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Physiotherapy in rural and regional Australia

Article  in  Australian Journal of Rural Health · January 2008

DOI: 10.1111/j.1440-1584.2007.00931.x · Source: PubMed

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Aust. J. Rural Health (2007) 15, 380–386
Original Article
Physiotherapy in rural and regional Australia
Elizabeth Williams, Wendy D’Amore and Joan McMeeken
School of Physiotherapy at the School of Rural Health, The University of Melbourne, Shepparton,
Victoria, Australia
Abstract
Objective: To inform rural physiotherapy recruitment
and retention strategies by describing physiotherapists
in the Shepparton region: reasons for career choice,
education and physiotherapy professional issues.
Design: Survey.
Setting: Health service providers.
Participants: Practising and non-practising physio-
therapists.
Main outcome measure: Survey responses.
Results: Survey response rate 79%. Eighty four physio-
therapists (79 practicing and 5 non-practicing; 80%
female) clustered in main regional centres responded.
Two-thirds worked part-time with most in the public
sector (70%), with one third holding more than one
position. One-third considered themselves generalists
and one-third specialists. Physiotherapy was first career
choice for 83% who made this decision between 14 and
19 years old (16.8–2.5 years) because of contact with a
physiotherapist. Professional issues challenging physio-
therapists in a rural location are compounded by lack of
career path, professional support, access to professional
development and postgraduate education. Additional
issues are the costs and time to attend courses and
conferences, travel/distance, and inadequate resources.
Positive elements of rural practice were part-time
employment opportunities, independence as primary
health providers, practice variety and community
recognition.
Conclusion: Rural physiotherapy recruitment and
retention strategies must address resource shortcomings
by developing career paths, access to postgraduate
education and support. Enhancing workforce capacity
could enable more students to have meaningful rural
experience to assist recruitment. Strategies highlighting
existing positive features of rural practice, reinforced
Correspondence: Elizabeth Williams, School of Physiotherapy,
School of Rural Health, University of Melbourne, Graham
Street, Shepparton, Victoria, 3630, Australia. Email:
e.williams@unimelb.edu.au
Accepted for publication 13 July 2007.
© 2007 The Authors
Journal Compilation © 2007 National Rural Health Alliance Inc.
with tangible rewards and recognition of physiothera-
pists’ contribution to the health care of Australians are
recommended.
KEY WORDS: physiotherapy, rural, workforce, allied
health.
Introduction
The Australian Government1 has a vision that rural,
regional and remote Australians will be as healthy as
other Australians. Currently the health of rural and
remote Australians lags behind city counterparts partly
due to shortages of health professionals,2 a situation
predicted to worsen as the population ages.3 Physio-
therapists are primary care health professionals who
maximise mobility and quality of life by using clinical
reasoning to select and apply appropriate management
and treatment strategies to promote health, prevent
injury and maintain function. For example, physiothera-
pists reduce waiting lists and improve patient satisfac-
tion in orthopaedic surgery outpatients and emergency
departments.
Physiotherapy consultations for people aged over
65 years have risen 43% between 2001 and 2005.4
However, the Department of Employment and Work-
place Relations identifies a national shortage of physio-
therapists for 9 of the last 10 years.5 This is greatest in
rural and remote areas, with only 18% of the workforce
located in rural Victoria.6
Previous investigation of workforce problems in rural
medicine has focused on government investment in
strategies to increase and support the medical work-
force.7,8 There is little in the peer-reviewed literature
that explicitly presents strategies for enhancing the
rural physiotherapy or broader allied health work-
force.9 Models for sustainable service delivery for
remote areas where the shortage of health professionals
is acute have been described,10 but there is limited tar-
geted investment for physiotherapy. Additionally, in
general there is poor recognition by governments that
physiotherapy is a discrete profession, as it is generally
aggregated into ‘allied health’ with a range of different
professionals as disparate as audiology and podiatry.
doi: 10.1111/j.1440-1584.2007.00931.x
PHYSIOTHERAPY IN RURAL AUSTRALIA
What is already known on this subject:
• There are many papers on the rural work-
force shortage of medical practitioners and
nurses but only a small number on physio-
therapy, which has had a severe national,
state and regional workforce shortage for
decades.
• Some recent reports provide aggregated data
which do not identify issues specific to the
physiotherapy profession.
Recently, allied health professions including physio-
therapy have been considered in projects to address
recruitment and retention of rural allied health
professionals.11–13 One paper identifies rural and remote
physiotherapy as its own discipline.14 The assumption
that results from one profession can be generalised to
others is a limitation, and current research strongly rec-
ommends that issues related to specific professions
should be addressed.15 Increasing recognition of the sig-
nificant contribution to health and wellbeing by phys-
iotherapists is beginning to be reflected by government
initiatives,16 although to date no strategic, national
workforce planning has been done.6
Physiotherapists, as one of the largest clinical profes-
sions and one with the most critical workforce shortages
and high attrition rates,17 was selected for this study as
an exemplar profession to develop and implement a
model for determining key professional practice issues
to inform recruitment and retention strategies in
regional Australia. There is no currently available local
rural physiotherapy workforce information in areas
such as Shepparton.
Shepparton is a regional city in the Goulburn river
valley in Victoria, Australia. It is renowned for dairying
and fruit growing, with the City of Greater Shepparton
as the site of secondary industries such as food process-
ing and supporting agricultural activities. Greater Shep-
parton has a population around 59 000 and is classified
rural. The catchment area of 100-km radius (population
135 000) defines the distribution of patients who attend
the region’s health services, and this region was selected
for the project.
The project aim was to describe the demographics of
practising and non-practising physiotherapists in the
Shepparton region, their distribution, reasons for career
choice, education and professional issues to rural prac-
tice. Physiotherapists would be invited to provide solu-
tions for issues identified. Responses of subgroups such
as public and private practitioners would be examined
to provide recommendations to improve recruitment
© 2007 The Authors
Journal Compilation © 2007 National Rural Health Alliance Inc.
381
What this study adds:
• Describes the distribution and work charac-
teristics of physiotherapists in a region of
rural Victoria.
• Identifies barriers to professional practice in
rural physiotherapy.
• Recommendations to promote rural physio-
therapy as a preferred career for students and
clinicians, and review employment planning,
including improved resources and promotion
of positive elements.
and retention of the workforce and, therefore, access to
physiotherapy in the region.
Method
The Human Research Ethics Committee of the Univer-
sity of Melbourne granted ethics approval.
Survey design
The survey contained sections on education and profes-
sional practice. Education referred to qualifications,
the age and reasons for respondents’ decisions to study
physiotherapy, experiences of physiotherapy, and fami-
ly’s professional backgrounds. Professional practice
recorded respondents’ current work situations, nature
of employment, hours worked in physiotherapy and
additional occupations. Questions explored issues in
working as a physiotherapist, whether these were
related to the rural location, and the community’s per-
ception of them as primary rural health care providers.
The final section invited physiotherapists to propose
solutions.
Participants
Names of physiotherapists were obtained from publicly
available resources, including the telephone directory,
the Physiotherapists Registration Board of Victoria
and the Australian Physiotherapy Association. Non-
practising physiotherapists were identified by personal
referrals.
Data collection and analysis
Physiotherapists provided informed consent and surveys
were completed by telephone interview or mail.
Responses to questions were numeric or categorical
with additional opportunities for open-ended or mul-
382 E. WILLIAMS ET AL.

FIGURE 1: Distribution of physiotherapists in the Shepparton region.

TABLE 1: Work-related travel

Distance travelled per day (km)

Travel n (%) 0–25 26–50 51–100 >100 Maximum Mean (range)

Home to work 79 (100) 57 15 6 1 120 20 (1–120)

For work 25 (32) 12 3 7 3 200 52 (0–200)
Between workplaces 18 (23) 7 8 3 0 100 32 (0–100)

tiple responses. Data were entered into Microsoft Excel
coded for anonymity. Open-ended responses were tran-
scribed and the data coded using descriptive thematic
analysis. Coding tables were developed from the most
prevalent answers to each question. Data were extracted
into SPSS v.12.0 (SPSS Inc., Chicago IL, USA) for
descriptive statistical analysis.
ing and five non-practising physiotherapists completed
the survey (n = 84; 79% response rate, 80% female,
57% aged less than 40 years), with most working in the
regional centres of Shepparton, Benalla and Wangaratta
(Fig. 1). Most physiotherapists travelled less than 25 km
to work, but 55% travelled for work or between
workplaces (Table 1).

Results
Education and career choice
Participants Physiotherapy studies were undertaken in Victoria
Physiotherapists were contacted for the survey between (69%), interstate (26%) and overseas. Baccalaureate
January and June 2005 (n = 107). Seventy-nine practis- degrees were most common (82%) with others holding

© 2007 The Authors

Journal Compilation © 2007 National Rural Health Alliance Inc.
PHYSIOTHERAPY IN RURAL AUSTRALIA
TABLE 2: Summary of full- or part-time positions by
Number of physiotherapists
gender
Part-time (%) Full-time (%) Total (%)
Male 5 (31) 11 (69) 16 (20)
Female 46 (76) 17 (24) 63 (80)
Total 51 28 79
diplomas. Twelve (14%) had completed postgraduate
masters degrees or diplomas, and two PhDs were in
progress.
Physiotherapists chose their careers at 16.8 ⫾
2.5 years. Three-quarters had previous experience of
physiotherapy as patients or through work experience.
Two-thirds had family backgrounds in health or educa-
tion. Those with no previous physiotherapy experience
wanted to work in health or with people, had sporting
interests, or received information from career/open
days. Physiotherapy was first career choice for 83%,
and 81% were accepted into physiotherapy on their first
application. Half (n = 7) of those who stated that phys-
iotherapy was not their first choice were among those
who had no previous experience of physiotherapy.
Employment characteristics
The 79 physiotherapists held 114 clinical positions, gen-
erally located in the public sector (70%). These were:
public hospitals 40%; community centres 15%; and
academic or government departments 15%. Private
practitioners comprised 30%. More than one position
was held by 37%. Physiotherapists worked an average
four days per week (range 0.5–6.5); 35% working four
to five days, with 19% working two days (Table 2,
Fig. 2). Half preferred part-time work owing to family
commitments. Seven of 11 practicing physiotherapists
who had other than physiotherapy work described
themselves as farmers.
Public-sector physiotherapists included managers,
senior clinicians and those in recent graduate rotation
positions. Fifteen per cent of those in private practices
were owner/managers, the others employees.
Including public and private physiotherapy, clinical
practice areas were described as outpatients (32%),
general physiotherapy (25%) or musculoskeletal phys-
iotherapy (22%). Thirty-eight per cent considered that
they specialised in a particular aspect of clinical practice.
Most wished to be recognised as specialists, some as
specialist generalists in ‘rural physiotherapy’. Many
responded that generalist skills were needed in rural
areas, owing to small communities, varied client base,
variety of treatments required and being a sole
practitioner.
© 2007 The Authors
Journal Compilation © 2007 National Rural Health Alliance Inc.
383
30
25
20
15
10
5
0
1 or less >1–2 >2–3 >3–4 >4–5 >5
Days worked per week
FIGURE 2: Total number of days physiotherapists worked
per week.
Health-promotion activities and illness-prevention
programs were delivered by both public and private
physiotherapists (53%). These activities included
strength and balance programs for older persons,
groups for hydrotherapy, cardiopulmonary rehabilita-
tion and community presentations. Fifteen per cent of
health promotion activities was volunteered time.
Nearly all respondents considered that they were
primary health care providers with patients self-
referring. Sixty per cent perceived that their community
regarded physiotherapists as primary health care pro-
viders, but were concerned at lack of recognition by
some medical GPs and specialists. While over half per-
ceived that their community knew physiotherapy’s
roles, some considered that the public were confused
between similar fields and had inadequate knowledge of
physiotherapy.
Professional issues in physiotherapy
and physiotherapy rural practice
Questions determining issues in rural physiotherapy
practice differentiated between those related to physio-
therapy generally or rural practice specifically. General
issues were needs for professional satisfaction and
rewards, support and supervision, and opportunities for
professional development. There was no difference
between public or private practitioners’ response to this
question. The 187 responses regarding professional
issues for rural physiotherapists are aggregated themati-
cally in Table 3.
Respondents offered solutions to resolve the issues
identified as specific to rural practice. These included
accessible and appropriate professional development.
They identified that the self-funding required for profes-
sional development often precluded participation by
respondents. Additional funding was necessary to
384 E. WILLIAMS ET AL.

TABLE 3: Professional issues for rural physiotherapists TABLE 4: Solutions or strategies for professional issues

Category Total† Category Total†

Professional development Professional development

Lack of access to professional development 38 Provide accessible and appropriate professional 25
Lack of access to postgraduate education 35 development
Lack of time for postgraduate/professional 2 Provide accessible and appropriate postgraduate 9
development education
Total 75 Provide teleconferencing, video-conferencing, 6
online education
Support and supervision Rotate hospital staff (between hospitals) 4
Lack of professional and peer support 30 Total 44
Isolation 9
Lack of networking: professional and 6 Support and supervision
community Set up links and meetings of 14
Lack of physiotherapy specialists/senior 3 physiotherapists/special interest groups
clinicians support
Total 48 Professional association provide more rural 12
representation, professional support and
Professional satisfaction mentoring
Lack of career path, career development and 17 Total 26
specialisation
Required to be a generalist 11 Professional satisfaction
Lack of job satisfaction and recognition 9 Develop career pathways/opportunities with 7
Total 37 acknowledgement of specialisation, including
as ‘rural generalist’
Recruitment, retention and lack of resources Improve medical practitioner and community 4
Staff shortages/inadequate staffing 13 awareness/understanding of physiotherapy
levels/difficulty recruiting Total 11
Personal financial return poor/lack of funding 11
Lack of locum availability 3 n = 84, †More than one response per person.
Total 27

n = 84, †More than one response per person.
improve salaries, to enable scholarships, and to facilitate
recruitment and retention of physiotherapists (Table 4).
Discussion
This study is the first to identify the work patterns and
workforce concerns of physiotherapists within a defined
rural health service catchment area. It revealed a
complex workforce that is fragmented by part-time
work, multiple workplaces, and overlap within the
public and private sector.
Participants
Nearly all physiotherapists in the survey area were in
practice. The most recent national physiotherapy work-
force data4 indicate that there are 70 full-time equivalent
(EFT) physiotherapists per 100 000 Victorians. Our
data indicate that in the Shepparton area, the ratio is
much less, at 45 per 100 000. Extrapolating from the
response rate where 6% were non-practising, there
could be 6 or 7 additional physiotherapists potentially
available. With the chronic and severe shortages of
physiotherapists, there might be potential to attract
non-practising physiotherapists back into the work-
force, provided that their professional and personal
concerns are addressed.
Education and career choice
The critical age for career choice of these physiothera-
pists was nearly in the final stage of secondary school-
ing. For students to study physiotherapy in Australia,
prerequisites in science subjects are required. Potential
rural physiotherapists are influenced by a rural second-
ary school background17 and need exposure to the pro-
fession before they have made irrevocable school subject
choices. Aside from family, physiotherapy work experi-
ence and being treated by a physiotherapist were major

© 2007 The Authors

Journal Compilation © 2007 National Rural Health Alliance Inc.
PHYSIOTHERAPY IN RURAL AUSTRALIA
career influencers for these respondents. Baldwin and
Agdo15 showed that although practitioners are influen-
tial, secondary school careers’ counsellors might be an
important information source for potential physiothera-
pists. The shortage of rural clinical physiotherapists
precludes work experience for many applicants.
Innovations, which do not compromise the existing
clinical practice of busy professionals, are required for
secondary students to learn about health careers in rural
areas.
Modification to employment to enhance
workforce efficiency
Physiotherapists in this region were predominantly
female (80%), higher than the Victorian physiotherapy
workforce average (72%).6 Female physiotherapists are
more likely to be working part-time and within the
public sector.4 In Victoria, 37% of the physiotherapy
workforce is part-time, compared with 51% in this
survey, where the average time worked was six hours
per week less than the State average.6 Family responsi-
bilities were cited for part-time work preference, but this
might also reflect lack of flexibility in positions or
factors such as inadequate child or after-school care.
Increased employer responsiveness to the needs of
female health professionals is essential.5
Many practitioners held more than one physiotherapy
position, leading to inefficiencies when travel is required
between positions or work sites. Although travel for
work for most physiotherapists was less than 25 km,
30% were required to travel longer distances. This
might be an additional factor limiting time available or
desired for professional practice. Expansion of roles and
funding to cover the existing 15% of time spent in
volunteer work might also increase necessary service
provision, while accommodating professional aspira-
tions.
Clinical practice focused on the breadth of general
physiotherapy with a large musculoskeletal component;
however, many physiotherapists desired recognition
for their specialist work as ‘rural physiotherapists’.
Sheppard and Nielsen14 reinforce supporting physio-
therapists’ frequent role as single practitioners needing
both to be generalists in physiotherapy and to overlap
into other disciplines where there are fewer medical
specialists and other allied health professionals. The
increasing importance of physiotherapy’s role in the
promotion and maintenance of health, particularly as
it applies to an ageing population with several
co-morbidities, is identified in the range of programs
described by the study physiotherapists. Recognition of
roles and responsibilities, largely in the public sector,
and the development of area resource networks and
© 2007 The Authors
Journal Compilation © 2007 National Rural Health Alliance Inc.
385
infrastructure, requires financial commitment by Gov-
ernment at local, State and Federal levels.9,14
Specific concerns related to practice were poor career
paths for both public and private clinical physiothera-
pists who received inadequate recognition from govern-
ments and the medical profession and consequent
under-use of their knowledge and skills, particularly in
the areas of illness and disability prevention, health
promotion and primary care. Concomitantly, there was
lack of professional development through postgraduate
and continuing education and professional support.
These were compounded by the cost and time to attend
distant courses and conferences, sometimes limited by
workplace restrictions on time off work, no availability
of locums, or lack of staff expertise to cover workload.
All issues were affected by lack of resources and sus-
tained concerns regarding recruitment and retention.
The impositions put upon physiotherapists for clinical
service where there are acute and/or chronic workforce
shortages and their roles are indispensable,11 are leading
to significant attrition.6
As the community’s need for physiotherapists grows,
reinforcement with tangible rewards and recognition
of the positive elements of rural practice is necessary.
Flexible employment opportunities, independence and
autonomy as primary health providers, variety in prac-
tice and community recognition are required. While
senior physiotherapists must be retained, strategies to
recruit physiotherapists through rural internships for
junior physiotherapists or bonded scholarships for
senior students have the potential to improve recruit-
ment and service delivery, and might assist staff
retention.7,8
Further research is indicated replicating the study at
other rural and regional centres so that targeted work-
force strategies for recruitment and retention could be
measured. It is recommended that questions be
expanded to include ‘intention to stay’. In order to
increase the opportunities for student physiotherapists
to experience rural practice, the perceived capacity and
concerns regarding having physiotherapy students for
clinical placements should be obtained.
Conclusions
Most physiotherapists living in a regional area of
Victoria are in practice, although they work shorter
hours than metropolitan contemporaries, but often
holding more than one part-time physiotherapy position
by choice, sometimes in both public and private sectors.
The project showed that time, cost and distance are
barriers to profession-specific and specialist postgradu-
ate education. Positive elements of rural practice are
part-time employment opportunities, independence as
primary health providers, variety in practice and some
 386
community recognition. Workforce strategies must be
reviewed and resourced to address the growing need
for clinical placements, reward unremunerated health-
promotion activities, and address shortcomings of
access to postgraduate qualifications, career paths and
providing professional support.
Author contributions
Elizabeth Williams developed the survey design,
methods, applied for ethics approval, contributed to
analysis, and drafted and finalised the manuscript.
Wendy D’Amore conducted the survey, acquired the
data, analysed the results and contributed to writing the
manuscript. Joan McMeeken made a substantive intel-
lectual contribution, reviewed the survey methods and
ethics application, and contributed to interpretation of
results and writing and finalising the manuscript.
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© 2007 The Authors
Journal Compilation © 2007 National Rural Health Alliance Inc.