Employment experiences of the oral health workforce in rural New South Wales: a qualitative study

Employment experiences of the oral health workforce in rural New South Wales: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Employment experiences of the oral health workforce in rural New South Wales: a qualitative study Lisa Hai My Do, Yvonne Dimitropoulos, Jessica Biles, Bradley Christian, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6295181/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jul, 2025 Read the published version in BMC Health Services Research → Version 1 posted 15 You are reading this latest preprint version Abstract Introduction: Rural oral health practitioners in New South Wales (NSW) face unique challenges related to workforce shortages, professional isolation and limited access to specialist services. Despite the critical role they play in providing oral health care to rural communities, little research has explored this workforce’s experiences. This study aims to explore these experiences as specifically the clinical, cultural and personal aspects of them. Methods: This qualitative study utilises an inductive research design and follows Braun and Clarke’s framework for thematic analysis. Virtual semi-structured interviews were conducted with five oral health practitioners working in three participating rural Local Health District in NSW. Results: Four key, interconnected themes were identified: (1) workforce recruitment and retention difficulties, (2) financial challenges and inadequate rural incentives, (3) barriers to accessing professional development opportunities, and (4) limitations to specialised oral health services access. Conclusion: This study highlights the complex challenges faced by rural oral health practitioners in NSW. Addressing workforce shortages, improving financial incentives, expanding CPD access and strengthening service delivery models are crucial for sustaining the rural oral health workforce. Targeted policy interventions and support systems are needed to enhance workforce retention and improve oral health access and therefore, outcomes, in rural communities. Clinical services dental health health services professional development rural and remote health rural incentives oral health workforce Figures Figure 1 Background Oral health services in rural regions of Australia presents distinct challenges that are shaped by geographic, socio-economic and cultural factors (1, 2). While the broader healthcare system in Australia has made strides towards improving accessibility and equity to accessing care, rural communities continue to experience significant disparities, particularly in oral health (3). In New South Wales (NSW), the provision of oral health services to rural communities is particularly difficult due to the geographically dispersed nature of these communities, limited access to health infrastructures and the scarcity of oral health practitioners (1, 4). In addition to logistical challenges, the rural oral health workforce, who often are new to the geographical area, are required to navigate diverse place-based cultural and social dynamics associated with the new area (5). Rural, remote and regional areas of NSW are home to a broad range of cultural groups, including Aboriginal and Torres Strait Islander peoples, migrants and people of various socio-economic backgrounds (2, 6). Each of these groups have unique oral health needs and preferences which must be considered in the delivery of care. Oral health practitioners working in rural regions, often operate in environments where professional isolation is also a significant concern (7). This is because, unlike their urban counterparts, rural practitioners tend to work in geographical disparate locations and, in smaller teams or as a sole practitioner; this limits their opportunities for peer support, collaboration and professional development (3, 7). Although the rural oral health workforce plays an integral role in the delivery of oral health care in rural regions, research focused specifically on the experiences of this workforce remains sparse. Moreover, limited research has sought to explore the intersections between clinical practice, cultural capability and their personal well-being within this workforce. This study aims to address this knowledge gap by examining the experiences of oral health practitioners working in rural regions of NSW. The specific study objectives are: 1. To explore the experiences of rural oral health practitioners, and how they perceive and navigate the clinical challenges associated with delivering care in rural regions 2. To understand how they integrate cultural awareness in their practice and, 3. To understand how their personal motivations and professional identities influence their approach to oral health care delivery. By exploring the multifaceted nature of rural oral health care practice, the findings from this study have the potential to inform policy development, workforce planning and target interventions aimed to improve oral health service delivery and hence, oral health outcomes. The results from this study may also be used to enhance workforce support systems, improve retention strategies and provide guidance for future professional development programs tailored to rural oral health practitioners. This paper presents the qualitative findings from a wider study which also explores quantitative parameters of the experiences of the rural oral health workforce. Methods Study design: This study adopts an inductive qualitative research design, utilising semi-structured interviews as the primary method for data collection. The interview used for this study was developed specifically for this study and not used in any other studies (Appendix 1). The choice of qualitative methodology is informed by Braun & Clarke (2022) facilitating the exploration of the subjective, experiences of oral health practitioners working in rural regions of NSW (8). Semi-structured interviews provided flexibility in allowing participants to speak freely while ensuring that key topics related to clinical practice, cultural considerations and personal experiences were explored (9). Participants: Purposive sampling was used to invite oral health professionals employed in three rural Local Health Districts (LHDs) in NSW to participant in this study. Email invites were sent to a representative of each LHD who then forwarded the invites to all potential participants. Inclusion criteria required participants to be an oral health practitioner (including but not limited to dentists, oral health therapists, dental therapists, dental hygienists and dental prosthetists). Any person not involved in the provision of an oral health service in any way or form, was excluded and were asked not to participant in this study. Rurality of the LHD’s were based on the Modified Monash Model, which categorised areas based on geographic isolation, population size and access to healthcare services (10). The participating LHDs all had Modified Monash Categories of MM5, “Small Rural Towns”. Ethical considerations: Ethical approval for this study was obtained from the Greater Western Human Research Ethics Committee [2024/ETH00501]. Following ethical approval, the project was submitted to the Research Ethics and Governance Information System (REGIS) and a site-specific application was subsequently submitted for each participating LHD. All potential participants were provided with an information sheet that outlined the study’s objectives, nature of their involvement and potential risks prior to participating. Online informed consent was obtained from each participant, ensuring that they understood their right to withdraw from the study at any time without consequence. The survey component of the study incorporated a skip logic function, which ensured that participants could only proceed with the survey after explicitly providing consent. Once the survey was completed, the participants were given the opportunity to opt-in to the interview component of the study. If participants agreed to take part in the interview, they were contacted directly by the lead researcher via email to then organise a suitable time for the virtual interview. To protect the participants’ confidentiality, unique study identification numbers were used throughout the data collection as well as the analysis process and all identifying information was removed from the transcripts. Video recordings were stored securely on the University of Sydney’s licence eNotebook (LabArchives) platform during analysis and only accessible by the research team. Upon completion, the data will then be archived securely on the non-public research platform, Research Data Store (RDS) for 5 years and then destroyed. Data Collection: Data were collected through semi-structured interviews conducted via virtual interview using video conferencing platform ZOOM™. The interview was conducted by the primary researcher who did not have any previous encounters or relationships with the participants. Although it is recognised that qualitative interviews normally have a duration of 30 minutes to 1 hour however, each interview lasted approximately 20 minutes for this specific study (9). However, after discussions with the ethics panel, the duration of the interviews was shortened to align with participant’s work schedules. Following verbal consent, the interviews were video recorded then transcribed using the program’s auto transcribe feature. The interviews were guided by an interview schedule that focused on three main themes: clinical challenges, cultural awareness and training, and personal reflections on rural practice (Table 1). Table 1: Summary of interview questions Category Key Questions Sociodemographic - What is your role/occupation? - How many years of experience do you have? - How long have you been in your current role? Cultural Experiences - Can you share your cultural experience as a clinician working in rural and remote NSW? - Have you faced any cultural challenges (e.g., prejudice, discrimination, cultural conflict)? How did you overcome them? - Would you consider your current workforce multicultural? - Are significant cultural events celebrated at your workplace (e.g., NAIDOC, Lunar New Year)? - Are cultural training or cultural immersion opportunities available at your workplace? How frequent are they? Clinical Experiences - Have you faced any clinical challenges (e.g., difficult cases, referral limitations)? How did you overcome them? - Are you confident in using your full scope of practice without support? - What options are available when faced with a difficult clinical case? - Is there an opportunity to liaise with other oral health practitioners? What is the process? - Is there an opportunity to liaise with other allied health professionals? What is the process? - Is continuing professional development (CPD) courses provided by your workplace? Are there designated CPD quotas? - How does the burden of dental disease in rural and remote areas compare to metropolitan areas? Why? Personal Experiences - What inspired you to work in rural and remote NSW? - How has your employment in rural and remote NSW influenced your personal growth? - What support systems are available to you (e.g., counselling, therapy, salary packaging)? - Where do you see yourself working in 10 years? Data Analysis: Interviews were recorded, transcribed and analysed. Given the low workforce numbers across the participating LHDs, to ensure anonymity, transcripts were numbered prior to analysis. The analysis was inductive in nature and used Braun and Clarke’s framework for thematic analysis (8). This framework consists of six stages and provide a clear and systematic approach to identifying, analysing and reporting themes within a qualitative dataset. Table 2 outlines each of these six stages and the approach used by the researcher to complete the analysis process for this study. Table 2: Summary of Braun and Clarke’s framework for thematic analysis. Stages Approach Used in This Study 1. Familiarisation with the data The researcher repeatedly read the transcripts and listened to the audio recording, taking initial notes on emerging ideas and patterns 2. Coding Data was systematically coded using an inductive approach, highlighting key experiences, challenges and any special remarks of each participant 3. Generating initial themes Codes were grouped into overarching themes which reflect workforce challenges, professional development and service access (including interprofessional and specialist referrals) 4. Developing and reviewing themes Themes were reviewed in multiple research meetings for consistency and accuracy with overlapping or redundant themes combined or refined 5. Reviewing, defining and naming themes Themes were clearly named and defined, ensuring they accurately represented participants’ experiences 6. Write up Themes were integrated into the results, supported by direct quotes to illustrate key findings of the study Braun and Clarke’s (2022) approach to thematic analysis emphasises researcher reflexivity throughout all stages. Reflexive thematic analysis refers to the researcher critically reflecting on their personal role, biases and assumptions, and how these factors may influence the analysis process (8). The primary researcher, a final year PhD candidate with experience in working rurally as an Oral Health Therapist (OHT), conducted the interview and analysis. Her clinical experience and familiarity with the topic provided valuable insight but also potential biases. To enhance reflexivity, the researcher critically examined her position, acknowledging potential biases stemming from her professional background and research interest but also understanding that these factors may shape data interpretation. Due to this, the researcher understood the importance of maintaining an ongoing reflective stance throughout each stage to ensure transparency, rigor and a nuanced understanding of the findings (8). The researcher used a combination of reflective journaling, team meetings and collaborative analysis to maintain this approach. Reflective notes allowed for documentation of thoughts, initial impressions and evolving interpretations throughout the analysis process, fostering reflexivity and critical engagement with the data (8). Regular team meetings provided an opportunity to discuss emerging themes, receive feedback and refine analytical approach. Collaborative analysis was also conducted with two other researchers for peer debriefing, resolving any discrepancies and enhancing the reliability of the identified themes (11). Results Individual semi-structured interviews were conducted with five oral health practitioners, including dental officers (n=1), OHTs (n=3) and dental therapists (n=1). Clinical experience ranged from new graduate (less than 1 year experience) to over 40 years. Majority of participants (n=3) had relocated to be in their current role, while others (n=2) were long-term residents who were already living in these rural communities. Participants were all females (n=5) and from across all three participating LHDs. No participants identified as Aboriginal and/or Torres Strait Islander. Table 3 highlights the demographic and characteristics of participants in this study. Table 3: Demographic and characteristics of participants Characteristics Category n (%) Occupation Dental Officers Oral Health Therapist Dental Therapist 1 (20%) 3 (60%) 1 (20%) Year of clinical experience Less than 1 year 1-4 years 5-9 years 10 years or more 1 (20%) 1 (20%) 0 (0%) 3 (60%) Years of rural living Less than 1 year 1-4 years 5-9 years 10 years or more 1 (20%) 3 (60%) 0 (0%) 1 (20%) Gender Female Male 5 (100%) 0 (0%) Aboriginal/Torres Strait Islander Origin Aboriginal Torres Strait Islander Neither 0 (0%) 0 (0%) 5 (100%) Four key themes were identified from this study: 1) difficulties attracting and retaining staff, 2) financial challenges and lack of incentives for rural practice, 3) challenges accessing external professional development opportunities and 4) access and provision of clinical services. The key themes are notably interrelated and not isolated from one another as illustrated in Figure 1. Key theme 1: Difficulties attracting and retaining staff Participants reported challenges related to the attraction and retention of not only oral health practitioners, but of all staff and especially for long term employment. “ We’re really struggling but with different types of staff in different clinics ” (Participant 3). Due to the difficulty of attracting and retaining staff, participants also reported increased workload pressures and a continuous cycle of training new employees, who often leave after a few years. This recurring process of recruiting and training in additional to increased workloads, contributed to work-related burnout in most participants. “ The workforce is very thin in terms of, we often get asked to do more with less and that’s unsustainable ” (Participant 1). “ You feel like you’re spread over multiple clinics which can take up a bit of extra capacity and particularly when there’s just random outside jobs that you have to do in additional to that as well ” (Participant 2). “S ome of the older staff get a bit of burnout because they’re constantly putting a lot of effort to train up new staff who then stay for that year or two and take all that wealth of knowledge and then leave and then regional staff have to do it all over again ” (Participant 2). Key theme 2: Financial challenges and lack of incentives for rural practice: Financial challenges and the lack of relocation incentives was also identified as a major obstacle for oral health practitioners wanting to relocate to a rural community. The competitive rural housing market as well as high costs of living were some factors that posed as obstacles for a relocating clinician. “ Remuneration for clinicians has not kept pace ... I don’t know whether that will be enough to attract people to public health jobs, particularly in rural areas where rent is still expensive, and housing is hard to get ” (Participant 3). Some participants mentioned that they were given a financial relocation incentive while others reported not receiving such benefit. Participants who did receive the incentive explained that after tax deductions, the incentive did not cover the costs for relocation. “ They gave me an incentive for moving to a rural area... but like half of it got taxed... so it wasn’t super helpful with all the costs of moving ” (Participant 3). “ A lot of other regional areas have got the incentive... [we] did not get it at all and at the moment it’s sitting with the unions to fight for it ” (Participant 4). There was also a noted disparity in the benefit amount between dental officers and oral health therapists. Dental officers received a larger amount upfront in additional to a continuous payment on an annual basis while oral health therapists received only the upfront benefit (of lower value) and no ongoing payments. “So the dentist gets an additional amount each year for working rural, but the OHTs only get it to help initially move” (Participant 3). While relocating practitioners received this incentive, oral health practitioners who were employed prior to the implementation of these relocation schemes have not received any financial incentive or remuneration for continuing to work in these rural communities. “ That’s the way to get the staff out to the regional areas but those of us who have stuck out here don’t get anything” (Participant 4). Key theme 3: Challenges accessing external professional development opportunities The interview revealed that participants have easy access to in-house or online continuing professional development (CPD) opportunities, and these are often well received. “We have regular dental officer and OHT meetings and people will pass on learnings that they’ve had from conferences ” (Participant 1). “ There is quite a lot of online opportunities where they will circulate invites for certain courses... and then we do have obviously our in-house specialists who will run sessions as well ” (Participant 5). Despite accessible in-house or online CPD opportunities, it was reported that there was significant difficulty in accessing external CPD opportunities. The geographic isolation nature of working in rural areas was reported to have played a part in this limitation. “I think there's that conference in Sydney at the moment... I think it’s a paediatric conference, that would have been good to have gone to” (Participant 4). “Which is why it’s sort of hard to apply and get it... because most of it’s in Sydney. Like if it's a workshop” (Participant 3). Despite reports of work-place funding for CPD courses, financial constraints were reported contributing to difficulty accessing external CPD. Participants explained that in addition to the cost of the CPD programs, they must also consider costs of transport and accommodation as they are often required to travel to larger cities to attend these courses. “ Every year, I think we have a day that we can take for CPD leave. And we also have I think it might be $750 that we can put towards [it]. They tend to not let us use it both together. So, you can pick one activity for the leave or one activity for their funding” (Participant 2). “But when you’re looking at a thousand dollars to go, that’s just for the conference and you’ve got to get accommodation, and you’ve got to get there. It just starts to get expensive” (Participant 4). Participants also reported the challenging nature of asking for leave to attend these external courses due to staffing shortages and high workload demands. Participants report a sense of guilt when attending these CPD courses and the need to convince their managers why their attendance is beneficial for the practice. “ It’s hard to be given like granted leave to go attend because the burden is then on everyone else back at the clinic. But what you’re learning is to help benefit them, but you have to really like prove why it’s benefiting them” (Participant 3). “They don’t advertise to us anything, and I’ve heard from coworkers like when they’re trying to go to these things or apply for these things, it’s quite difficult” (Participant 3). Key theme 4: Access and provision of clinical services Participants described a supportive working environment, highlighting the ability to refer patients to both internal and external dental specialists or other clinicians when cases were beyond their clinical scope of practice. “We have an in-house oral surgeon which is super helpful... We have a pain specialist who visits from Sydney... We do have the option to refer to Sydney for specialist services... Otherwise, it is just to a private provider if the patient chooses. We have our own general anaesthetic clinic though so we do have that option should we need it for both children and adults” (Participant 5). However, it was revealed that lengthy wait times for specialist services combined with long travel distances, often pose as challenges for patients seeking treatment. “We do have an oral surgeon that we can refer to... but the wait list is terribly long, probably 12 months minimum for an assessment and then you go back on another list if you need to have a general anaesthetic” (Participant 4). “ Whenever it comes to referring patients to specialist services, that can be a major challenge because we know that they might not be able to travel to access those services” (Participant 2). Participants expressed a mixed desire for greater interprofessional relationships with Aboriginal Health Workers and local Aboriginal Community Controlled Health Services (ACCHSs). Some participants expressed the appeal of having an Aboriginal Health Work involved with the appointment, especially with following up patients; while others expressed although available, Aboriginal Health Workers are generally not required to be present for the appointment. “I think it would be really helpful, particularly for following up our really vulnerable patients who are very irregular attenders... It'd be so good if we had an Aboriginal Health Worker who could get along with the family, support them to come into appointments” (Participant 2). “There are some Aboriginal Health Workers, but they don’t really get involved. I think because most of the population are Aboriginal or Torres Strait Islander, I don’t think they need a liaison present.” (Participant 3). Participants were deeply interested in the patient’s well-being and personally took into consideration the patient’s travel time when planning and providing treatment. Participants expressed the need to provide sufficient care to make the trip worthwhile for the patient. “ You’re not going to bring them back for one little thing. You might do your exam, x-rays and fissure protectants or you know one little filling in a visit to try and get them done a bit quicker” (Participant 4). “ Patients travelling like hours to come see me, I definitely feel like I need to do as much as I can for them to make it worth their while” (Participant 3). Overall, participants reported significant difficulties in attracting and retaining staff, leading to increased workloads, frequent staff turnover and work-related burnout. Financial challenges, such as the high cost of living and inconsistent relocation incentives, further impacted workforce stability and rural living. While in-house and online CPD opportunities were readily available for rural oral health practitioners, they revealed that accessing external CPD was hindered by geographic isolation, financial constraints and staffing shortages. In terms of clinical service provision, participants described supportive working environments with access to specialist referrals when required however, lengthy wait times and long travel distances often posed as challenges for patients. Strong interprofessional relationships between oral health professionals helped to accommodate the travel burdens faced by rural patients. However, the desire to strength the relationship with Aboriginal Health Workers and ACCHSs remains split. Discussion Exploration of the rural oral health practitioners’ experiences, particularly focusing on their cultural, clinical and personal experiences, has revealed four key related themes. Their interconnected nature is illustrated in Figure 1. Difficulties in attracting and retaining staff (key theme 1) was found to be compounded by financial challenges and the lack of rural incentives (key theme 2). This not only deterred new practitioners from relocating rurally but also resulted in existing practitioners to move out of these rural regions. Financial constraints were also found to limit opportunities for external professional development (key theme 3) due to the financial burdens associated with travel and accommodation for these external courses. This made it difficult for rural practitioners to upskill, further exacerbating workforce shortages as well as barriers to retention. In turn, the limited availability of dental specialists in rural NSW resulted in long wait lists and difficulty accessing such services (key theme 4). This again highlights the workforce shortages and ongoing difficulty to maintain an adequate rural oral health workforce. The findings from this study highlights the significant challenges faced by oral health practitioners working in rural NSW, particularly in terms of workforce attraction and retention, financial incentives, professional development and access to services. These issues are not unique to oral health alone but are consistent with broader trends observed in rural healthcare settings in Australia (2, 12). The implications of these findings are critical for informing workforce policies, service delivery models and support mechanisms for rural oral health practitioners. Without solutions, the sustainability of the rural oral health workforce will remain at risk and may further cause health disparities in oral health access between rural and metropolitan areas (13, 14). Workforce attraction, retention and burnout The study identified consistent difficulties in attracting and retaining not only oral health practitioners in rural areas but also support staff, leading to increased workload pressures and workforce burnout. These findings align with previous research that has reported high turnover rates and recruitment difficulties in other rural health professions, exacerbated by professional isolation and limited career progression opportunities (3, 7, 12). The frequent cycle of training new staff who leave after a short tenure further compounds these challenges, placing stain on those who remain. Developing initiatives that promote rural practice as a long-term career can help address these issues. Targeted strategies such as enhanced financial incentives, structured mentorships programs and clearer career development pathways can all support early-career practitioners (12, 15). Similar approaches have proven successful in other health professions, contributing to improved increase employment, workforce retention and job stratification in rural areas (16, 17). Additionally, increasing opportunities for professional networking within rural settings may also help alleviate feelings of isolation, encourage long-term workforce retention and reduce workforce burnout (12, 17, 18). While these strategies are viable options, they are often not considered in small oral health clinics due to resource limitations and workforce constraints (19). Financial Incentives and Cost of Rural Practice Financial challenges were a predominant concern among participants, particularly in relation to relocation incentives and the high cost of living in rural areas. While some participants received relocation incentives, inconsistencies in benefit allocation and taxation reduced their effectiveness. Furthermore, the disparity in incentive structures between dental officers and oral health therapists may contribute to dissatisfaction and inequities within the workforce (19). Similar findings have been reported in rural healthcare research, where financial incentives alone have been insufficient in ensuring long-term retention (5, 20). Although financial incentives can serve as an initial motivator for oral health practitioners to relocate to rural regions, a broader support system may be required for practitioner retention (19, 20). Policy adjustments that offer more competitive and continuous financial incentives, along with potential assistance in housing or other rural living costs can encourage long-term retention. Adjustments can also be made to ensure incentive structures are equitable across different professional categories, recognising the different contributions of various oral health practitioners. Addressing financial constrains is critical in making rural practice more attractive and sustainable long-term to mitigate these employment concerns. Additionally, promoting oral health careers to oral health university students – particularly those who relocated to metropolitan areas for their studies – could help strengthen the rural workforce as many may seek to return home after their degrees (21, 22). Continuing Professional Development and Education Barriers Access to professional development opportunities was another key concern raised by participants. While in-house and online CPD opportunities were available, attending external CPD programs was often difficult due to geographic isolation, financial constraints, and staffing shortages. This finding is consistent with existing research in rural health workforce training, which emphasises the need for flexible and regionally accessible CPD opportunities (19, 23, 24). Limited access to external CPD can restrict skill development, career progression and professional satisfaction, potentially contributing to workforce retention challenges (24). Efforts should be made to evenly distribute CPD opportunities and ensure that rural practitioners have equitable access to training. This could include increasing funding for travel to attend CPD programs or paid study-leave for attending such programs, expanding regional CPD workshops and strengthening virtual learning options with interactive and hands-on training element (23-25). Structured peer learning networks could help facilitate knowledge-sharing and skill-building opportunities among rural oral health practitioners, fostering a sense of professional community and reducing isolation (17, 19, 25). Implementing these policies and allowing employees a more flexible study-leave option can significantly help oral health practitioners in attending CPD programs without negatively impacting staffing or increasing workloads for those who remain at the clinics. Such policies may include designating a certain amount of professional development days on an annual basis (24, 26). Clinical Service Provision and Patient Access Despite challenges, participants reported a supportive working environment with access to specialist dental referrals when necessary. However, these referrals often involve lengthy wait times and long travel distances for patients. The long wait times for patients to access specialist dental care identified in this study are consistent with previous studies exploring the limitations of rural health services(4, 27). This limitation can result in delayed treatment and therefore, worsening of oral health conditions, progression of symptoms and increased social costs in terms of time and financial costs associated with travel (4). Participants described adapting their treatment approaches to take into consideration the length of travel required by patients to access care, ensuring that each visit provided maximum benefit. This highlights the need for service models that are flexible and patient-centred, recognising the challenges of rural healthcare provision (28). Strategies such as expanding telehealth consultations, increasing outreach specialist services and enhancing local training opportunities can all contribute to alleviate these issues (29, 30). In addition to this, strengthening interprofessional collaborations, particularly with Aboriginal Health Workers and local ACCHSs, has proven to improve care coordination and enhance patient engagement (31, 32). Enhancing these partnerships through integrated care models may lead to better patient outcomes and reduce the impact of geographic barriers. Implications for Policy and Workforce Planning The findings of this study emphasise the need for targeted workforce strategies and policy interventions to address the challenges experienced by oral health practitioners in rural regions. Strategies such as structured incentive programs to improve recruitment and retention, regionally accessible CPD opportunities as well as improved workforce support systems can ensure sustainable rural oral health service provision. Integrating rural oral health workforce considerations into broader healthcare policy planning is important for creating long-term solutions. The development of strategic workforce plans that align with the needs of rural populations, including targeted recruitment strategies and improved service delivery models, could lead to meaningful improvements in rural oral health outcomes (33-35). Limitations: While this study provided valuable insights, its findings are limited by the inclusion of only three LHDs. This may have limited the study’s generalisability and representation of the workforce, resulting in an uneven distribute of oral health practitioners (e.g. no dental prosthetists were interviewed) and therefore, a lack of workforce representation. Another limitation is the potential for interviewer bias. Despite effort to remain neutral throughout the interview process, the researcher’s prior experiences and perspectives may have inadvertently influenced the way questions were asked or the way in which responses were interpreted. Conclusions This study highlights the multifaceted and interconnected challenges faced by the rural oral health workforce in NSW. These challenges include workforce retention difficulties, financial constraints, barriers to professional development opportunities and limitations in specialised oral health service access. Addressing these issues requires a comprehensive approach that incorporates policy reform, targeted incentives and enhanced workforce support systems. Prioritising these strategies, could strength recruitment, retention and overall job satisfaction as well as improve oral health outcomes for people in rural communities. Abbreviations ACCHS Aboriginal Community Controlled Health Service CPD Continuing professional development LHD Local Health District NSW New South Wales OHT Oral Health Therapist Declarations Ethics approval and consent to participate: Ethical approval for this study was obtained from the Greater Western Human Research Ethics Committee [2024/ETH00501]. Following ethical approval, the project was submitted to the Research Ethics and Governance Information System (REGIS) and a site-specific application was subsequently submitted for each participating LHD. All potential participants were provided with an online information statement that outlined the study’s objectives, nature of their involvement and potential risks prior to participating. Online informed consent was obtained from each participant, ensuring that they understood their right to withdraw from the study at any time without consequence. The survey component of the study incorporated a skip logic function, which ensured that participants could only proceed with the survey after explicitly providing consent. Once the survey was completed, the participants were given the opportunity to opt-in to the interview component of the study. If participants agreed to take part in the interview, they were contacted directly by the lead researcher via email to then organise a suitable time for the virtual interview. Consent for publication: Not applicable Availability of data and materials: The datasets generated and analysed during the current study are not publicly available due to confidentiality reasons and are not available upon request. It was stored securely on the University of Sydney’s licence eNotebook (LabArchives) platform during analysis and only accessible by the research team. The data is now archived securely on the non-public research platform, Research Data Store (RDS) and will be for 5 years and then destroyed. Completing interest declaration: The authors declare that they have no competing interests. Funding: This research was support by the Australia Dental Research Foundation. The authors affirm that this study was conducted independently and was not influenced by any external organisation, financial interest or institutional bias. The funding received was solely for research purposes and did not influence the study design, data collection, analysis or interpretation of the results. Authors’ contributions: L.D. took part in the conceptualisation, analysis, funding acquisition, investigation, methodology, visualisation and writing of the original draft. L.D. also prepared all figures and tables. Y.D. helped with the conceptualisation, investigation, methodology and supervision of this study. J.B. assisted with the investigation, methodology and supervision of this study. B.C. was involved in funding acquisition and supervision. W.S. took lead in conceptualisation and supervision of this study. All authors read, reviewed, edited and approved the final manuscript. Acknowledgements: This research was support by the Australia Dental Research Foundation and we are grateful for their funding assistance. Additionally, we extend our appreciation to the University of Sydney in support of this study. I would also like to acknowledge the contributions of the oral health practitioners from the participating Local Health Districts for being part of this study and generously sharing their insights on their experiences working in rural New South Wales. References AIHW. Oral health and dental care in Australia. Canberra: Australian Institute of Health Welfare; 2024. AIHW. Rural and remote health. Canberra: AIHW; 2024. Bourke L, Coffin J, Taylor J, Fuller J. Rural health in Australia. 2010. p. 2-9. Schwarz E. Access to oral health care–an Australian perspective. Community dentistry and oral epidemiology. 2006;34(3):225-31. Cortie CH, Garne D, Parker‐Newlyn L, Ivers RG, Mullan J, Mansfield KJ, et al. The Australian health workforce: Disproportionate shortfalls in small rural towns. Australian Journal of Rural Health. 2024. Baxter J, Hayes A, Gray M. Families in regional, rural and remote Australia (Facts Sheet). Melbourne: Australian Institute of Family Studies; 2011. Godwin DM, Hoang H, Crocombe LA, Bell E. Dental practitioner rural work movements: a systematic review. Rural and remote health. 2014;14(3):431-43. Braun V, Clarke V. Thematic analysis: A Practical Guide: SAGE Publications; 2022. 338 p. Karatsareas P. Semi-structured interviews. Research methods in language attitudes. 2022:99-113. Department of Health and Aged Care. Modified Monash Model 2024 [Available from: https://www.health.gov.au/topics/rural-health-workforce/classifications/mmm. Richards KAR, Hemphill MA. A practical guide to collaborative qualitative data analysis. Journal of Teaching in Physical education. 2018;37(2):225-31. Rose H, Skaczkowski G, Gunn KM. Addressing the challenges of early career rural nursing to improve job satisfaction and retention: Strategies new nurses think would help. Journal of advanced nursing. 2023;79(9):3299-311. Steele L, Pacza T, Tennant M. Rural and remote oral health, problems and models for improvement: a Western Australian perspective. Australian Journal of Rural Health. 2000;8(1):22-8. Spencer A, Teusner D, Carter K, Brennan D. The dental labour force in Australia: the position and policy directions. Australian Institute of Health and Welfare (Media and Publishing Unit); 2003. Goetz K, Marx M, Marx I, Brodowski M, Nafula M, Prytherch H, et al. Working atmosphere and job satisfaction of health care staff in Kenya: an exploratory study. BioMed research international. 2015;2015(1):256205. Jaeger FN, Bechir M, Harouna M, Moto DD, Utzinger J. Challenges and opportunities for healthcare workers in a rural district of Chad. BMC health services research. 2018;18:1-11. Skinner J, Dimitropoulos Y, Moir R, Johnson G, McCowen D, Rambaldini B, et al. A graduate oral health therapist program to support dental service delivery and oral health promotion in Aboriginal communities in New South Wales, Australia. Rural and Remote Health. 2021;21(1):1-9. Cunningham FC, Ranmuthugala G, Plumb J, Georgiou A, Westbrook JI, Braithwaite J. Health professional networks as a vector for improving healthcare quality and safety: a systematic review. BMJ quality & safety. 2012;21(3):239-49. Kruger E, Tennant M. Oral health workforce in rural and remote Western Australia: practice perceptions. Australian Journal of Rural Health. 2005;13(5):321-6. Buykx P, Humphreys J, Wakerman J, Pashen D. Systematic review of effective retention incentives for health workers in rural and remote areas: Towards evidence‐based policy. Australian Journal of Rural Health. 2010;18(3):102-9. Tadakamadla SK, Balla SB, Tadakamadla J, Semmens L, Down S, McKinstry C, et al. Determinants of rural practice among a cohort of dental professionals in Australia. BMC Medical Education. 2025;25(1):142. Russell D, Mathew S, Fitts M, Liddle Z, Murakami-Gold L, Campbell N, et al. Interventions for health workforce retention in rural and remote areas: a systematic review. Human Resources for Health. 2021;19(1):103. Wakerman J, Humphreys J, Russell D, Guthridge S, Bourke L, Dunbar T, et al. Remote health workforce turnover and retention: what are the policy and practice priorities? Human Resources for Health. 2019;17(1):99. Mlambo M, Silén C, McGrath C. Lifelong learning and nurses’ continuing professional development, a metasynthesis of the literature. BMC Nursing. 2021;20(1):62. Campbell N, McAllister L, Eley D. The influence of motivation in recruitment and retention of rural and remote allied health professionals: a literature review. Rural Remote Health. 2012;12:1900. Joyce K, Pabayo R, Critchley JA, Bambra C. Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Syst Rev. 2010;2010(2):Cd008009. Dudko Y, Kruger E, Tennant M. Shortage of dentists in outer regional and remote areas and long public dental waiting lists: changes over the past decade. Australian Journal of Rural Health. 2018;26(4):284-9. Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public health. 2015;129(6):611-20. Totten AM, Womack DM, Eden KB, McDonagh MS, Griffin JC, Grusing S, et al. Telehealth: mapping the evidence for patient outcomes from systematic reviews. 2016. Knowles M, Crowley AP, Vasan A, Kangovi S. Community Health Worker Integration with and Effectiveness in Health Care and Public Health in the United States. Annu Rev Public Health. 2023;44:363-81. Mackean T, Withall E, Dwyer J, Wilson A. Role of Aboriginal Health Workers and Liaison Officers in quality care in the Australian acute care setting: a systematic review. Australian Health Review. 2020;44(3):427-33. Pacza T, Steele L, Tennant M. Development of oral health training for rural and remote Aboriginal health workers. Australian Journal of Rural Health. 2001;9(3):105-10. Department of Health and Age Care. Healthy mouths, healthly lives - Australia’s National Oral Health Plan 2015-2014. Australian Government Department of Health and Aged Care.; 2015. Strategy CfOH. NSW Oral Health Strategic Plan 2022-2032. NSW Ministry of Health; 2023. Australia HW. Australia’s Future Health Workforce - Oral Health - Detailed Report. Canberra Department of Health; 2014. Additional Declarations No competing interests reported. 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While the broader healthcare system in Australia has made strides towards improving accessibility and equity to accessing care, rural communities continue to experience significant disparities, particularly in oral health (3). In New South Wales (NSW), the provision of oral health services to rural communities is particularly difficult due to the geographically dispersed nature of these communities, limited access to health infrastructures and the scarcity of oral health practitioners (1, 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition to logistical challenges, the rural oral health workforce, who often are new to the geographical area, are required to navigate diverse place-based cultural and social dynamics associated with the new area (5). Rural, remote and regional areas of NSW are home to a broad range of cultural groups, including Aboriginal and Torres Strait Islander peoples, migrants and people of various socio-economic backgrounds (2, 6). Each of these groups have unique oral health needs and preferences which must be considered in the delivery of care. Oral health practitioners working in rural regions, often operate in environments where professional isolation is also a significant concern (7). This is because, unlike their urban counterparts, rural practitioners tend to work in geographical disparate locations and, in smaller teams or as a sole practitioner; this limits their opportunities for peer support, collaboration and professional development (3, 7).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough the rural oral health workforce plays an integral role in the delivery of oral health care in rural regions, research focused specifically on the experiences of this workforce remains sparse. Moreover, limited research has sought to explore the intersections between clinical practice, cultural capability and their personal well-being within this workforce.\u003c/p\u003e\n\u003cp\u003eThis study aims to address this knowledge gap by examining the experiences of oral health practitioners working in rural regions of NSW. The specific study objectives are:\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp; To explore the experiences of rural oral health practitioners, and how they perceive and navigate the clinical challenges associated with delivering care in rural regions\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;To understand how they integrate cultural awareness in their practice and,\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;To understand how their personal motivations and professional identities influence their approach to oral health care delivery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBy exploring the multifaceted nature of rural oral health care practice, the findings from this study have the potential to inform policy development, workforce planning and target interventions aimed to improve oral health service delivery and hence, oral health outcomes. The results from this study may also be used to enhance workforce support systems, improve retention strategies and provide guidance for future professional development programs tailored to rural oral health practitioners. This paper presents the qualitative findings from a wider study which also explores quantitative parameters of the experiences of the rural oral health workforce.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy design:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study adopts an inductive qualitative research design, utilising semi-structured interviews as the primary method for data collection. The interview used for this study was developed specifically for this study and not used in any other studies (Appendix 1). The choice of qualitative methodology is informed by Braun \u0026amp; Clarke (2022) facilitating the exploration of the subjective, experiences of oral health practitioners working in rural regions of NSW (8). Semi-structured interviews provided flexibility in allowing participants to speak freely while ensuring that key topics related to clinical practice, cultural considerations and personal experiences were explored (9).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling was used to invite oral health professionals employed in three rural Local Health Districts (LHDs) in NSW to participant in this study. Email invites were sent to a representative of each LHD who then forwarded the invites to all potential participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInclusion criteria required participants to be an oral health practitioner (including but not limited to dentists, oral health therapists, dental therapists, dental hygienists and dental prosthetists). Any person not involved in the provision of an oral health service in any way or form, was excluded and were asked not to participant in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRurality of the LHD\u0026rsquo;s were based on the Modified Monash Model, which categorised areas based on geographic isolation, population size and access to healthcare services (10). The participating LHDs all had Modified Monash Categories of MM5, \u0026ldquo;Small Rural Towns\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical considerations:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Greater Western Human Research Ethics Committee [2024/ETH00501]. Following ethical approval, the project was submitted to the Research Ethics and Governance Information System (REGIS) and a site-specific application was subsequently submitted for each participating LHD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll potential participants were provided with an information sheet that outlined the study\u0026rsquo;s objectives, nature of their involvement and potential risks prior to participating. Online informed consent was obtained from each participant, ensuring that they understood their right to withdraw from the study at any time without consequence. The survey component of the study incorporated a skip logic function, which ensured that participants could only proceed with the survey after explicitly providing consent. Once the survey was completed, the participants were given the opportunity to opt-in to the interview component of the study. If participants agreed to take part in the interview, they were contacted directly by the lead researcher via email to then organise a suitable time for the virtual interview.\u003c/p\u003e\n\u003cp\u003eTo protect the participants\u0026rsquo; confidentiality, unique study identification numbers were used throughout the data collection as well as the analysis process and all identifying information was removed from the transcripts. Video recordings were stored securely on the University of Sydney\u0026rsquo;s licence eNotebook (LabArchives) platform during analysis and only accessible by the research team. Upon completion, the data will then be archived securely on the non-public research platform, Research Data Store (RDS) for 5 years and then destroyed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Collection:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through semi-structured interviews conducted via virtual interview using video conferencing platform ZOOM\u0026trade;. The interview was conducted by the primary researcher who did not have any previous encounters or relationships with the participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough it is recognised that qualitative interviews normally have a duration of 30 minutes to 1 hour however, each interview lasted approximately 20 minutes for this specific study (9). However, after discussions with the ethics panel, the duration of the interviews was shortened to align with participant\u0026rsquo;s work schedules. Following verbal consent, the interviews were video recorded then transcribed using the program\u0026rsquo;s auto transcribe feature. The interviews were guided by an interview schedule that focused on three main themes: clinical challenges, cultural awareness and training, and personal reflections on rural practice (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: Summary of interview questions\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey Questions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSociodemographic\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003e- What is your role/occupation?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- How many years of experience do you have?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- How long have you been in your current role?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCultural Experiences\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003e- Can you share your cultural experience as a clinician working in rural and remote NSW?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- Have you faced any cultural challenges (e.g., prejudice, discrimination, cultural conflict)? How did you overcome them?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- Would you consider your current workforce multicultural?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- Are significant cultural events celebrated at your workplace (e.g., NAIDOC, Lunar New Year)?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- Are cultural training or cultural immersion opportunities available at your workplace? How frequent are they?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Experiences\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003e- Have you faced any clinical challenges (e.g., difficult cases, referral limitations)? How did you overcome them?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- Are you confident in using your full scope of practice without support?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- What options are available when faced with a difficult clinical case?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- Is there an opportunity to liaise with other oral health practitioners? What is the process?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- Is there an opportunity to liaise with other allied health professionals? What is the process?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- Is continuing professional development (CPD) courses provided by your workplace? Are there designated CPD quotas?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- How does the burden of dental disease in rural and remote areas compare to metropolitan areas? Why?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonal Experiences\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003e- What inspired you to work in rural and remote NSW?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- How has your employment in rural and remote NSW influenced your personal growth?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- What support systems are available to you (e.g., counselling, therapy, salary packaging)?\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e- Where do you see yourself working in 10 years?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eData Analysis:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInterviews were recorded, transcribed and analysed. Given the low workforce numbers across the participating LHDs, to ensure anonymity, transcripts were numbered prior to analysis. The analysis was inductive in nature and used Braun and Clarke\u0026rsquo;s framework for thematic analysis (8). This framework consists of six stages and provide a clear and systematic approach to identifying, analysing and reporting themes within a qualitative dataset. Table 2 outlines each of these six stages and the approach used by the researcher to complete the analysis process for this study.\u003c/p\u003e\n\u003cp\u003eTable 2: Summary of Braun and Clarke\u0026rsquo;s framework for thematic analysis.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStages\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eApproach Used in This Study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Familiarisation with the data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eThe researcher repeatedly read the transcripts and listened to the audio recording, taking initial notes on emerging ideas and patterns\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Coding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eData was systematically coded using an inductive approach, highlighting key experiences, challenges and any special remarks of each participant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Generating initial themes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eCodes were grouped into overarching themes which reflect workforce challenges, professional development and service access (including interprofessional and specialist referrals)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4. Developing and reviewing themes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eThemes were reviewed in multiple research meetings for consistency and accuracy with overlapping or redundant themes combined or refined\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5. Reviewing, defining and naming themes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eThemes were clearly named and defined, ensuring they accurately represented participants\u0026rsquo; experiences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6. Write up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eThemes were integrated into the results, supported by direct quotes to illustrate key findings of the study\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBraun and Clarke\u0026rsquo;s (2022) approach to thematic analysis emphasises researcher reflexivity throughout all stages. Reflexive thematic analysis refers to the researcher critically reflecting on their personal role, biases and assumptions, and how these factors may influence the analysis process (8). The primary researcher, a final year PhD candidate with experience in working rurally as an Oral Health Therapist (OHT), conducted the interview and analysis. Her clinical experience and familiarity with the topic provided valuable insight but also potential biases. To enhance reflexivity, the researcher critically examined her position, acknowledging potential biases stemming from her professional background and research interest but also understanding that these factors may shape data interpretation. Due to this, the researcher understood the importance of maintaining an ongoing reflective stance throughout each stage to ensure transparency, rigor and a nuanced understanding of the findings (8). The researcher used a combination of reflective journaling, team meetings and collaborative analysis to maintain this approach. Reflective notes allowed for documentation of thoughts, initial impressions and evolving interpretations throughout the analysis process, fostering reflexivity and critical engagement with the data (8). Regular team meetings provided an opportunity to discuss emerging themes, receive feedback and refine analytical approach. Collaborative analysis was also conducted with two other researchers for peer debriefing, resolving any discrepancies and enhancing the reliability of the identified themes (11).\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIndividual semi-structured interviews were conducted with five oral health practitioners, including dental officers (n=1), OHTs (n=3) and dental therapists (n=1). Clinical experience ranged from new graduate (less than 1 year experience) to over 40 years. Majority of participants (n=3) had relocated to be in their current role, while others (n=2) were long-term residents who were already living in these rural communities. Participants were all females (n=5) and from across all three participating LHDs. No participants identified as Aboriginal and/or Torres Strait Islander. Table 3 highlights the demographic and characteristics of participants in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3: Demographic and characteristics of participants\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eDental Officers\u003c/p\u003e\n \u003cp\u003eOral Health Therapist\u003c/p\u003e\n \u003cp\u003eDental Therapist\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003cp\u003e3 (60%)\u003c/p\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear of clinical experience\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eLess than 1 year\u003c/p\u003e\n \u003cp\u003e1-4 years\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5-9 years\u003c/p\u003e\n \u003cp\u003e10 years or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e3 (60%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of rural living\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eLess than 1 year\u003c/p\u003e\n \u003cp\u003e1-4 years\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5-9 years\u003c/p\u003e\n \u003cp\u003e10 years or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003cp\u003e3 (60%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5 (100%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAboriginal/Torres Strait Islander Origin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003eAboriginal\u003c/p\u003e\n \u003cp\u003eTorres Strait Islander\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNeither\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e5 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Four key themes were identified from this study: 1) difficulties attracting and retaining staff, 2) financial challenges and lack of incentives for rural practice, 3) challenges accessing external professional development opportunities and 4) access and provision of clinical services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe key themes are notably interrelated and not isolated from one another as illustrated in Figure 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eKey theme 1: Difficulties attracting and retaining staff\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported challenges related to the attraction and retention of not only oral health practitioners, but of all staff and especially for long term employment.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWe\u0026rsquo;re really struggling but with different types of staff in different clinics\u003c/em\u003e\u0026rdquo; (Participant 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDue to the difficulty of attracting and retaining staff, participants also reported increased workload pressures and a continuous cycle of training new employees, who often leave after a few years. This recurring process of recruiting and training in additional to increased workloads, contributed to work-related burnout in most participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThe workforce is very thin in terms of, we often get asked to do more with less and that\u0026rsquo;s unsustainable\u003c/em\u003e\u0026rdquo; (Participant 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eYou feel like you\u0026rsquo;re spread over multiple clinics which can take up a bit of extra capacity and particularly when there\u0026rsquo;s just random outside jobs that you have to do in additional to that as well\u003c/em\u003e\u0026rdquo; (Participant 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;S\u003cem\u003eome of the older staff get a bit of burnout because they\u0026rsquo;re constantly putting a lot of effort to train up new staff who then stay for that year or two and take all that wealth of knowledge and then leave and then regional staff have to do it all over again\u003c/em\u003e\u0026rdquo; (Participant 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eKey theme 2: Financial challenges and lack of incentives for rural practice:\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFinancial challenges and the lack of relocation incentives was also identified as a major obstacle for oral health practitioners wanting to relocate to a rural community. The competitive rural housing market as well as high costs of living were some factors that posed as obstacles for a relocating clinician.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eRemuneration for clinicians has not kept pace ... I don\u0026rsquo;t know whether that will be enough to attract people to public health jobs, particularly in rural areas where rent is still expensive, and housing is hard to get\u003c/em\u003e\u0026rdquo; (Participant 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome participants mentioned that they were given a financial relocation incentive while others reported not receiving such benefit. Participants who did receive the incentive explained that after tax deductions, the incentive did not cover the costs for relocation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThey gave me an incentive for moving to a rural area... but like half of it got taxed... so it wasn\u0026rsquo;t super helpful with all the costs of moving\u003c/em\u003e\u0026rdquo; (Participant 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eA lot of other regional areas have got the incentive... [we] did not get it at all and at the moment it\u0026rsquo;s sitting with the unions to fight for it\u003c/em\u003e\u0026rdquo; (Participant 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was also a noted disparity in the benefit amount between dental officers and oral health therapists. Dental officers received a larger amount upfront in additional to a continuous payment on an annual basis while oral health therapists received only the upfront benefit (of lower value) and no ongoing payments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So the dentist gets an additional amount each year for working rural, but the OHTs only get it to help initially move\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile relocating practitioners received this incentive, oral health practitioners who were employed prior to the implementation of these relocation schemes have not received any financial incentive or remuneration for continuing to work in these rural communities. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThat\u0026rsquo;s the way to get the staff out to the regional areas but those of us who have stuck out here don\u0026rsquo;t get anything\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eKey theme 3: Challenges accessing external professional development opportunities\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe interview revealed that participants have easy access to in-house or online continuing professional development (CPD) opportunities, and these are often well received.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We have regular dental officer and OHT meetings and people will pass on learnings that they\u0026rsquo;ve had from conferences\u003c/em\u003e\u0026rdquo; (Participant 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThere is quite a lot of online opportunities where they will circulate invites for certain courses... and then we do have obviously our in-house specialists who will run sessions as well\u003c/em\u003e\u0026rdquo; (Participant 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite accessible in-house or online CPD opportunities, it was reported that there was significant difficulty in accessing external CPD opportunities. The geographic isolation nature of working in rural areas was reported to have played a part in this limitation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think there\u0026apos;s that conference in Sydney at the moment... I think it\u0026rsquo;s a paediatric conference, that would have been good to have gone to\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Which is why it\u0026rsquo;s sort of hard to apply and get it... because most of it\u0026rsquo;s in Sydney. Like if it\u0026apos;s a workshop\u0026rdquo;\u003c/em\u003e (Participant 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite reports of work-place funding for CPD courses, financial constraints were reported contributing to difficulty accessing external CPD. Participants explained that in addition to the cost of the CPD programs, they must also consider costs of transport and accommodation as they are often required to travel to larger cities to attend these courses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eEvery year, I think we have a day that we can take for CPD leave. And we also have I think it might be $750 that we can put towards [it]. They tend to not let us use it both together. So, you can pick one activity for the leave or one activity for their funding\u0026rdquo;\u003c/em\u003e (Participant 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;But when you\u0026rsquo;re looking at a thousand dollars to go, that\u0026rsquo;s just for the conference and you\u0026rsquo;ve got to get accommodation, and you\u0026rsquo;ve got to get there. It just starts to get expensive\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants also reported the challenging nature of asking for leave to attend these external courses due to staffing shortages and high workload demands. Participants report a sense of guilt when attending these CPD courses and the need to convince their managers why their attendance is beneficial for the practice.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIt\u0026rsquo;s hard to be given like granted leave to go attend because the burden is then on everyone else back at the clinic. But what you\u0026rsquo;re learning is to help benefit them, but you have to really like prove why it\u0026rsquo;s benefiting them\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They don\u0026rsquo;t advertise to us anything, and I\u0026rsquo;ve heard from coworkers like when they\u0026rsquo;re trying to go to these things or apply for these things, it\u0026rsquo;s quite difficult\u0026rdquo;\u003c/em\u003e (Participant 3).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eKey theme 4: Access and provision of clinical services\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described a supportive working environment, highlighting the ability to refer patients to both internal and external dental specialists or other clinicians when cases were beyond their clinical scope of practice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We have an in-house oral surgeon which is super helpful... We have a pain specialist who visits from Sydney... We do have the option to refer to Sydney for specialist services... Otherwise, it is just to a private provider if the patient chooses. We have our own general anaesthetic clinic though so we do have that option should we need it for both children and adults\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 5).\u003c/p\u003e\n\u003cp\u003eHowever, it was revealed that lengthy wait times for specialist services combined with long travel distances, often pose as challenges for patients seeking treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We do have an oral surgeon that we can refer to... but the wait list is terribly long, probably 12 months minimum for an assessment and then you go back on another list if you need to have a general anaesthetic\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWhenever it comes to referring patients to specialist services, that can be a major challenge because we know that they might not be able to travel to access those services\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants expressed a mixed desire for greater interprofessional relationships with Aboriginal Health Workers and local Aboriginal Community Controlled Health Services (ACCHSs). \u0026nbsp;Some participants expressed the appeal of having an Aboriginal Health Work involved with the appointment, especially with following up patients; while others expressed although available, Aboriginal Health Workers are generally not required to be present for the appointment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it would be really helpful, particularly for following up our really vulnerable patients who are very irregular attenders... It\u0026apos;d be so good if we had an Aboriginal Health Worker who could get along with the family, support them to come into appointments\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There are some Aboriginal Health Workers, but they don\u0026rsquo;t really get involved. I think because most of the population are Aboriginal or Torres Strait Islander, I don\u0026rsquo;t think they need a liaison present.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 3).\u003c/p\u003e\n\u003cp\u003eParticipants were deeply interested in the patient\u0026rsquo;s well-being and personally took into consideration the patient\u0026rsquo;s travel time when planning and providing treatment. Participants expressed the need to provide sufficient care to make the trip worthwhile for the patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eYou\u0026rsquo;re not going to bring them back for one little thing. You might do your exam, x-rays and fissure protectants or you know one little filling in a visit to try and get them done a bit quicker\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 4).\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003ePatients travelling like hours to come see me, I definitely feel like I need to do as much as I can for them to make it worth their while\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 3).\u003c/p\u003e\n\u003cp\u003eOverall, participants reported significant difficulties in attracting and retaining staff, leading to increased workloads, frequent staff turnover and work-related burnout. Financial challenges, such as the high cost of living and inconsistent relocation incentives, further impacted workforce stability and rural living. While in-house and online CPD opportunities were readily available for rural oral health practitioners, they revealed that accessing external CPD was hindered by geographic isolation, financial constraints and staffing shortages. In terms of clinical service provision, participants described supportive working environments with access to specialist referrals when required however, lengthy wait times and long travel distances often posed as challenges for patients. Strong interprofessional relationships between oral health professionals helped to accommodate the travel burdens faced by rural patients. However, the desire to strength the relationship with Aboriginal Health Workers and ACCHSs remains split.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eExploration of the rural oral health practitioners\u0026rsquo; experiences, particularly focusing on their cultural, clinical and personal experiences, has revealed four key related themes. Their interconnected nature is illustrated in Figure 1. Difficulties in attracting and retaining staff (key theme 1) was found to be compounded by financial challenges and the lack of rural incentives (key theme 2). This not only deterred new practitioners from relocating rurally but also resulted in existing practitioners to move out of these rural regions. Financial constraints were also found to limit opportunities for external professional development (key theme 3) due to the financial burdens associated with travel and accommodation for these external courses. This made it difficult for rural practitioners to upskill, further exacerbating workforce shortages as well as barriers to retention. In turn, the limited availability of dental specialists in rural NSW resulted in long wait lists and difficulty accessing such services (key theme 4). This again highlights the workforce shortages and ongoing difficulty to maintain an adequate rural oral health workforce.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe findings from this study highlights the significant challenges faced by oral health practitioners working in rural NSW, particularly in terms of workforce attraction and retention, financial incentives, professional development and access to services. These issues are not unique to oral health alone but are consistent with broader trends observed in rural healthcare settings in Australia (2, 12). The implications of these findings are critical for informing workforce policies, service delivery models and support mechanisms for rural oral health practitioners. Without solutions, the sustainability of the rural oral health workforce will remain at risk and may further cause health disparities in oral health access between rural and metropolitan areas (13, 14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eWorkforce attraction, retention and burnout\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study identified consistent difficulties in attracting and retaining not only oral health practitioners in rural areas but also support staff, leading to increased workload pressures and workforce burnout. These findings align with previous research that has reported high turnover rates and recruitment difficulties in other rural health professions, exacerbated by professional isolation and limited career progression opportunities (3, 7, 12). The frequent cycle of training new staff who leave after a short tenure further compounds these challenges, placing stain on those who remain.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDeveloping initiatives that promote rural practice as a long-term career can help address these issues. Targeted strategies such as enhanced financial incentives, structured mentorships programs and clearer career development pathways can all support early-career practitioners (12, 15). Similar approaches have proven successful in other health professions, contributing to improved increase employment, workforce retention and job stratification in rural areas (16, 17). \u0026nbsp;Additionally, increasing opportunities for professional networking within rural settings may also help alleviate feelings of isolation, encourage long-term workforce retention and reduce workforce burnout (12, 17, 18). While these strategies are viable options, they are often not considered in small oral health clinics due to resource limitations and workforce constraints (19).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eFinancial Incentives and Cost of Rural Practice\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFinancial challenges were a predominant concern among participants, particularly in relation to relocation incentives and the high cost of living in rural areas. While some participants received relocation incentives, inconsistencies in benefit allocation and taxation reduced their effectiveness. Furthermore, the disparity in incentive structures between dental officers and oral health therapists may contribute to dissatisfaction and inequities within the workforce (19). Similar findings have been reported in rural healthcare research, where financial incentives alone have been insufficient in ensuring long-term retention (5, 20).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough financial incentives can serve as an initial motivator for oral health practitioners to relocate to rural regions, a broader support system may be required for practitioner retention (19, 20). Policy adjustments that offer more competitive and continuous financial incentives, along with potential assistance in housing or other rural living costs can encourage long-term retention. Adjustments can also be made to ensure incentive structures are equitable across different professional categories, recognising the different contributions of various oral health practitioners. Addressing financial constrains is critical in making rural practice more attractive and sustainable long-term to mitigate these employment concerns.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, promoting oral health careers to oral health university students \u0026ndash; particularly those who relocated to metropolitan areas for their studies \u0026ndash; could help strengthen the rural workforce as many may seek to return home after their degrees (21, 22).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eContinuing Professional Development and Education Barriers\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAccess to professional development opportunities was another key concern raised by participants. While in-house and online CPD opportunities were available, attending external CPD programs was often difficult due to geographic isolation, financial constraints, and staffing shortages. This finding is consistent with existing research in rural health workforce training, which emphasises the need for flexible and regionally accessible CPD opportunities (19, 23, 24). Limited access to external CPD can restrict skill development, career progression and professional satisfaction, potentially contributing to workforce retention challenges (24).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEfforts should be made to evenly distribute CPD opportunities and ensure that rural practitioners have equitable access to training. This could include increasing funding for travel to attend CPD programs or paid study-leave for attending such programs, expanding regional CPD workshops and strengthening virtual learning options with interactive and hands-on training element (23-25). Structured peer learning networks could help facilitate knowledge-sharing and skill-building opportunities among rural oral health practitioners, fostering a sense of professional community and reducing isolation (17, 19, 25).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eImplementing these policies and allowing employees a more flexible study-leave option can significantly help oral health practitioners in attending CPD programs without negatively impacting staffing or increasing workloads for those who remain at the clinics. Such policies may include designating a certain amount of professional development days on an annual basis (24, 26).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eClinical Service Provision and Patient Access\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDespite challenges, participants reported a supportive working environment with access to specialist dental referrals when necessary. However, these referrals often involve lengthy wait times and long travel distances for patients. The long wait times for patients to access specialist dental care identified in this study are consistent with previous studies exploring the limitations of rural health services(4, 27). This limitation can result in delayed treatment and therefore, worsening of oral health conditions, progression of symptoms and increased social costs in terms of time and financial costs associated with travel (4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants described adapting their treatment approaches to take into consideration the length of travel required by patients to access care, ensuring that each visit provided maximum benefit. This highlights the need for service models that are flexible and patient-centred, recognising the challenges of rural healthcare provision (28). Strategies such as expanding telehealth consultations, increasing outreach specialist services and enhancing local training opportunities can all contribute to alleviate these issues (29, 30). In addition to this, strengthening interprofessional collaborations, particularly with Aboriginal Health Workers and local ACCHSs, has proven to improve care coordination and enhance patient engagement (31, 32). Enhancing these partnerships through integrated care models may lead to better patient outcomes and reduce the impact of geographic barriers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eImplications for Policy and Workforce Planning\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this study emphasise the need for targeted workforce strategies and policy interventions to address the challenges experienced by oral health practitioners in rural regions. Strategies such as structured incentive programs to improve recruitment and retention, regionally accessible CPD opportunities as well as improved workforce support systems can ensure sustainable rural oral health service provision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIntegrating rural oral health workforce considerations into broader healthcare policy planning is important for creating long-term solutions. The development of strategic workforce plans that align with the needs of rural populations, including targeted recruitment strategies and improved service delivery models, could lead to meaningful improvements in rural oral health outcomes (33-35).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile this study provided valuable insights, its findings are limited by the inclusion of only three LHDs. This may have limited the study\u0026rsquo;s generalisability and representation of the workforce, resulting in an uneven distribute of oral health practitioners (e.g. no dental prosthetists were interviewed) and therefore, a lack of workforce representation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother limitation is the potential for interviewer bias. Despite effort to remain neutral throughout the interview process, the researcher\u0026rsquo;s prior experiences and perspectives may have inadvertently influenced the way questions were asked or the way in which responses were interpreted.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study highlights the multifaceted and interconnected challenges faced by the rural oral health workforce in NSW. These challenges include workforce retention difficulties, financial constraints, barriers to professional development opportunities and limitations in specialised oral health service access. Addressing these issues requires a comprehensive approach that incorporates policy reform, targeted incentives and enhanced workforce support systems. Prioritising these strategies, could strength recruitment, retention and overall job satisfaction as well as improve oral health outcomes for people in rural communities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACCHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAboriginal Community Controlled Health Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContinuing professional development\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLocal Health District\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNSW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNew South Wales\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOHT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOral Health Therapist\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Greater Western Human Research Ethics Committee [2024/ETH00501]. Following ethical approval, the project was submitted to the Research Ethics and Governance Information System (REGIS) and a site-specific application was subsequently submitted for each participating LHD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll potential participants were provided with an online information statement that outlined the study’s objectives, nature of their involvement and potential risks prior to participating. Online informed consent was obtained from each participant, ensuring that they understood their right to withdraw from the study at any time without consequence. The survey component of the study incorporated a skip logic function, which ensured that participants could only proceed with the survey after explicitly providing consent. Once the survey was completed, the participants were given the opportunity to opt-in to the interview component of the study. If participants agreed to take part in the interview, they were contacted directly by the lead researcher via email to then organise a suitable time for the virtual interview.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to confidentiality reasons and are not available upon request. It was stored securely on the University of Sydney’s licence eNotebook (LabArchives) platform during analysis and only accessible by the research team. The data is now archived securely on the non-public research platform, Research Data Store (RDS) and will be for 5 years and then destroyed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompleting interest declaration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was support by the Australia Dental Research Foundation. The authors affirm that this study was conducted independently and was not influenced by any external organisation, financial interest or institutional bias. The funding received was solely for research purposes and did not influence the study design, data collection, analysis or interpretation of the results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eL.D. took part in the conceptualisation, analysis, funding acquisition, investigation, methodology, visualisation and writing of the original draft. L.D. also prepared all figures and tables. Y.D. helped with the conceptualisation, investigation, methodology and supervision of this study. J.B. assisted with the investigation, methodology and supervision of this study. B.C. was involved in funding acquisition and supervision. W.S. took lead in conceptualisation and supervision of this study. All authors read, reviewed, edited and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was support by the Australia Dental Research Foundation and we are grateful for their funding assistance. Additionally, we extend our appreciation to the University of Sydney in support of this study. I would also like to acknowledge the contributions of the oral health practitioners from the participating Local Health Districts for being part of this study and generously sharing their insights on their experiences working in rural New South Wales.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAIHW. Oral health and dental care in Australia. Canberra: Australian Institute of Health Welfare; 2024.\u003c/li\u003e\n \u003cli\u003eAIHW. Rural and remote health. Canberra: AIHW; 2024.\u003c/li\u003e\n \u003cli\u003eBourke L, Coffin J, Taylor J, Fuller J. Rural health in Australia. 2010. p. 2-9.\u003c/li\u003e\n \u003cli\u003eSchwarz E. Access to oral health care\u0026ndash;an Australian perspective. Community dentistry and oral epidemiology. 2006;34(3):225-31.\u003c/li\u003e\n \u003cli\u003eCortie CH, Garne D, Parker‐Newlyn L, Ivers RG, Mullan J, Mansfield KJ, et al. The Australian health workforce: Disproportionate shortfalls in small rural towns. Australian Journal of Rural Health. 2024.\u003c/li\u003e\n \u003cli\u003eBaxter J, Hayes A, Gray M. Families in regional, rural and remote Australia (Facts Sheet). Melbourne: Australian Institute of Family Studies; 2011.\u003c/li\u003e\n \u003cli\u003eGodwin DM, Hoang H, Crocombe LA, Bell E. Dental practitioner rural work movements: a systematic review. Rural and remote health. 2014;14(3):431-43.\u003c/li\u003e\n \u003cli\u003eBraun V, Clarke V. Thematic analysis: A Practical Guide: SAGE Publications; 2022. 338 p.\u003c/li\u003e\n \u003cli\u003eKaratsareas P. Semi-structured interviews. Research methods in language attitudes. 2022:99-113.\u003c/li\u003e\n \u003cli\u003eDepartment of Health and Aged Care. Modified Monash Model 2024 [Available from: https://www.health.gov.au/topics/rural-health-workforce/classifications/mmm.\u003c/li\u003e\n \u003cli\u003eRichards KAR, Hemphill MA. A practical guide to collaborative qualitative data analysis. Journal of Teaching in Physical education. 2018;37(2):225-31.\u003c/li\u003e\n \u003cli\u003eRose H, Skaczkowski G, Gunn KM. Addressing the challenges of early career rural nursing to improve job satisfaction and retention: Strategies new nurses think would help. Journal of advanced nursing. 2023;79(9):3299-311.\u003c/li\u003e\n \u003cli\u003eSteele L, Pacza T, Tennant M. Rural and remote oral health, problems and models for improvement: a Western Australian perspective. Australian Journal of Rural Health. 2000;8(1):22-8.\u003c/li\u003e\n \u003cli\u003eSpencer A, Teusner D, Carter K, Brennan D. The dental labour force in Australia: the position and policy directions. Australian Institute of Health and Welfare (Media and Publishing Unit); 2003.\u003c/li\u003e\n \u003cli\u003eGoetz K, Marx M, Marx I, Brodowski M, Nafula M, Prytherch H, et al. Working atmosphere and job satisfaction of health care staff in Kenya: an exploratory study. BioMed research international. 2015;2015(1):256205.\u003c/li\u003e\n \u003cli\u003eJaeger FN, Bechir M, Harouna M, Moto DD, Utzinger J. Challenges and opportunities for healthcare workers in a rural district of Chad. BMC health services research. 2018;18:1-11.\u003c/li\u003e\n \u003cli\u003eSkinner J, Dimitropoulos Y, Moir R, Johnson G, McCowen D, Rambaldini B, et al. A graduate oral health therapist program to support dental service delivery and oral health promotion in Aboriginal communities in New South Wales, Australia. Rural and Remote Health. 2021;21(1):1-9.\u003c/li\u003e\n \u003cli\u003eCunningham FC, Ranmuthugala G, Plumb J, Georgiou A, Westbrook JI, Braithwaite J. Health professional networks as a vector for improving healthcare quality and safety: a systematic review. BMJ quality \u0026amp; safety. 2012;21(3):239-49.\u003c/li\u003e\n \u003cli\u003eKruger E, Tennant M. Oral health workforce in rural and remote Western Australia: practice perceptions. Australian Journal of Rural Health. 2005;13(5):321-6.\u003c/li\u003e\n \u003cli\u003eBuykx P, Humphreys J, Wakerman J, Pashen D. Systematic review of effective retention incentives for health workers in rural and remote areas: Towards evidence‐based policy. Australian Journal of Rural Health. 2010;18(3):102-9.\u003c/li\u003e\n \u003cli\u003eTadakamadla SK, Balla SB, Tadakamadla J, Semmens L, Down S, McKinstry C, et al. Determinants of rural practice among a cohort of dental professionals in Australia. BMC Medical Education. 2025;25(1):142.\u003c/li\u003e\n \u003cli\u003eRussell D, Mathew S, Fitts M, Liddle Z, Murakami-Gold L, Campbell N, et al. Interventions for health workforce retention in rural and remote areas: a systematic review. Human Resources for Health. 2021;19(1):103.\u003c/li\u003e\n \u003cli\u003eWakerman J, Humphreys J, Russell D, Guthridge S, Bourke L, Dunbar T, et al. Remote health workforce turnover and retention: what are the policy and practice priorities? Human Resources for Health. 2019;17(1):99.\u003c/li\u003e\n \u003cli\u003eMlambo M, Sil\u0026eacute;n C, McGrath C. Lifelong learning and nurses\u0026rsquo; continuing professional development, a metasynthesis of the literature. BMC Nursing. 2021;20(1):62.\u003c/li\u003e\n \u003cli\u003eCampbell N, McAllister L, Eley D. The influence of motivation in recruitment and retention of rural and remote allied health professionals: a literature review. Rural Remote Health. 2012;12:1900.\u003c/li\u003e\n \u003cli\u003eJoyce K, Pabayo R, Critchley JA, Bambra C. Flexible working conditions and their effects on employee health and wellbeing. Cochrane Database Syst Rev. 2010;2010(2):Cd008009.\u003c/li\u003e\n \u003cli\u003eDudko Y, Kruger E, Tennant M. Shortage of dentists in outer regional and remote areas and long public dental waiting lists: changes over the past decade. Australian Journal of Rural Health. 2018;26(4):284-9.\u003c/li\u003e\n \u003cli\u003eDouthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public health. 2015;129(6):611-20.\u003c/li\u003e\n \u003cli\u003eTotten AM, Womack DM, Eden KB, McDonagh MS, Griffin JC, Grusing S, et al. Telehealth: mapping the evidence for patient outcomes from systematic reviews. 2016.\u003c/li\u003e\n \u003cli\u003eKnowles M, Crowley AP, Vasan A, Kangovi S. Community Health Worker Integration with and Effectiveness in Health Care and Public Health in the United States. Annu Rev Public Health. 2023;44:363-81.\u003c/li\u003e\n \u003cli\u003eMackean T, Withall E, Dwyer J, Wilson A. Role of Aboriginal Health Workers and Liaison Officers in quality care in the Australian acute care setting: a systematic review. Australian Health Review. 2020;44(3):427-33.\u003c/li\u003e\n \u003cli\u003ePacza T, Steele L, Tennant M. Development of oral health training for rural and remote Aboriginal health workers. Australian Journal of Rural Health. 2001;9(3):105-10.\u003c/li\u003e\n \u003cli\u003eDepartment of Health and Age Care. Healthy mouths, healthly lives - Australia\u0026rsquo;s National Oral Health Plan 2015-2014. Australian Government Department of Health and Aged Care.; 2015.\u003c/li\u003e\n \u003cli\u003eStrategy CfOH. NSW Oral Health Strategic Plan 2022-2032. NSW Ministry of Health; 2023.\u003c/li\u003e\n \u003cli\u003eAustralia HW. Australia\u0026rsquo;s Future Health Workforce - Oral Health - Detailed Report. Canberra Department of Health; 2014.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical services, dental health, health services, professional development, rural and remote health, rural incentives, oral health, workforce","lastPublishedDoi":"10.21203/rs.3.rs-6295181/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6295181/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eRural oral health practitioners in New South Wales (NSW) face unique challenges related to workforce shortages, professional isolation and limited access to specialist services. Despite the critical role they play in providing oral health care to rural communities, little research has explored this workforce’s experiences. This study aims to explore these experiences as specifically the clinical, cultural and personal aspects of them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis qualitative study utilises an inductive research design and follows Braun and Clarke’s framework for thematic analysis. Virtual semi-structured interviews were conducted with five oral health practitioners working in three participating rural Local Health District in NSW.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cem\u003e \u003c/em\u003eFour key, interconnected themes were identified: (1) workforce recruitment and retention difficulties, (2) financial challenges and inadequate rural incentives, (3) barriers to accessing professional development opportunities, and (4) limitations to specialised oral health services access.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cem\u003e \u003c/em\u003eThis study highlights the complex challenges faced by rural oral health practitioners in NSW. Addressing workforce shortages, improving financial incentives, expanding CPD access and strengthening service delivery models are crucial for sustaining the rural oral health workforce. Targeted policy interventions and support systems are needed to enhance workforce retention and improve oral health access and therefore, outcomes, in rural communities.\u003c/p\u003e","manuscriptTitle":"Employment experiences of the oral health workforce in rural New South Wales: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-15 08:46:25","doi":"10.21203/rs.3.rs-6295181/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-08T05:08:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-07T12:29:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227549230619374556911354095519802275385","date":"2025-04-06T02:14:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-03T01:31:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104306591634857500541474611143969449032","date":"2025-04-01T17:27:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22467586645107996967659089331479491039","date":"2025-03-28T11:39:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326965193188658770825291112555019176406","date":"2025-03-28T10:20:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-28T03:08:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"333480722236909227807224154624827096403","date":"2025-03-27T23:55:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"156401293461446103731036433069618288480","date":"2025-03-27T23:07:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-27T15:14:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-27T08:44:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-26T09:12:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-26T01:06:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-03-26T01:05:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e6725e0a-b119-4a94-a355-983fbe5e2b1b","owner":[],"postedDate":"April 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T15:59:32+00:00","versionOfRecord":{"articleIdentity":"rs-6295181","link":"https://doi.org/10.1186/s12913-025-13066-0","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-07-03 15:56:58","publishedOnDateReadable":"July 3rd, 2025"},"versionCreatedAt":"2025-04-15 08:46:25","video":"","vorDoi":"10.1186/s12913-025-13066-0","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13066-0","workflowStages":[]},"version":"v1","identity":"rs-6295181","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6295181","identity":"rs-6295181","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}