"A golden opportunity": Exploring interprofessional learning and practice in rural clinical settings.

Little is known about interprofessional practice (IPP) and interprofessional learning (IPL) in rural health services, despite national funding and continuing emphasis on increasing students' clinical placements in rural areas. This short paper outlines a study in Tasmania, Australia, which investigated how and under what contexts and conditions IPP and IPL occur in rural clinical settings, and the enabling factors and strategies that promote this learning and practice. This study employed a mixed method design comprising focus group discussions and a survey involving health professionals from two rural health services. The findings demonstrate that formal and informal arrangements, the collaborative nature of small, close-knit healthcare teams and patient-centred models of care employed in rural practice settings, provide ideal contexts for IPP and IPL. The study has implications for promoting organisational readiness for IPP and IPL and harnessing the potential of rural services to promote and develop students' interprofessional capability.

Interprofessional learning and rural paramedic care.

INTRODUCTION: The traditional view of paramedic practice is one of provision of emergency care and transport within community or industrial settings. With greater integration of emergency services with the overall health system, this role is changing. Paramedics, especially in rural areas, are now working more closely with other professions in new and extended roles that incorporate non-emergency community-based care, preventative medicine and social care. Workforce shortages, health service budget cuts, population size and the changing demographic profile of many rural and remote communities highlight the need for effective interaction between the health professions to respond to the health needs of these communities. The rural environment therefore provides an opportune setting in which to explore the evolving role of paramedics and their interaction with other healthcare professionals in ways that can improve health outcomes for patients and the community. This article presents a critical review of the literature in this area and identifies gaps in which further research is required to further interprofessional learning (IPL) for paramedics. METHODS: Search databases included MEDLINE, SCOPUS, CINAHL and the University of Tasmania (UTAS) electronic library. Specific journal searches included the Journal of Emergency Pre-Hospital Care (JEPHC) and the Journal of Interprofessional Care. Search terms for this literature review consisted of a combination of prefixes 'inter' and 'multi' with adjectives 'professional', 'disciplinary' and 'shared' and the nouns 'education', 'learning' and 'training'. These search terms were then used in combination with each of the terms 'rural' and 'remote' then with 'paramedic/s' and 'pre-hospital' in order to source reports of interprofessional activities in these areas. Each of these was also combined with the search term 'collaboration'. On completion of the initial search process, the reference lists of relevant articles were examined for reports of professional interactions and rural paramedic care. RESULTS: Three major concepts emerged from 24 articles: interprofessional education (IPE), multidisciplinary teamwork, and interprofessional learning. Six articles focused on IPE; nine concerned multidisciplinary teamwork and nine IPL. Examination of the reference lists of these articles revealed a further eight articles with the theme of IPL incorporating paramedics. Predominantly, IPL was associated with new roles for rural paramedics where collaborative practice incorporated community-based care rather than being focused on emergency treatment and transport to hospital. Only two articles reported on a measurable patient care outcome related to IPL. The majority of articles described programs or interventions without having directly examined the interactions and relationships between professions. CONCLUSIONS: Rural paramedics are involved with other healthcare professionals, often in new or expanded roles. Published journal articles that report on this interaction are largely descriptive in nature and few describe the dynamics of this interaction or the conditions under which interprofessional activity could yield potential benefit to health service delivery or patient outcomes. As an overarching construct, IPL may be used to frame further investigation of this interaction and may help shape the emerging role of paramedics in rural settings where population size and other factors limit the availability of health professionals.

A 'RIPPER' Project: advancing rural inter-professional health education at the University of Tasmania.

INTRODUCTION: Attending to the shortage and sustainability of health care professionals and resources in rural areas in Australia is a continuing challenge. In response, there is a heightened focus on new models of healthcare delivery and collaboration that optimise the quality of patient care, respond to complex health needs and increase professional job satisfaction. Interprofessional rural health education within universities has been proposed as one way of addressing these challenges. BACKGROUND AND OBJECTIVE: This article reports on the development, design, implementation and evaluation of the RIPPER initiative (Rural Interprofessional Program Education Retreat). RIPPER is an interprofessional rural health education initiative developed by a team at the University of Tasmania's Faculty of Health Science. The objective of the program was to develop a rural interprofessional learning module for final year undergraduate health science students at the University of Tasmania. The program was first piloted in a rural Tasmanian community in 2006, with a second iteration in 2007. Participants in the program included approximately 60 students from the disciplines of Medicine, Nursing and Pharmacy. METHOD: The format and educational design of the RIPPER program was focussed on a multi-station learning circuit using interprofessional case-based scenarios. Each learning station employed experiential and interactive educational strategies that included high and low fidelity simulation, role play and reflection. The learning stations required students to work collaboratively in small interprofessional teams to respond to a series of rural emergency healthcare scenarios. RESULTS: Qualitative and quantitative evaluation data was collected from student participants over two years utilising a pre- and post-test quasi experimental design. Results demonstrated a positive shift in students' understanding of interprofessional practice and the roles and skills of other health professions. There was also an increase in the value ascribed by students to collaboration and team work as a way of problem solving and improving patient outcomes. CONCLUSION: The project evaluation indicated the importance of developing a sustainable and embedded interprofessional rural module within the undergraduate health science curriculum. The project evaluation findings also point to some of the strengths and limitations of implementing interprofessional education activities in a rural setting.

Re-thinking approaches to undergraduate health professional education: Interdisciplinary Rural Placement Program.

The Interdisciplinary Rural Placement Program involved the development, implementation and evaluation of a common rural primary health care module. Designed for undergraduate nursing, medical and pharmacy students of the University of Tasmania, students undertook clinical experiences and a collaborative primary health care project at two different Rural Health Teaching Sites across Tasmania. The aim of the project was for interdisciplinary students to work and learn together to enhance their understanding of the cooperative and collaborative nature of professional practice among rural health care workers. This paper will describe the development and implementation of the Interdisciplinary Rural Placement Program and critically discuss the outcomes in relation to nursing. In this paper, three issues will be explored. Firstly, how student nurses questioned their sense of subordination when in fact the level of recognition by their interdisciplinary peers led them to refute this. Secondly, concerns with overcoming the difficulties of coordinating student recruitment and conflicting timetables, while working within existing curricula, will be discussed. The final issue explores the student nurses' recognition that despite inherent tensions and conflict, the need to work as a cohesive and cooperative interdisciplinary team was vital. This project highlighted the challenges that health professions continue to work through in contemporary practice and education sectors. A key recommendation for education providers is that true interdisciplinary education must be achieved through an experiential framework.

Development of a tool to evaluate health science students' experiences of an interprofessional education (IPE) programme.

INTRODUCTION: The Rural Interprofessional Programme Emergency Retreat (RIPPER) is an educational programme collaboratively developed and evaluated by an interprofessional team from Schools within Faculty of Health Science (FHS), University of Tasmania (UTAS), Australia. The aims of RIPPER are to foster and facilitate positive and productive interprofessional learning experiences for undergraduate students in a rural setting; and to develop a firmly embedded and sustainable interprofessional healthcare module within the health science curriculum. This paper reports on the development of a reliable and valid survey tool to evaluate students' understandings and experiences of this interprofessional learning programme. MATERIALS AND METHODS: Twenty-nine students from the Schools of Nursing, Medicine and Pharmacy of the FHS, UTAS participated in the RIPPER programme which offers a number of interactive rural emergency healthcare scenarios using high- and low-fidelity simulation. To evaluate the programme a survey which consisted of 2 main components was developed and implemented before and after the programme. The first component was designed to gather students' demographic information, their understanding of the interprofessional practice concepts, and their expectations of the RIPPER programme using open-ended questions. The second component consisted of a 5-point Likert scale for students to rank their level of agreement pre- and post- intervention with 12 statements about team working, programme evaluation and collaborative learning. Three processes were used to establish the validity and reliability of the survey. Content validity was assessed by academics and experts in health science education. Construct validity was assessed using exploratory factor analysis. The internal consistency and reliability of the survey was checked using Cronbach's alpha coefficient. RESULTS: Factor analysis of the 12 statements identified 3 main factors including appreciation of professional roles and responsibilities, improved professional practice based on effective teamwork and the importance of students learning and working together for improved clinical practice. Reliability of the survey was established. The survey is able to evaluate students' understandings and experiences of this interprofessional learning programme.

Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis?

OBJECTIVE: The purpose of this study was to assess the efficacy of an insulin priming dose with a continuous insulin infusion versus two continuous infusions without a priming dose. RESEARCH DESIGN AND METHODS: This prospective randomized protocol used three insulin therapy methods: 1) load group using a priming dose of 0.07 units of regular insulin per kg body weight followed by a dose of 0.07 unit x kg(-1) x h(-1) i.v. in 12 patients with diabetic ketoacidosis (DKA); 2) no load group using an infusion of regular insulin of 0.07 unit . kg body weight(-1) x h(-1) without a loading dose in 12 patients with DKA, and 3) twice no load group using an infusion of regular insulin of 0.14 x kg(-1) x h(-1) without a loading dose in 13 patients with DKA. Outcome was based on the effects of insulin therapy on biochemical and hormonal changes during treatment and recovery of DKA. RESULTS: The load group reached a peak in free insulin value (460 microU/ml) within 5 min and plateaued at 88 microU/ml in 60 min. The twice no load group reached a peak (200 microU/ml) at 45 min. The no load group reached a peak (60 microU/ml) in 60-120 min. Five patients in the no load group required supplemental insulin doses to decrease initial glucose levels by 10%; patients in the twice no load and load groups did not. Except for these differences, times to reach glucose or=7.3, and HCO(3)(-) >or=15 mEq/l did not differ significantly among the three groups. CONCLUSIONS: A priming dose in low-dose insulin therapy in patients with DKA is unnecessary if an adequate dose of regular insulin of 0.14 unit x kg body weight(-1) x h(-1) (about 10 units/h in a 70-kg patient) is given.

Religious beliefs and quality of life in an American inner-city haemodialysis population.

BACKGROUND: The ability to adapt to the long-term aspects of chronic haemodialysis is multifactorial and poorly understood. Given the many comorbidities of a patient on haemodialysis, religious beliefs may be an important factor in the patient's ability to cope. METHODS: End-stage renal disease patients in an inner-city American in-center haemodialysis unit were given two surveys to quantify their quality of life (KDQOL) and beliefs (Royal Free Score). The population studied included 97% African Americans. The demographics were collected and recorded. The relationship between religious/spiritual beliefs, demographic variables, and how quality of life (QOL) is viewed was analysed. RESULTS: The vast majority of patients considered themselves religious, spiritual or both. KDQOL scores did not correlate with belief in a higher power, but the non-religious group demonstrated a significantly lower blood urea nitrogen (BUN) and creatinine as compared with the religious group. There was a negative correlation with age and physical function as reported by KDQOL and physical health composite. CONCLUSION: As physical function declines, religious and spiritual beliefs are stronger in the haemodialysis population studied. Given the overwhelming prevalence of religious and spiritual beliefs in this population, further study is needed as acknowledging and incorporating these beliefs into patient treatment plans may be warranted.