of high acuity clients was also attributed to a general reluctance to arrange
involuntary admissions under the NSW Mental Health Act (2007)[5]. This reluctance was
especially so if the client would have to leave their home town, which was commonly the case for
clients living in the small remote towns, as P25 explains:
We try to keep them out of hospital […]. To get a client from here, X to Y is traumatic for them and
traumatic for us. Often the ambulances won’t take them, and they have to be “specialled”[6] overnight.
And they [the hospital] are [usually] short-staffed, so they bring in Health’s security assistants.
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

Clients on community treatment orders (CTOs)[7] were also described by some participants
as being very demanding and significantly adding to workloads, as P4 relates:
Our CTO clients, obviously, the majority of them are non-compliant with medication. So according to
the Mental Health Act, we have to follow certain procedures and protocols with that. And on a day
when they are overdue with their medication, we would liaise with the police and ambulance to come
with us to find this client out in the community somewhere. That could take six–seven hours of an
eight-hour day and you’ve still got to fit in everybody else in that day as well.
The stress of working with a client group who often experienced poor outcomes such as
self-harm, suicide attempts and inpatient admissions was frequently described by participants as
taking an ever-increasing toll, both personally and professionally, and was associated with
burnout, both actual and anticipated, as P18 explains:
Those complex cases affect us. If we have done a counselling session, and the next day we are
hearing from the mother that he did self-harming or he tried to kill himself […]. One of the first
things that would be going through our mind is that I’m not a good enough clinician, it must be my fault.
[…] There is always this guilty feeling we are worrying about it. Did I document that properly,
does the documentation protect me? All these thoughts. […] So, we are carrying all of this
into our personal lives, and if you have three or four complex cases, then you won’t be happy on
weekends [laughs].
Managing personal and professional boundaries
An important responsibility for all CMH professionals is to protect client privacy and
confidentiality and to maintain professional and personal boundaries. Most participants
spoke of finding this challenging, given that personal relationships and professional
roles tended to overlap living and working in rural towns. These challenges increased the
smaller the town and/or the better-known, the health professional in the community,
as P21 explained:
It’s harder to maintain the privacy, and confidentiality like in terms of people go: “Oh how do you know
him?”or “How do you know that person?”or “Do you know them?”Because it is a small town
everyone kind of knows everyone, so people kind of figure it out.
While personal and professional boundary issues were something all CMH workers spoke of
having to learn to manage, boundary setting was found to pose additional difficulties for the
AMHWs[8], as P8 explained it was not the cultural norm in Australian Aboriginal culture:
As Aboriginal mental health workers […] we just don’t knock off at 4.30-5 o’clock at the end of the day.
If we see a community member, we can’t say, “No sorry, it’s five o’clock”. That stuff doesn’t fly in
Aboriginal communities, you don’t say no to people and expect them to be okay about it. You’ve got to
give them something, you know, or help in some way.
While protecting client privacy and maintaining personal and professional boundary issues were
ongoing concerns, participants spoke of these being much more problematic at the start of their
employment, and that over time, it got easier as they found ways to manage. This involved having
strategies in place for handling the allocation of clients who were known to them personally or
when meeting their clients on the street or in social situations.
Discussion
These findings identify the key factors negatively affecting the job satisfaction of rural-based,
early career CMH professionals, and provides a more nuanced, in-depth understanding of
these factors. Developing a professional identity was found to be very important for all
CMH staff, regardless of their discipline, but of particular concern in the initial years of early
career (Ashby et al., 2013; Lloyd et al., 2002). Given this, having regular opportunities to
participate in discipline-specific networking and/or CPD activities with other early career
professionals was identified as being extremely important for job satisfaction (Crowther and
Ragusa, 2011). In line with previous reports, a lack of respect and understanding between staff
members from different disciplines sometimes resulted in early career staff being the targets of
workplace hostility and bullying from longer serving staff members (Ashby et al., 2013; Lea and
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

Cruickshank, 2007; Lloyd, King, et al., 2002). Widespread staffing constraints commonly
resulted in there being little capacity to match clients’needs to the most appropriately skilled
team member, thus limiting the opportunities for rural-based staff to use their discipline-specific
skills. Allied health participants were observed to experience additional challenges relating to
the development of their professional identity and in providing multidisciplinary care, particularly
if working in small remote towns.
Working in a rural CMH service was confirmed as being stressful and demanding due to the
heightened mental health acuity of clients and limited availability of other service supports.
This had a cumulative negative effect on job satisfaction, which supports previous findings
(Drury et al., 2005; Perkins et al., 2007). In this study, the major factor negatively affecting job
satisfaction was large caseloads (Drury et al., 2005; Gibb et al., 2003). While accepting that client
numbers are a crude indicator of workload, it is still considered valuable to discuss caseload
sizes. A number of participants had caseloads that were well above the recognised average adult
caseload size of 20 clients (King, 2009), and these resulted from a high staff turnover and/or
long-term staffing vacancies (Ceramidas, 2010; Ragusa and Crowther, 2012). Personal and
professional boundary issues were confirmed as being a service-specific challenge experienced
by all rural-based CMH staff but posing greater challenges for those working in the small, more
remote towns and who were strongly connected to community. This usually concerned early
career staff who were working in their hometowns (Gillespie and Redivo, 2012). In rural CMH
services, AMHWs were found to experience the greatest personal and professional boundary
challenges, given this clashed with Australian Aboriginal cultural norms (Cosgrave, Maple and
Hussain, 2018).
In summary, many of the factors identified as negatively affecting the job satisfaction of
rural-based early career CMH professionals are well recognised in research. The study’s
findings suggest that collectively these factors have a negative multiplier effect on job
satisfaction for those in early career years. This multiplier effect is a likely explanation for the high
levels of job dissatisfaction and turnover experienced by this cohort of CMH workers.
While the findings focus on the work challenges experienced in the early career years, the study
found that these challenges affect all rural-based CMH professionals, although to a lesser
extent among the more “experienced”staff. These challenges were also observed to be
heightened for CMH staff working in small towns in the more remote geographical areas
(RA3 and RA4).
Practical implications
The findings highlight the need to provide time-critical supports to address the challenges
facing rural-based CMH professionals in their early career years in order to maximise job
satisfaction and reduce avoidable turnover among this cohort. Having supports in place from
the outset is of importance for all early career CMH professionals and especially for those who
are working in small, remote towns. Suggested strategies for improving job satisfaction among
rural-based CMH professionals in their early career years include: ensuring regular clinical
supervision with a discipline-specific supervisor; providing in-house training for learning to
manage professional and personal boundary issues; ensuring funds are budgeted to cover
CPD training and associated travel costs; enabling back-filling of positions to support staff to
undertake training and opportunities for networking; and working to ensure workloads and
caseloads are, and remain, reasonable by promptly recruiting vacancies and engaging agency
staff until vacancies are filled.
Study limitations
While it is likely that these findings have relevance beyond the scope of this study, some
limitations require noting. First, the reliance on the early career reflections of experienced health
professionals who had been working in CMH for over five years, rather than only those
experiencing their first years in practice is limited by recall bias. This was particularly the
situation for the limited participants from RA4, as was the need to loosen the inclusion criteria
for RA4 participants.
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

Conclusions
Overall the study found that the factors negatively affecting the job satisfaction of early career
rural-based CMH professionals affect all professionals working in rural CMH, and these
negative effects increase with service remoteness. For those in early career, having to
simultaneously deal with significant rural health and sector-specific constraints and
professional challenges has a negative multiplier effect on their job satisfaction. It is this
phenomenon that likely explains the high levels of job dissatisfaction and turnover found among
Australia’s rural-based early career CMH professionals. By understanding these multiple and
simultaneous pressures on rural-based early career CMH professionals, public health
services and governments involved in addressing rural mental health workforce issues will be
better able to identify and implement time-critical supports for this cohort of workers.
The authors consider the findings and proposed strategies for improving job satisfaction, as
potentially having relevance beyond NSW rural CMH services, to the broader early career
nursing and allied health workforce in rural Australia, and also, internationally, to rural health
workforces in countries with similar physical geography, population distribution, political and
health systems, such as Canada. The authors consider testing the generalisability of the
findings and effectiveness of the strategies for improving job satisfaction to be important areas
for future research.
Glossary
ASGC-RA Australian Standard Geographical Classification –Remoteness Structure
AMHW Aboriginal mental health worker
CMH Community mental health
CPD Continuing professional development
CTO Community treatment order
LHD Local Health District
MHA Mental Health Act
NSW New South Wales
P Participant
Notes
1. In 2014, following the election of a new Federal Government, Health Workforce Australia was
closed down and its essential functions were transferred over to the federal government’s Department
of Health.
2. In this manuscript, the term “regional, rural and remote”includes any areas outside of Australia’s major
cities and use of the term “rural”from herein should be considered to include regional and remote, unless
otherwise specified.
3. NSW is Australia’s most populous state, situated on its eastern seaboard.
4. NSW Health is responsible for public health care of NSW residents. This occurs through the operation of
local health districts (LHDs). There are 15 LHDs operating, and 7 are situated in rural NSW.
5. The NSW Mental Health Act (MHA) (2007) makes provisions for the mental health care of people who
are admitted to hospital voluntarily (informal patient); are admitted to, or detained in hospital
against their wishes (involuntary patient); are required to receive treatment under a community
treatment order (CTO); and those who have committed a serious offence and are mentally ill (forensic
patient). Most clients using CMH services are non-MHA clients, and only a small number of clients
are on CTOs.
6. Assigned an individual staff member to provide one-on-one care.
7. A CTO is a legal order made by the Mental Health Review Tribunal, providing for community-based
treatment as an alternative to involuntary hospitalisation. It requires a person to accept medication,
therapy, rehabilitation or other services for up to 12 months.
8. This and other challenges uniquely affecting the job satisfaction of AMHWs were identified in the broader
study, and these have been published in a separate paper (Cosgrave, Maple and Hussain, 2018).
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

References
Ashby, S., Ryan, S., Gray, M. and James, C. (2013), “Factors that influence the professional resilience of
occupational therapists in mental health practice”,Australian Occupational Therapy Journal, Vol. 60 No. 2,
pp. 110-19, doi: 10.1111/1440-1630.12012.
Australian Bureau of Statistics (2006), “Australian standard geographical classification –remoteness structure
(ASGC-RA)-New South Wales remoteness area boundaries”, available at: www.ausstats.abs.gov.au/
ausstats/subscriber.nsf/0/DC74D8E8C0C777C8CA25796B0015019B/$File/1216015003_asgc_2006_ra_
nsw_map.pdf (accessed 10 February 2017).
Australian Government (2010), “National mental health report 2010: summary of 15 years of reform in
Australia’s mental health services under the national mental health strategy 1993-2008”, Commonwealth of
Australia, Canberra.
Australian Institute of Health and Welfare (2013a), “Allied health workforce 2012”, Australian Institute of Health
and Welfare, Canberra.
Australian Institute of Health and Welfare (2013b), “Nursing and midwifery workforce 2012”, Australian
Institute of Health and Welfare, Canberra.
Barak, M., Nissly, J. and Levin, A. (2001), “Antecedents to retention and turnover among child welfare, social
work, and other human service employees: what can we learn from past research? A review and
metanalysis”,Social Service Review, Vol. 75 No. 4, pp. 625-61.
Buykx, P., Humphreys, J., Wakerman, J. and Pashen, D. (2010), “Systematic review of effective retention
incentives for health workers in rural and remote areas: towards evidence-based policy”,Australian Journal of
Rural Health, Vol. 18 No. 3, pp. 102-09, doi: 10.1111/j.1440-1584.2010.01139.x.
Ceramidas, D. (2010), “A case against generalisation of mental health occupational therapy in Australia”,
Australian Occupational Therapy Journal, Vol. 57 No. 6, pp. 409-16, doi: 10.1111/j.1440-1630.2010.00876.x.
Charmaz, K. (2014), Constructing Grounded Theory, 2nd ed., Sage Publications, London.
Cosgrave, C., Hussain, R. and Maple, M. (2015a), “Factors impacting on retention amongst community
mental health clinicians working in rural Australia: a literature review”,Advances in Mental Health, Vol. 13
No. 1, pp. 58-71, doi: 10.1080/18374905.2015.1023421.
Cosgrave, C., Hussain, R. and Maple, M. (2015b), “Retention challenge facing Australia’s rural community
mental health services: service managers’perspectives”,Australian Journal of Rural Health, Vol. 23 No. 5,
pp. 272-6, doi: 10.1111/ajr.12205.
Cosgrave, C., Maple, R. and Maple, (2018), “An explanation of turnover intention among early-career nursing
and allied health professionals working in rural and remote Australia: findings from a grounded theory study”,
Rural and Remote Health Accepted, 22 March.
Cosgrave, C., Maple, M. and Hussain, R. (2018), “Factors affecting job satisfaction of Aboriginal mental health
workers working in community mental health in rural and remote New South Wales”,Australian Health
Review, Vol. 41 No. 6, pp. 707-711.
Cranny, C.J., Smith, P.C. and Stone, E.F. (1992), Job Satisfaction: How People Feel about their Jobs and
How it Affects their Performance, Lexington Books, New York, NY.
Crowther, A. and Ragusa, T. (2011), “Realities of mental health nursing practice in rural Australia”,Issues in
Mental Health Nursing, Vol. 32 No. 8, pp. 512-18, doi: 10.3109/01612840.2011.569633.
Drury, V., Francis, K. and Dulhunty, G. (2005), “The lived experience of rural mental health nurses”,Online
Journal of Rural Nursing and Health Care, Vol. 5 No. 1, pp. 19-27.
Duckett, S.J. (2005), “Health workforce design for the 21st century”,Australian Health Review, Vol. 29 No. 2,
pp. 201-10, available at: http://dx.doi.org/10.1071/AH050201
Eley, D., Synnott, R., Baker, P. and Chater, A. (2012), “A decade of Australian rural clinical school graduates:
where are they and why?”,Rural and Remote Health, Vol. 12 No. 1937, pp. 1-12.
Fox, V. (2013), “Professional roles in community mental health practice: generalist versus specialist”,
Occupational Therapy in Mental Health, Vol. 29 No. 1, pp. 3-9, doi: 10.1080/0164212X.2013.760276.
Gibb, H., Livesey, L. and Zyla, W. (2003), “At 3 am who the hell do you call? Case management issues in sole
practice as a rural community mental health nurse”,Australasian Psychiatry, Vol. 11 No. S1, pp. S127-30,
doi: 10.1046/j.1038-5282.2003.02005.x.
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

Gillespie, J. and Redivo, R. (2012), “Personal–professional boundary issues in the satisfaction of rural
clinicians recruited from within the community: findings from an exploratory study”,Australian Journal of Rural
Health, Vol. 20 No. 1, pp. 35-9, doi: 10.1111/j.1440-1584.2011.01249.x.
Health Workforce Australia (2013), Mental Health Workforce Planning Data Inventory, HWA, Adelaide,
available at: www.hwa.gov.au/resources/publications (accessed 15 September 2016).
Keane, S., Lincoln, M. and Smith, T. (2012), “Retention of allied health professionals in rural New South Wales:
a thematic analysis of focus group discussions”,BMC Health Services Research, Vol. 12 No. 175, pp. 1-11,
doi: 10.1186/1472-6963-12-175.
King, R. (2009), “Caseload management, work-related stress and case manager self-efficacy among
Victorian mental health case managers”,Australian & New Zealand Journal of Psychiatry, Vol. 43 No. 5,
pp. 453-9, doi: 10.1080/00048670902817661.
Lea, J. and Cruickshank, M. (2007), “The experience of new graduate nurses in rural practice in New South
Wales”,Rural and Remote Health, Vol. 7 No. 814, pp. 1-11.
Lea, J. and Cruickshank, M. (2015), “The support needs of new graduate nurses making the transition to rural
nursing practice in Australia”,Journal of Clinical Nursing, Vol. 24 Nos 7-8 pp. 948-60, doi: 10.1111/
jocn.12720.
Lloyd, C., Bassett, H. and King, R. (2002), “Mental health: how well are occupational therapists equipped for a
changed practice environment?”,Australian Occupational Therapy Journal, Vol. 49 No. 3, pp. 163-6, doi:
10.1046/j.1440-1630.2002.00332.x.
Lloyd, C., King, R. and Bassett, H. (2002), “A survey of Australian mental health occupational therapists”,
British Journal of Occupational Therapy, Vol. 65 No. 2, pp. 88-96, doi: 10.1177/030802260206500207.
Lloyd, C., King, R. and McKenna, K. (2004), “Generic versus specialist clinical work roles of occupational
therapists and social workers in mental health”,Australian & New Zealand Journal of Psychiatry, Vol. 38 No. 3,
pp. 119-24, doi: 10.1080/j.1440-1614.2004.01316.x.
McNeil, K.A., Mitchell, R.J. and Parker, V. (2013), “Interprofessional practice and professional identity threat”,
Health Sociology Review, Vol. 22 No. 3, pp. 291-307.
Moore, T., Sutton, K. and Maybery, D. (2010), “Rural mental health workforce difficulties: a management
perspective”,Rural and Remote Health, Vol. 10 No. 4.
National Mental Health Commission (n.d.), “Review of mental health programmes and services”, available at:
www.mentalhealthcommission.gov.au/our-reports/review-of-mental-health-programmes-and-services.aspx
(accessed 26 April 2015).
NSW Health (2007), Drug and Alcohol Clinical Supervision Guidelines, Department of Health, NSW, Sydney.
O’Toole, K., Schoo, A. and Hernan, A. (2010), “Why did they leave and what can they tell us? Allied health
professionals leaving rural settings”,Australian Health Review, Vol. 34 No. 1, pp. 66-72, doi: 10.1071/AH09711.
Onnis, L.-a. L. and Dyer, G. (2017), “Maintaining hope: the intrinsic role of professional support”,The Journal
of Mental Health Training, Education and Practice, Vol. 12 No. 1, pp. 13-23.
Onyett, S., Heppleston, T. and Muijen, M. (1995), “Making community mental health teams work”, Sainsbury
Centre for Mental Health, London.
Perkins, D., Larsen, K., Lyle, D. and Burn, P. (2007), “Securing and retaining a mental health workforce in far
western New South Wales”,Australian Journal of Rural Health, Vol. 15 No. 2, pp. 94-8, doi: 10.1111/j.1440-
1584.2007.00860.x.
Perkins, D., Fuller, J., Kelly, B., Lewin, T., Fitzgerald, M., Coleman, C. and Roberts, R. (2013), “Factors
associated with reported service use for mental health problems by residents of rural and remote communities:
cross-sectional findings from a baseline survey”,BMC Health Services Research,Vol.13No.157,pp.1-13.
Ragusa, A. and Crowther, A. (2012), “I think it is the best job…I love it!’engendering workplace satisfaction in
rural and remote Australian mental health nursing”,Rural Society, Vol. 22 No. 1, pp. 45-58, doi: 10.5172/
rsj.2012.22.1.45.
Watson, C. and Harrison, N. (2009), New South Wales Aboriginal Mental Health Worker Training Program:
Implementation Review, Cooperative Research Centre for Aboriginal Health and NSW Department of
Health, Darwin.
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)

Wilson, B. and Crowe, M. (2008), “Maintaining equilibrium: a theory of job satisfaction for community mental
health nurses”,Journal of Psychiatric and Mental Health Nursing, Vol. 15 No. 10, pp. 816-22, doi: 10.1111/
j.1365-2850.2008.01319.x.
World Health Organization (2010), Increasing Access to Health Workers in Remote and Rural Areas Through
Improved Retention: Global Policy Recommendations, WHO, Geneva, available at: www.who.int/hrh/
retention/guidelines/en/ (accessed 9 February 2017).
Corresponding author
Catherine Cosgrave can be contacted at: ccosgrave@unimelb.edu.au
For instructions on how to order reprints of this article, please visit our website:
www.emeraldgrouppublishing.com/licensing/reprints.htm
Or contact us for further details: permissions@emeraldinsight.com
THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE
Downloaded by 120.144.149.31 At 21:51 18 April 2018 (PT)