Adapting a Nurse-Managed Mobile Simulation Program to Meet Rural Health Nursing Continuing Education Needs.

BACKGROUND: Rural nurses often practice in settings with limited access to continuing education resources. A hospital alliance in southeastern North Carolina developed a unique nurse-led mobile simulation program as a shared regional asset, for the purpose of meeting continuing education needs of rural nurses. METHOD: The alliance used a hub-and-spoke model to deliver education to staff in rural, critical access hospitals in order to reduce costs associated with education travel, the resulting staffing shortages, and delays in critical training. Continuing education credit was awarded to nurses participating in the learning activity. RESULTS: Fully mobile simulation can be an effective delivery mode for continuing and just-in-time education for nurses practicing in rural settings. Establishing the program as a regional shared resource can make this a financially viable option for rural hospitals. CONCLUSION: Lessons learned during the mobile simulation program's evolution and the resulting financial sustainability are discussed. [J Contin Educ Nurs. 2020;51(2):82-86.].

Demonstrating a new approach to planning and monitoring rural medical training distribution to meet population need in North West Queensland.

BACKGROUND: Improving the health of rural populations requires developing a medical workforce with the right skills and a willingness to work in rural areas. A novel strategy for achieving this aim is to align medical training distribution with community need. This research describes an approach for planning and monitoring the distribution of general practice (GP) training posts to meet health needs across a dispersed geographic catchment. METHODS: An assessment of the location of GP registrars in a large catchment of rural North West Queensland (across 11 sub-regions) in 2017 was made using national workforce supply, rurality and other indicators. These included (1): Index of Access -spatial accessibility (2); 10-year District of Workforce Shortage (DWS) (3); MMM (Modified Monash Model) rurality (4); SEIFA (Socio-Economic Indicator For Areas) (5); Indigenous population and (6) Population size. Distribution was determined relative to GP workforce supply measures and population health needs in each health sub-region of the catchment. An expert panel verified the approach and reliability of findings and discussed the results to inform planning. RESULTS: 378 registrars and 582 supervisors were well-distributed in two sub-regions; in contrast the distribution was below expected levels in three others. Almost a quarter of registrars (24%) were located in the poorest access areas (Index of Access) compared with 15% of the population located in these areas. Relative to the population size, registrars were proportionally over-represented in the most rural towns, those consistently rated as DWS or those with the poorest SEIFA value and highest Indigenous proportion. CONCLUSIONS: Current regional distribution was good, but individual town-level data further enabled the training provider to discuss the nuance of where and why more registrars (or supervisors) may be needed. The approach described enables distributed workforce planning and monitoring applicable in a range of contexts, with increased sensitivity for registrar distribution planning where most needed, supporting useful discussions about the potential causes and solutions. This evidence-based approach also enables training organisations to engage with local communities, health services and government to address the sustainable development of the long-term GP workforce in these towns.

Proposal for a National Interprofessional School of Rural Health.

Shortages of health professionals persist in much of rural New Zealand despite a range of targeted university and professional college initiatives. In response to this a collective of universities, professional colleges and sector groups have put a proposal to Government for a National Interprofessional School of Rural Health. If adopted, this proposal would embed rural health professional education and research in rural communities around New Zealand, empowering them to organise the education that occurs in their community, in a coherent and coordinated way. What is being proposed is not a new or separate education provider but rather an 'enabling body' that would lever off the expertise and resources of the existing tertiary institutions, colleges and rural communities. It calls for an 'all of systems' approach that encompasses all the health professions that practise in rural areas, undergraduate education and postgraduate training, and rural health research. Although modelled on successful Australian rural clinical schools, it is a uniquely New Zealand solution that is cognisant of the New Zealand context and resources.

Supports for medical students during rural clinical placements: factors associated with intention to practise in rural locations.

INTRODUCTION: Through rural clinical schools (RCSs), medical students may undertake an extended block of clinical training in rural Australia. The premise of these placements is that meaningful rural exposure will facilitate rural career uptake. RCSs offer a range of supports to facilitate student engagement in the program. This study aims to analyse RCS students' perceptions of these supports and impact on intentions to work rurally. METHODS: Between September 2012 and January 2013 RCS students were invited to complete questions regarding perceptions of student support, as a part of the annual Federation of Australian Medical Educators survey. Multivariable logistic regression was used to identify associations between supports and intentions for rural internship or career. RESULTS: There were 454 participants. A majority of students (n=349, 79.1%) felt well supported by their RCS. Students from a rural background (odds ratio (OR)=1.64 (95% confidence interval (CI):1.13-2.38)), or who indicated that their placement had a positive impact on their wellbeing (OR=1.38 (95%CI:1.07-1.80)), were more likely to intend to complete a rural internship. Those who felt socially isolated were less likely to elect this (OR=0.82 (0.70-0.97)). Outcomes were similar for those indicating a preference for rural or remote practice after completing training. CONCLUSIONS: Student perceptions of supports offered by RCSs were generally very positive. Perceptions of financial support were not predictive of rural career intent. Although this does not negate the importance of providing appropriate financial supports, it does demonstrate that student wellbeing is a more important recruitment factor for rural practice.

Clinical training in the rural setting: using photovoice to understand student experiences.

INTRODUCTION: Attracting and retaining healthcare providers in rural locations in the USA has been an issue for more than two decades. In response to this need, many health sciences education institutions in the USA have developed special programs to encourage students to become healthcare providers in rural locations. One approach is the use of community-based education experiences through rural track programs. Rural track programs seek to address the shortage of healthcare providers working in rural areas by nurturing and educating students interested in rural practice and primary care. Such programs serve both medical students and students of other health professions. Yet, little is known about student experiences in rural track programs. As such, this study aimed to generate discourse on student experiences in the rural training environment and gain insight into the impact of rural environments on student learning. METHODS: An exploratory qualitative analysis of medical and physician assistant student experiences in two rural medical education training programs was conducted using the photovoice methodology. Photovoice is a participatory research method combining photography with participant commentary and focus groups. RESULTS: Twenty-two third-year medical and six second-year physician assistant students participated in the study. Students noted that in their rural sites the learning environment extended beyond direct clinical teaching in four primary ways: (1) relationships with clinical faculty translated to a sense of meaningful participation in healthcare teams; (2) connections with community members outside of clinical settings led to increased awareness of healthcare concerns; (3) rural settings provided important space to reflect on their experiences; and (4) the importance of infrastructure was highlighted. Students also believed that diversity of occupation, education, attitude, and perception of medical care impact learning in rural environments. CONCLUSIONS: The photovoice participatory research methodology allowed for a deeper understanding of the aspects of the rural training experience that resonated most among students in real time, using visual representations of students' lived experiences as defined by the students.

Improving the Return on Investment of Graduate Medical Education in North Carolina.

The National Academy of Medicine has called for fundamental reform in the governance and accountability of graduate medical education, but how to implement this change is unclear. We describe the North Carolina graduate medical education system, and we propose tracking outcomes and aligning residency stipends with outcomes such as specialty choice, practice in North Carolina, and acceptance of new Medicaid and Medicare patients.

A modular approach to rural and remote research education: a project report.

INTRODUCTION: A lack of support structures in rural and remote Australia has led to limitations in the ability of health services to develop research skills in their staff and to conduct research within their organisations. Distance, limited access to research expertise and a lack of established research networks are examples of structural contributors to limited research training and research activity. METHODS: To address this issue the Centre for Research Excellence in Rural and Remote Primary Health Care Research (CRE) established a Research Capacity Building Program (RCBP) in 2012. The program used a modular design built around hub sites at Alice Springs, Bendigo and Broken Hill. It sought to develop research skills in key health workers in collaboration with strategic primary healthcare (PHC) partners. These partners included health service organisations and federally funded networks designed to support the development of PHC. By training within the workplace and community, the program sought to develop research skills in novice researchers, with a view to building both individual and organisational capacity in health services research within their rural or remote environment. The RCBP was evaluated in late 2014. A survey was conducted using a combination of emailed paper questionnaires and phone surveys with trainees from the RCBP (n=8), the trainee's workplace managers (n=4) and staff of the CRE involved in supervising RCBP trainees (n=8). Participants were asked about both the processes and outcomes of the RCBP. Research skill development was assessed using the research spider instrument, a validated tool for assessing research confidence. This report both describes the RCBP and details the evaluation of the RCBP. RESULTS: This project has shown that in rural and remote Australia the use of collaborative processes and a decentralised capacity building research training model can develop research skills in rural or remote health workers and create potential for ongoing research activity. The RCBP produced measurable improvements in perceived research experience, with mean research spider scores improving from 2.2/5 (standard deviation 0.5) to 2.8/5 (standard deviation 0.5), a change that was significant (z=-2.8, p=0.005). Projects completed through the program matched well with organisational goals of the partner organisations. Completing trainees and partnering organisations both expressed interest in ongoing research activity. The program's modular nature created local peer-support networks, with some additional cross-site collaboration. CONCLUSIONS: Partnering with PHC organisations created the potential for ongoing PHC research activity, with organisational and individual interest in further research. The challenge for policy makers is to build on this potential by providing ongoing support for local research training.

A successful longitudinal graduate tracking system for monitoring Australian medical school graduate outcomes.

CONTEXT: Maintaining an adequate health workforce in rural and remote Australia is challenging. The Australian Government has addressed this challenge by encouraging the admission of rural background students and supporting the growth of regionally based academic health faculties and clinical schools. ISSUE: It is imperative to assess the relevance and effectiveness of regionally based academic health faculties and clinical schools so standards can be maintained and health workforce supply and distribution can be maximised to benefit local populations. APPROACH: The James Cook University (JCU) College of Medicine and Dentistry, the first regional Australian medical school, has developed a longitudinal tracking system for its medical graduates. Processes include administering an exit survey to each cohort immediately prior to graduation (which also collects each graduate's details and consent to be contacted for follow-up studies and practice/career choice data), a FacebookTM page to search for hard-to-trace graduates, and accessing the Australian Health Practitioner Regulation Authority (AHPRA) website. CONCLUSIONS: The comprehensive personal contact tracking system backed by the AHPRA website has resulted in a 98% complete longitudinal tracking database, and thus a comprehensive picture of the practice location of JCU medical graduates from 2006 to 2013, enabling exploration of the patterns of practice to be conducted with considerable confidence. It is intended that the tracking database will be maintained for many years to allow regular follow-up of graduates well into their established careers. However, as graduate numbers increase at the JCU medical school, personal contact will be made with the majority of graduates on a less frequent basis.

Factors Associated with Awareness, Attitudes and Practices Regarding Common Eye Diseases in the General Population in a Rural District in Bangladesh: The Bangladesh Population-based Diabetes and Eye Study (BPDES).

BACKGROUND: To assess the awareness, attitudes, and practices associated with common eye diseases and eye care utilization in a rural district of Bangladesh. METHODS: Data were collected using a multilevel cluster random sampling technique from 3104 adults aged ≥30 years from the Banshgram union with a questionnaire assessing the awareness, attitudes and practice about diabetes and common eye diseases, educational attainment, socio-economic status, and medical history. RESULTS: Participants were aged between 30 and 89 years with a mean (SD) age of 51 (12) years and 65% were female. The majority of participants had heard of cataracts (90%), trachoma (86%) and Pterygium (84%), yet only 4% had heard of diabetic retinopathy (DR), 7% of glaucoma and 8% of Age-related macular degeneration (AMD). However, 58% of participants did not know vision loss could be prevented. Factors associated with lower awareness regarding common eye diseases were increasing age, lack of formal schooling, and lower socio-economic status. A lower proportion (57%) of people with no schooling compared to those who had attained at least secondary school certificate education (72%) reported that they knew that vision loss could be prevented (p<0.001). Overall 51% of people had heard of at least six (67%) out of nine items relating to awareness of common eye diseases. This included 41% of participants aged 65 years or older compared to 61% of those aged 30-35 years (p<0.001). Only 4% had an eye check at least once a year and higher education and better SES were associated with higher frequency of eye checks. CONCLUSIONS: In rural Bangladesh awareness of cataract, trachoma and pterygium was good but limited in relation to the potentially blinding conditions of glaucoma, DR, and AMD. The results show a large gap between public awareness and treatment practices about common eye diseases. Public health promotion should be designed to address these knowledge gaps.

Stakeholder reactions toward iodine biofortified foods. An application of protection motivation theory.

OBJECTIVE/PURPOSE: To use Protection Motivation Theory (PMT) to evaluate stakeholders' intention to adopt iodine biofortified foods as an alternative means to improve children's iodine status and overall school performance. METHODS: A survey was administered with 360 parents of primary school children and 40 school heads. Protection motivation is measured through matching the cognitive processes they use to evaluate iodine deficiency (threat appraisal), as well as iodine biofortified foods to reduce the threat (coping appraisal). Data were analyzed through Robust (Cluster) regression analysis. RESULTS: Gender had a significant effect on coping appraisal for school heads, while age, education, occupation, income, household size and knowledge were significant predictors of threat, coping appraisal and/or protection motivation intention among parents. Nevertheless, in the overall protection motivation model, only two coping factors, namely self-efficacy (parents) and response cost (school heads), influenced the intention to adopt iodine biofortified foods. CONCLUSION: School feeding programs incorporating iodine biofortification should strive to increase not only consumer knowledge about iodine but also its association to apparent deficiency disorders, boost self-efficacy and ensure that the costs incurred are not perceived as barriers of adoption. The insignificant threat appraisal effects lend support for targeting future communication on biofortification upon the strategies itself, rather than on the targeted micronutrient deficiency. PMT, and coping factors in particular, seem to be valuable in assessing intentions to adopt healthy foods. Nevertheless, research is needed to improve the impacts of threat appraisal factors.

Colorado Immersion Training in Community Engagement: Because You Can't Study What You Don't Know.

BACKGROUND: Community engagement (CE)has become a major element in medical research. In alliance with the goals of the Clinical and Translational Sciences Award program, Colorado Immersion Training in Community Engagement (CIT) is a community-campus partnership that aims to introduce an expanded pool of researchers to community-based participatory research (CBPR) and CE. OBJECTIVES: To describe CIT components and preliminary results. METHODS: CIT attempts to support a change in the research trajectory of academic health researchers, program developers, and graduate students toward CE. The program occurs on campus and in six community settings: Urban African American, urban Asian and refugee, urban Latino, urban American Indian/Alaska Native, rural northeast Colorado, and rural San Luis Valley. Components include a 4-week Directed Reading, a seminar on CBPR, 4-day community immersion, reflection, and 6-month support. Evaluation describes recruitment, implementation, and participants' understanding of CBPR and skills post-training. RESULTS: Fifty-eight people have participated. A comprehensive curriculum was developed to address (1) principals of CBPR, (2) health disparities, (3) listening to community, (4) self-reflection, and (5) engagement tools. Community immersions expose participants to a community's culture and opportunities to discuss health issues with a range of community members. Local "community guides" enhance participants' experience. Of the first two cohorts, 90% changed the way they plan to approach their research, 94% changed how they viewed community involvement in research, and 77% learned new skills to help engage communities in research. CONCLUSIONS: CIT applies to and positively impacts researchers from a variety of disciplines. CIT creates opportunities for long lasting partnerships between researchers and communities.

Telehealth: preparing advanced practice nurses to address healthcare needs in rural and underserved populations.

Healthcare is being confronted with questions on how to deliver quality, affordable, and timely care to patients, especially those in rural areas, in systems already burdened by the lack of providers. Advanced Practice Registered Nurses (APRNs) have been challenged to lead this movement in providing care to these populations through the use of technologies, specifically telehealth. Unfortunately, APRNs have limited exposure to telehealth during their educational experience, thereby limiting their understanding and comfort with telehealth. To address this problem, a telehealth program was developed at a large university that prepares Doctor of Nursing Practice (DNP) APRN students. The telehealth program, embedded into the DNP curriculum, consisted of a simulation workshop, practice immersion, and written project. This program was well received by students, making them aware of the benefits and barriers to the implementation of telehealth as a care delivery modality. Telehealth was embraced as students implemented the program in their own practices.

'I could never have learned this in a lecture': transformative learning in rural health education.

Health indicators for rural populations in Australia continue to lag behind those of urban populations and particularly for Indigenous populations who make up a large proportion of people living in rural and remote Australia. Preparation of health practitioners who are adequately prepared to face the 'messy swamps' of rural health practice is a growing challenge. This paper examines the process of learning among health science students from several health disciplines from five Western Australian universities during 'Country Week': a one-week intensive experiential interprofessional education program in rural Western Australia. The paper weaves together strands of transformative theory of learning with findings from staff and student reflections from Country Week to explore how facilitated learning in situ can work to produce practitioners better prepared for rural health practice.

Transforming rural health systems through clinical academic leadership: lessons from South Africa.

CONTEXT: Under-resourced and poorly managed rural health systems challenge the achievement of universal health coverage, and require innovative strategies worldwide to attract healthcare staff to rural areas. One such strategy is rural health training programs for health professionals. In addition, clinical leadership (for all categories of health professional) is a recognised prerequisite for substantial improvements in the quality of care in rural settings. ISSUE: Rural health training programs have been slow to develop in low- and middle-income countries (LMICs); and the impact of clinical leadership is under-researched in such settings. A 2012 conference in South Africa, with expert input from South Africa, Canada and Australia, discussed these issues and produced recommendations for change that will also be relevant in other LMICs. The two underpinning principles were that: rural clinical leadership (both academic and non-academic) is essential to developing and expanding rural training programs and improving care in LMICs; and leadership can be learned and should be taught. LESSONS LEARNED: The three main sets of recommendations focused on supporting local rural clinical academic leaders; training health professionals for leadership roles in rural settings; and advancing the clinical academic leadership agenda through advocacy and research. By adopting the detailed recommendations, South Africa and other LMICs could energise management strategies, improve quality of care in rural settings and impact positively on rural health outcomes.

The redistribution of graduate medical education positions in 2005 failed to boost primary care or rural training.

Graduate medical education (GME), the system to train graduates of medical schools in their chosen specialties, costs the government nearly $13 billion annually, yet there is little accountability in the system for addressing critical physician shortages in specific specialties and geographic areas. Medicare provides the bulk of GME funds, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 redistributed nearly 3,000 residency positions among the nation's hospitals, largely in an effort to train more residents in primary care and in rural areas. However, when we analyzed the outcomes of this recent effort, we found that out of 304 hospitals receiving additional positions, only 12 were rural, and they received fewer than 3 percent of all positions redistributed. Although primary care training had net positive growth after redistribution, the relative growth of nonprimary care training was twice as large and diverted would-be primary care physicians to subspecialty training. Thus, the two legislative and regulatory priorities for the redistribution were not met. Future legislation should reevaluate the formulas that determine GME payments and potentially delink them from the hospital prospective payment system. Furthermore, better health care workforce data and analysis are needed to link GME payments to health care workforce needs.