Health workforce retention in remote Aboriginal and Torres Strait Islander communities in high-income countries: a rapid realist review

It is vital to reduce avoidable turnover and optimise retention of healthcare staff in Australian remote Aboriginal and Torres Strait Islander health services. However, evidence informing the implementation of retention interventions is limited as existing literature inadequately articulates and synthesises how retention interventions produce intended retention outcomes, and for whom , in remote settings. A rapid realist review (RRR) methodology was adopted. Initial program theory (i.e., collection of propositions) was developed by drawing on the authors’ and project advisory group’s topic knowledge and expertise. These were structured using Context–Intervention–Mechanism–Outcome (CIMO) configurations. Further development and refinement were informed by searches of relevant literature, augmented with primary qualitative data collected through individual interviews and focus group discussions with remote health workforce academic and industry experts (‘thought leaders’). A preliminary list of key references was identified from the expert knowledge of the review team and recommendations from thought leaders and advisory group members. The MEDLINE database was also searched for systematic reviews on the topic, complemented by citation tracking and reviewing reference lists. Additional targeted searches in Google Scholar and MEDLINE were also conducted to explore different aspects of CIMO configurations. Sixteen systematic review articles, 93 grey literature articles and 15 interviews/focus groups with 20 thought leaders contributed data. Initial program theory comprised a total of 15 propositions. These were subsequently refined to three principles and nine propositions. The three principles to consider when developing retention interventions were: optimising flexibility to meet staff needs; equity; and the importance of recruiting the right staff for retention. Two propositions relating to addressing housing/infrastructure and safety issues in remote Aboriginal and Torres Strait Islander communities and health services had great importance, hence termed ‘prerequisite’. Seven general propositions related to management, career progression, professional support and mentoring, roles and responsibilities, prevention and management of occupational stress, recognition and remuneration, and training and support. This peer-reviewed synthesis is the first to use a realist approach to identify contextual factors and related mechanisms that affect how retention interventions work to alter the reasoning, motivations, beliefs, norms and preferences of remote health staff to support longer retention.