SCIENTIFIC ARTICLE

Australian Dental Journal 2006;51:(1):46-51

Factors influencing recent dental graduates location and sector of employment in Victoria
M Silva,* K Phung,* W Huynh,* H Wong,* J Lu,* A Aijaz,* M Hopcraft*

Abstract Background: Recruitment and retention of dentists in the public sector and rural areas in Victoria has become increasingly difficult in recent years. There are little available data on the factors that influence the sector and location of practice of new dental graduates. The objective of this study was to investigate the factors considered by new graduates in determining the location and sector of employment after graduation, and influencing any early changes in career path. Methods: Questionnaires were sent to dentists who graduated from The University of Melbourne from 2000-2003 who were currently practising in Victoria. There were 154 subjects to whom questionnaires were sent and 109 useable questionnaires were returned, a response rate of 74 per cent. Results: Upon graduation, 53 per cent of the new graduates chose to work in the private sector only, compared to 15 per cent in public sector only and 33 per cent in both. At present, 71 per cent work in the private sector only, 17 per cent in the public sector only and 12 per cent in both. The most important factors for choosing to work in the private sector were receiving broad range of clinical experience, opportunities to familiarize with practice management and providing a continuity of care. The principal factors for practising in the public sector were clinical mentoring and advice, consolidating clinical skills and work environment. Initially, 48 per cent of the sample chose to work in metropolitan areas only, 39 per cent in rural areas only and 13 per cent in both. Factors that influenced the decision to work in rural areas were the broad range of clinical experience and remuneration, while the main factors for choosing to work in metropolitan areas were lifestyle and proximity to family and friends. Conclusions: This study found that a large proportion of new dental graduates initially chose to work in the public sector and rural areas on graduation primarily as a means of consolidating their clinical skills. However, retention of dentists in both these areas appears to be a problem, with less than 10 per cent of 2000-2001 graduates still working in the public sector and only 20 per cent of 2000-2001 graduates still working in rural areas.

Key words: Workforce, demographics, rural health, dental graduates, public sector. Abbreviation: GSP = government subsidized places. (Accepted for publication 20 May 2005.)

*School of Dental Science, The University of Melbourne, Victoria.

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INTRODUCTION There are significant disparities in oral health outcomes across Victoria. Geographical and financial barriers to dental services continue to prevent many people from receiving vital treatment.1 The rates of tooth extraction and edentulism in Australians dependent on public dental services are higher than other Australians, and low-income groups eligible for public dental services seek dental care less frequently, and display problem oriented visiting patterns.2 Similar trends have also been identified in rural and remote areas.2 An important factor contributing to these health inequalities is the shortage of dentists in both the public sector and rural areas.3 This is reflected by the fact that waiting lists in public rural clinics increased by 31 per cent during 2001, with an increase of 16 per cent in metropolitan public clinics.4 The demand for dental services has been projected to rise significantly in the following five years.5 However, the ability of the oral health workforce to provide services increases only marginally. The most significant discrepancies between demand and supply of services are expected to be seen in the public sector and rural and remote areas.5 Approximately one-third of the Victorian adult population is eligible for public dental services but only 10 per cent of dentists work in the public sector.4 The Victorian Oral Health Services Labour Force Planning Report investigated the current perceptions of the public sector by interviewing a panel of final year dental students from The University of Melbourne, who viewed the public system as a training ground for subsequent private practice, with a broad range of clinical experience and mentoring.6 The negative aspects of the Victorian public sector included restrictions on treatment autonomy and limited materials, limited ability to specialize, a lack of
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continuity of care, poor remuneration, issues with management and ill-defined career pathways. This report also identified that female dentists were more likely to work in the public sector than their male counterparts. The Victorian Department of Human Services has recently improved incentives to recruit recent dental graduates to the public sector.7 These include better remuneration, mentor support and a new career structure. However, there are little data regarding the effects of these measures on the recruitment and retention of recent graduates in the public sector. There are also little data currently regarding the influence of the fee status of dental students upon their employment choices, in particular the sector of employment. Approximately 25 per cent of each cohort of dental students at The University of Melbourne are full-fee paying international students, the majority of whom return home after gaining their qualification due to visa restrictions.6 A small proportion of the domestic students are accepted into full-fee paying positions although this is projected to increase in the future with reforms to the higher education sector. In addition, fees for government subsidized places (GSP) have increased 25 per cent from 2004 to 2005. In contrast to the workforce issues in the public sector, the workforce shortages in rural areas are part of a universal shortage of rural health practitioners. There are 52.4 dentists per 100 000 population in Melbourne, compared with only 29.9 dentists per 100 000 population in the rest of Victoria.8 Recruitment and retention in rural areas poses a unique set of problems. A number of studies have shown that health professionals who were born or raised in rural areas were more likely to work in rural areas after graduation.9,10 The rural lifestyle and a broad range of clinical experiences have also been cited as reasons for choosing to work in rural areas.10 Studies of rural general medical practitioners found that the main areas of concern were overwork, lack of locum relief, professional contact with colleagues, specialist backup in emergencies, downsizing of hospital facilities, continuing medical education and income.10-12 However, most of the research in this area does not specifically focus on the reasons that influence the initial recruitment, or retention, of dentists in rural areas. The aims of this study were to describe the patterns of employment of recent University of Melbourne dental graduates currently employed in Victoria and to determine the factors that influence their choice of initial location and sector of employment. MATERIALS AND METHODS Data were gathered by a postal survey of dentists who graduated from the School of Dental Science, The University of Melbourne, between 2000 and 2003 who were currently practising in Victoria. There were 198 dental graduates from The University of Melbourne between 2000 to 2003, with 154 currently registered
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Table 1. Socio-demographic characteristics of the sample population

n % Location Where Born Australia metropolitan Australia rural Overseas Not answered Fee Status GSP Local full-fee International full-fee n 45 6 57 1 95 7 7 % 41.3 5.5 52.3 0.9 87.2 6.4 6.4 Year of Graduation 2000 21 19.3 2001 23 21.1 2002 32 29.3 2003 33 30.3 Gender Male Female

47 62

43.1 56.9

with the Dental Practice Board of Victoria. The questionnaire was mailed to subjects with a selfaddressed reply paid envelope included to return the questionnaire. A total of 116 questionnaires were subsequently returned, seven of which were excluded since the subjects were not practising in Victoria. The useable 109 questionnaires constituted a response rate of 74 per cent. The questionnaire comprised four sections. The first section contained socio-demographic questions regarding age, gender, year of graduation, country of birth, university fee status and locations of practice since graduation. The following three sections investigated factors that were important for graduates when initially choosing to work in the public or private sector, or in rural or metropolitan locations, and the factors that were important when they changed sectors and/or locations. A list of possible factors was provided and subjects were asked to respond on a standard fivepoint Likert scale (1 strongly disagree to 5 strongly agree). Results were analysed using SPSS v.11.0 for Windows. The study was approved by The University of Melbourne Human Research Ethics Committee, and participation was voluntary. RESULTS A total of 109 subjects participated in the study, and their socio-demographic profile is shown in Table 1. There was a relatively even spread of participants across the four years of graduation, with a greater participation from the 2002 and 2003 cohorts. Fiftyseven per cent of the subjects were female and more than half were born overseas. The breakdown of overseas born students was as follows: Malaysia 13; Hong Kong 8; Vietnam 8; Taiwan 5; China 4; Singapore 4; less than three from England, Fiji, Sri Lanka, Ukraine, Afghanistan, Egypt, India, Italy, Macau, Mauritius and Russia. Only six subjects were born in rural areas in Australia. Furthermore, seven subjects were domestic full-fee paying students and seven were international full-fee paying students. Sector of employment Figure 1 shows the initial and current sector of employment by year of graduation. Approximately half of the subjects in each graduating year initially worked in the public sector but less than 30 per cent of the
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Table 2. Reasons for choosing public sector by year of graduation (1 strongly disagree, 5 strongly agree)
2000 (n=10) Clinical mentoring Remuneration Salary packaging Opportunities for CE Consolidating clinical skills Work environment Altruism Fig 1. Percentage of graduates working in each sector of practice, initially and currently, by year of graduation. 4.50 1.80 3.10 3.40 4.40 3.30 3.10 2001 (n=9) 4.33 2.56 3.11 3.22 4.22 4.11 3.00 2002 (n=17) 4.41 2.24 2.47 3.24 4.06 3.59 2.87 2003 (n=15) 4.40 3.33 3.40 4.07 4.33 4.20 3.86 Total (n=51) 4.41 2.53 2.98 3.51 4.24 3.80 3.22

2000 and nine per cent of the 2001 graduates still work in the public sector, compared with 34 per cent of the 2002 and 36 per cent of 2003 graduates. At present, 78 per cent of all respondents work in the private sector only, compared to 17 per cent in both sectors and 12 per cent in the public sector exclusively. Of those who had changed or intended to change sector, the vast majority moved from the public to the private sector. A higher proportion of males (62 per cent) initially chose to work in the private sector only on graduation, compared to females (47 per cent). Seventy-one per cent of domestic full-fee paying students chose to initially work in the private sector only, compared to 52 per cent of GSP students and 50 per cent of international full-fee paying students. Location of employment Almost half of all the graduates initially chose to work in metropolitan locations, while 39 per cent chose rural practices and 13 per cent worked in both rural and metropolitan areas. At present, 60 per cent of the graduates from all four graduating cohorts are working in metropolitan practices, 31 per cent in rural locations and nine per cent in both. Figure 2 shows the location of practice by year of graduation. Approximately 50 per cent of the 2000 and 2001 graduates initially worked in rural areas, however, less than 25 per cent of

them were still working in rural areas. In contrast, there was little change in the practice location for the 2002 and 2003 graduates. Interestingly, 71 per cent of international full-fee paying graduates initially chose to practise in rural locations only, with 29 per cent in metropolitan locations only, compared with 49 per cent of GSP and 57 per cent of domestic full-fee paying graduates who initially chose to work in rural areas. Eighty-three per cent of rural born Australians initially chose to work either in rural locations exclusively or in both rural and metropolitan areas, compared with only 56 per cent of metropolitan Australian born graduates and 46 per cent of overseas born graduates. Factors influencing choice of sector and location of employment Table 2 shows the potential factors influencing the decision to work in the public sector. The factors that were rated as being the most important for graduates choosing to work in the public sector were clinical mentoring and consolidating clinical skills. Remuneration was consistently rated the least important factor in each year, however, it rated considerably higher in the 2003 cohort than in the 2000 cohort. Table 3 shows the potential factors influencing the decision to work in the private sector. Continuity of patient care, a broad range of clinical experience and work environment were the key reasons given for choosing to work in private practice. However, all of the listed factors rated highly.

Table 3. Reasons for choosing private sector by year of graduation (1 strongly disagree, 5 strongly agree)
2000 (n=18) Continuity of patient care Remuneration Broad range of clinical experience Familiarize with private practice management Work environment 3.94 3.83 4.56 4.00 4.00 2001 (n=22) 4.00 3.73 4.32 4.18 4.27 2002 (n=29) 4.00 3.69 4.52 3.83 3.86 2003 (n=23) 4.17 3.61 4.43 4.00 3.96 Total (n=92) 4.03 3.71 4.46 3.99 4.01

Fig 2. Percentage of graduates working in each location of practice, initially and currently, by year of graduation.
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Table 4. Reasons for choosing rural practice by year of graduation (1 strongly disagree, 5 strongly agree)
2000 (n=10) Work where born Remuneration Broad range of clinical experience Remote area benefit Lifestyle Rural scholarship Proximity to family/friends 1.60 3.20 4.50 2.50 2.70 1.44 1.30 2001 (n=10) 1.20 3.40 4.30 2.90 3.70 1.10 1.60 2002 (n=21) 1.86 3.33 4.19 2.86 3.19 1.29 2.20 2003 (n=15) 1.60 3.53 4.40 2.80 3.33 2.21 2.20 Total (n=56) 1.63 3.38 4.32 2.79 3.23 1.52 1.93

Table 6. Reasons for changing from public to private sector by year of graduation (1 strongly disagree, 5 strongly agree)
2000 (n=7) Continuity of patient care Remuneration Broad range of clinical experience Familiarize with private practice management Work environment 4.00 4.43 4.71 4.43 4.14 2001 (n=4) 3.50 4.00 3.50 3.50 4.00 2002 (n=9) 3.67 3.78 4.22 4.22 3.78 2003 (n=5) 3.00 3.80 4.00 4.00 3.00 Total (n=25) 3.60 4.00 4.20 4.12 3.76

Table 4 shows the potential factors influencing the decision to work in rural locations. A broad range of clinical experience was seen as the most important factor for graduates choosing to work in rural locations, with remuneration rated as the second most important factor. All other factors were not considered by the respondents to be important in determining whether to work in rural areas. However, some of these factors were applicable to only a small number of graduates, e.g., rural scholarship or working where graduates were born. Notably, rural born Australians rated working where they were born highly (4.00) when choosing to work in rural locations compared with metropolitan born Australians (1.25) and overseas born graduates (1.48), and proximity to family/friends also scored highly for the rural graduates (4.20), compared to the metropolitan born (1.32) and overseas born (1.94). Table 5 shows the potential factors influencing the decision to work in metropolitan locations. Lifestyle and proximity to family and friends were the most important factors given for choosing to work in metropolitan areas on graduation. Remuneration was consistently scored as the least important factor by members of each cohort for choosing to work in metropolitan areas. All of the listed factors were considered to be important for graduates when choosing to change from the public to private sector (Table 6). A broad range of clinical experience was scored as the most important factor, followed by familiarization with private practice

management and remuneration. Personal factors such as lifestyle and proximity to family/friends and shops/facilities were the principal factors given for graduates choosing to change from rural to metropolitan locations (Table 7). Access to continuing education was also seen as an important factor. The number of graduates choosing to change from private to public and from metropolitan to rural locations was too small to provide a meaningful analysis. DISCUSSION This study has revealed several key issues that need to be resolved in order to address the workforce shortages experienced by public and rural dental services. They may be broadly categorized into those affecting the public sector and those affecting rural locations. Issues affecting recruitment and retention in the public sector This study found that the current workforce shortage trends in the public sector are most likely due to deficiencies in the retention of staff and not in recruitment since there appeared to be high levels of recruitment from new graduates into the public sector over the previous four years. This contradicts earlier findings and may reflect the success of recent measures taken to recruit dental graduates into the public sector.4 The problems associated with retention in the public sector are significant, with almost 50 per cent of recent

Table 5. Reasons for choosing metropolitan practice by year of graduation (1 strongly disagree, 5 strongly agree)
2000 (n=10) Remuneration Proximity to family/friends Lifestyle Proximity to shops/facilities Access to CE Broad range of clinical experience 3.31 4.23 4.23 3.77 4.00 3.46 2001 (n=10) 3.13 4.60 4.27 4.21 3.60 3.33 2002 (n=21) 2.67 3.89 3.94 3.56 3.22 3.67 2003 (n=15) 2.58 3.58 4.05 3.47 2.84 3.26 Total (n=56) 2.88 4.03 4.11 3.72 3.35 3.43

Table 7. Reasons for changing from rural to metropolitan practice by year of graduation (1 strongly disagree, 5 strongly agree)
2000 (n=8) Remuneration Proximity to family/friends Lifestyle Proximity to shops/facilities Access to CE Broad range of clinical experience 3.25 5.00 4.75 4.50 3.75 3.25 2001 (n=7) 2.71 4.57 4.00 4.71 4.29 3.29 2002 (n=10) 3.00 4.30 4.00 4.20 3.70 3.10 2003 (n=4) 2.00 4.75 4.25 4.50 4.50 2.75 Total (n=29) 2.86 4.62 4.24 4.45 3.97 3.14
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graduates who initially chose to work in the public sector in the past four years having already left or intending to leave in the next two years. This is remarkable when compared with only two per cent who intend to leave the private sector. This attrition is most notable in the 2000 and 2001 graduates, who have gained several years of experience. Thus, a steady shift towards the private sector from the public sector is evident. These results appear to confirm anecdotal evidence that the public sector serves more as a training ground for private practice than a permanent professional choice for most new graduates.5,6 This study also confirmed the findings of other studies that the main reasons for working in the public sector were for consolidation of clinical skills and mentoring.9 It is understandable that these factors are less important once a certain degree of experience is gained. Based on the findings of this study, these dentists move to the private sector for the broad range of clinical experience, meaning that they are now able to handle and enjoy clinical challenges currently not afforded in the public sector. They also seek greater professional rewards and independence, citing experience with practice management and remuneration as priorities. This study supports the view that the public sector is unable to satisfy the broadening needs of the young dentist with some experience. Improvements in retention may be gained through well-established career pathways with opportunities for promotion, including improvements in remuneration with experience.6 Since remuneration did not appear to be a driving factor for recent graduates choosing to work in the public sector, it may be more pertinent to reward experience with greater salary increase rather than to drive recruitment by offering large initial salaries. This would provide a sense of recognition and career advancement for dentists who continue to work in the public sector. Exposing public sector dentists to a broader range of complex and specialist treatment must also be considered as a means of improving retention. This would satisfy the need for greater clinical challenges sought by graduates as they gain experience. Newer graduates are keen to consolidate clinical skills and do not seek these challenges until they have gained more experience. Despite the current high levels of recruitment into public practice, the preference for domestic full-fee paying local students to work solely in the private sector upon graduation may have important future ramifications. Although remuneration did not score as highly as might be expected in this group, this may also be due to an unwillingness to rate remuneration highly. The small number of domestic and international fullfee paying graduates in the sample means that any conclusions drawn from this data should be viewed with caution. However, if this is indicative of the influence of the increasing costs of a dental education,
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recruitment into the public sector may reduce in the future as both GSP fees and full-fee student places increase. Conversely, international students, whose fees are higher than either GSP or local fee-paying students, do not appear to demonstrate a similar predilection for the private sector. However, the majority of these students choose to return to their countries of origin. Other factors, such as the ability to gain permanent residency, may also influence their choice of sector. Currently, little data exist regarding the influence of fee status upon graduates employment patterns and this is an important area for further investigation. Issues affecting recruitment and retention in rural areas The issues pertaining to the workforce shortages in rural locations reflect a similar pattern to those in public practice. It appears that retention, and not recruitment, is the main reason for the workforce shortages with over half of the graduate dentists choosing initially to work, at least part time, in rural practice. However, this high level of recruitment can be attributed to a broader group of reasons than that in the public sector. Whilst clinical experience is an important reason, so too is lifestyle and prospective remuneration. Unfortunately, like the public sector, attrition rates are high with 50 per cent of those graduates who chose to work in rural practice over the previous four years having already moved or intending to do so in the next two years. Once again, a cycle of loss of experienced dentists and replacement with inexperienced graduates is evident. Although the literature regarding retentive influences on rural health practitioners is controversial, the results from this study indicate that recent dental graduates predominantly leave rural practice for personal reasons such as proximity to family, friends, shops, facilities and lifestyle. This contrasts with other studies which focus predominantly on general medical practitioners. Firstly, rural dental practice is unique and may not be amenable to comparisons with other health professions. Secondly, some retentive factors are not applicable to generally young recent graduates. For example, the commonly identified stress of a lack of locum relief may not be as significant to a recent graduate employee as it is to a principal. Studies assessing personal reasons for leaving rural practices identify the wishes of the spouse and childrens education as important.12 The former seems supported by the high scores given to proximity to family and friends, although a specific question regarding spouses or children was not asked. Professional isolation and lack of continuing professional development, noted as important reasons for low rural retention of health practitioners in other studies, were not supported by the relatively low scores ascribed to continuing education in the present study.11 Factors that were not assessed in the present study included loss of privacy in rural towns and burnout.
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However, these were notably absent in participants comments. This research supports the findings of other studies that students from rural backgrounds are more likely to work in rural locations upon graduation.9 Predictably, the reasons for choosing the location of employment differed in the group of rural born graduates compared to those born in metropolitan areas. Returning to their place of birth, proximity to family/friends and lifestyle scored far higher in rurally born respondents who returned to work in rural areas. The small number of subjects born in rural areas makes analysis difficult. Of these graduates, the majority that are currently working in rural locations intended to continue in rural practice. Furthermore, those rural born graduates who had initially not worked in rural practice intended to change from metropolitan to rural practice in the next two years. Thus, these graduates may be easier to retain in rural areas, in addition to being easier to recruit. The considerable proportion (over 70 per cent) of international students who chose rural locations was an unexpected finding. However, conclusions must be tempered with appropriate caution due to the small number of these respondents and the fact that the majority of these graduates will have already returned home.4 Graduates fee status did not appear to have a bearing on the reasons given for working in rural areas. Little data currently exist regarding patterns of employment of international students who graduate in Victoria. With about 25 per cent of the annual undergraduate intake being international students, their recruitment and retention into Victoria could provide a major increase in the supply of dental services. Further considerations This study focused solely on graduates who were currently working in Victoria, and therefore was unable to address graduates who may have initially worked in Victoria and were now working either interstate or overseas. There may be additional factors that are relevant in the recruitment and retention of these dentists that were not identified. Similarly, the study did not include recent graduates who were working in Victoria but did not graduate from The University of Melbourne. Therefore, factors that were responsible for the recruitment and retention of these dentists were also not identified. Finally, the small sample size affected the ability to adequately assess factors that influence students from rural areas, and domestic fullfee paying students. Further research at the national level is required to address these issues. CONCLUSION The oral health workforce shortages currently hampering dental service provision in the public sector and rural locations in Victoria appear to stem predominantly from problems in retention of recent graduates, not necessarily in their recruitment. The
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problems in the retention of recent graduates in the public sector are mainly professional. In contrast, personal reasons seem to influence the low retention of recent graduates in rural locations. Improved recognition of experienced staff in the public sector, with enhanced clinical opportunities, is essential to improve the workforce issues in the public sector. Resolution of the retentive issues in rural locations may involve both selective recruitment of rural students into dentistry and greater integration of recent graduates into local communities. ACKNOWLEDGEMENTS The authors wish to thank the Australian Dental Association (Victorian Branch) for their support of this research project. REFERENCES
1. Australian Health Ministers Advisory Council, Steering Committee for National Planning for Oral Health. Oral health of Australians: National planning for oral health improvement. Adelaide: South Australian Department of Human Services, 2001. 2. Australian Institute of Health and Welfare Dental Statistics and Research Unit. Oral health and access to dental care the gap between the deprived and the privileged in Australia. Research report. AIHW Cat. No. DEN 67. Adelaide: The University of Adelaide, 2001. 3. Stewart JF, Carter KD, Brennan DS. Adult access to dental care rural and remote dwellers. AIHW Cat. No. 41. Adelaide: AIHW Dental Statistics and Research Unit (Dental Statistics and Research Series No. 17), 1998. 4. Auditor-General Victoria. Community Melbourne: Government Printer, 2002. Dental Services.

5. Spencer AJ, Teusner DN, Carter KD, Brennan DS. The dental labour force in Australia: the position and policy directions. AIHW Cat. No. POH 2. Canberra: Australian Institute of Health and Welfare (Population Oral Health Series No. 2), 2003. 6. Australian Institute of Health and Welfare Dental Statistics and Research Unit. Victorian Oral Health Services Labour Force Planning Report. Melbourne: Victorian Department of Human Services, 2002. 7. Dental Health Services Victoria. Annual Report 2003. Melbourne, 2003. 8. Teusner D, Spencer AJ. Dental labour force, Australia 2000. AIHW Cat. No. DEN 116. Adelaide: AIHW Dental Statistics and Research Unit (Dental Statistics and Research Series No. 28), 2003. 9. Baldwin PJ, Dodd M, Rennie JS. Careers and patterns of work of Scottish dental graduates: 1991 and 1994. Br Dent J 1998;185:238-243. 10. Colditz GA, Elliott CJ. Queensland's rural practitioners: background and motivations. Med J Aust 1978;2:63-66. 11. Hays R, Wynd S, Veitch C, Crossland L. Getting the balance right GPs who chose to stay in rural practice. Aust J Rural Health 2003;11:193-198. 12. Kamien M. Staying in or leaving rural practice: 1996 outcomes of rural doctors' 1986 intentions. Med J Aust 1998;169:318-321.

Address for correspondence/reprints: Dr Matthew Hopcraft School of Dental Science The University of Melbourne Melbourne, Victoria 3010 Email: m.hopcraft@unimelb.edu.au
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