'Dimensions and tensions?': embracing the complexity of 'working in a rural area' through qualitative research interpreting perspectives of dermatologists and dermatology trainees.

INTRODUCTION: Challenges to addressing workforce maldistribution for equitable rural healthcare access continue, including for dermatology services. The conceptual complexity of the notion of 'rural' adds to the challenges, with the term 'rural' reflecting socially constructed meanings. In relation to healthcare workforce strategies, socially constructed meanings of 'rural' indicate preferences for quantifiable framings and tendencies towards deficit-based portrayals. While quantifiable framings provide impetus for implementing and evaluating important rural healthcare workforce strategies, their tendency towards deficit-based portrayals risks overlooking positives of rural healthcare practice and stereotyping rural areas as problematic environments for health care. The importance of balancing deficit-based portrayals of 'rural' with more positive orientations is recognised as important for addressing the maldistribution of the healthcare workforce. Adding further to the complexity of addressing workforce maldistribution is the range of strategies required. Encompassed in these strategies are socially constructed approaches and conflicting interests. The notion of 'tensions' has potential for making sense of, and addressing, the complexity of these competing interests. Importantly, not all 'tensions' need to be resolved. By identifying, embracing and holding 'tensions' rather than necessarily resolving them, space for ongoing rich discussion can be deliberately created. METHODS: This qualitative research used a wide-angle, strength-based lens to explore the topic of working in a rural area, from the perspectives of dermatologists and dermatology trainees. The wide-angle lens allowed consideration of the multiplicity of approaches. The strength-based lens allowed the research to go beyond deficit-based portrayals and embrace 'tensions' inherent in the complexities of addressing workforce maldistribution. This study, undertaken in the interpretive research paradigm, was informed by philosophical hermeneutics. The research question was, 'How can working in a rural area be conceptualised from the perspectives of dermatologists and dermatology trainees?'. Data collected through semi-structured interviews with 17 participants providing dermatology services in rural areas (11 dermatologists and 6 dermatology trainees) were iteratively interpreted. Data were initially coded descriptively, with iterations moving towards more conceptual themes. RESULTS: A conceptual model of dimensions and tensions of working in a rural area, from the perspective of dermatologists and dermatology trainees, is presented to illustrate the interpreted key themes, subthemes and implications. The four key themes are dimensions of working in a rural area: choosing to work in a rural area, transitioning out of a metropolitan area, embedding into the rural community and working within the complexity of 'rural'. As illustrated in the model, subthemes are characteristics capturing inherent diversity within each dimension, and the implications are 'tensions'. Issues for ongoing discussion arising from these 'tensions' include metropolitan as a gravitational force to be overcome; complexities of individual choice, including implications for absence of choice; importance of community as people at the core of the strategies; and the taken-for-granted language for 'rural' inadvertently reinforcing deficit-based portrayals. A set of reflective questions related to these issues is provided. CONCLUSION: The reflective questions posed can be discussed, grappled with and considered when developing strategies that address workforce maldistribution and when exploring different experiences within the complex social construction of 'rural'.

Valued but tenuous? Postgraduate clinical psychology placements for psychology students in rural and remote areas - implications for future directions.

INTRODUCTION: This study is located at the complex intersection of healthcare service provision, healthcare workforce and practice-based education. The study explored postgraduate clinical psychology placements in rural and remote locations and was part of a larger study known as the Mental Health Tertiary Curriculum project. METHOD: A qualitative approach incorporating thematic analysis was used to explore experiences. Ten structured individual interviews were conducted across Australia. Participants were eight postgraduate psychology students, one service provider and one representative of an educational institution. RESULTS: Two key themes were derived from the data. The first theme, 'Beyond expectations, but …', recognised the value of clinical placements from the students' perspectives, but cautioned against the challenges faced by supervisors supporting these placements. The second theme, 'Immersed in connectedness with …', makes explicit the growing sense of belonging and professional identity that accompanied students' engagement with their rural communities, other health professions and their own profession. CONCLUSION: This study highlights the complexity of developing workplace readiness for psychology students and provides areas for future consideration including the role of practice-based education and where this notion fits within undergraduate psychology degrees.

Educating for collaborative practice: an interpretation of current achievements and thoughts for future directions.

CONTEXT: The Edinburgh Declaration, developed in 1998 as a pledge to alter the character of medical education to more effectively meet the needs of society, included a recommendation to increase the opportunity for joint learning between health and health-related professions, as part of the training for teamwork. This article acknowledges achievements since the Declaration in relation to this recommendation, using an umbrella term for the phenomenon, 'educating for collaborative practice', and presents a perspective framed as a series of questions to encourage reflection on future directions. METHODS: A literature interpretation, informed by philosophical hermeneutics, was conducted using text sets comprising reports and reviews from a section of the international literature since 1988. The interpretation involved: engaging with meanings as presented in the chosen texts; making iterative returns to the texts to explore emerging understanding; and ensuring parts of our understanding from particular texts were fused with complete understanding of the texts as a whole. A lens of appreciative inquiry facilitated acknowledgement of what has been achieved, while being curious about how it could be. RESULTS: Interpretation of the selected literature revealed notable achievements. Areas for further consideration were identified in relation to three themes: establishing shared understanding AND purpose behind use of terminology; being a conduit AND sharing responsibility for change; exploring ways of doing things AND ensuring ongoing inclusivity. CONCLUSIONS: Interpreting the current literature on 'educating for collaborative practice' has generated questions for reflection on how it may be otherwise. Readers are encouraged to embrace the tensions inherent in unanswered questions, providing space for communication, initiative and diversity of thought. An ongoing dialogue with the literature is proposed, asking whether educating students for a collective identity in settings where they are learning for and with patients is likely to advance educating for patient-centred collaborative practice.

Rural multidisciplinary training: opportunity to focus on interprofessional rapport-building.

In 2016, the Australian Government committed further funds in support of quality rural health education to improve the health and wellbeing of rural and remote communities. The stated funding requirement for longer rural placements in all disciplines is an exciting opportunity for greater investment in interprofessional education to foster collaborative practice, a global system imperative for health care. This commentary explores how findings from earlier research, which investigated how students in a co-located area learn to work with other health professions, can be translated into practice. While recognising the importance of an individual's interpersonal capabilities, this commentary focuses on how the core contextual conditions for interprofessional-rapport-building opportunities (shared space, adequate time and balance of disciplines) were considered in one rural centre. Educational leaders and academics globally should recognise that offering health professional students opportunity to live and work together in extended placements in rural settings has potential benefits for interprofessional education. Understanding the contextual conditions for building rapport between health professional learners, and reflecting on these, potentially will lay the foundation for collaborative practice when these learners become health professionals. Through the reflective questions we pose, policy-makers, health managers and clinical leaders from all health disciplines can build on this foundation by considering the interpersonal capability and contextual conditions for rapport-building in the health workforce to foster a collaborative practice environment for graduates to embrace when they enter the health workplace.

Educators working together for interprofessional education: From "fragmented beginnings" to being "intentionally interprofessional".

This article explores the development of interprofessional relationships between healthcare educators working together for interprofessional education (IPE). As part of a collaborative dialogical inquiry, data from 19 semi-structured interviews and 9 focus groups were used to explore how IPE educators develop shared purpose to help students learn to work with other health professions. Consistent with this methodology, the research group and study participants comprised educators from eight different professions. Questions asked of the data, using a lens of intersubjectivity, included: "What implicit assumptions are brought to interactions?" and "What happens to these assumptions as educators interact?" The emergent themes caution against assuming that all educators initially bring to interprofessional spaces only positive attitudes towards all professions. Educators beginning in a fragmented interprofessional space needed to reflect on earlier negative experiences with particular professions for reframing in a socially aware interprofessional space to enable collaborating in an intentional interprofessional space.

Interprofessional education: does recent literature from rural settings offer insights into what really matters?

CONTEXT: As rural health staff of different disciplines often know one another and share workplace facilities, rural areas are well suited to the implementation of interprofessional education (IPE) strategies. Details of such strategies are often shared in journal articles so that educators can learn from and build on the experiences of others. A common theme in the apparent success of rural interprofessional initiatives concerns collaborative relationships among educators. However, do readers of journals see the full picture of the collaborative relationships among educators of different disciplines as they plan and implement strategies? METHODS: A literature interpretation informed by philosophical hermeneutics was used to explore the nature of educators' collaborative relationships in the planning and implementation of IPE initiatives as portrayed by authors of articles on rural IPE. Twenty-four articles suitable for inclusion in the text set were identified through searches of databases and relevant journals. RESULTS: The nature of the collaborative relationships involved in planning and implementing educational strategies was rarely explicit. However, within an implied sense of interpersonal relationships, three themes were interpreted: grounded beginnings; untold stories, and anthropomorphised collectives. CONCLUSIONS: Being explicit about educators' collaborative relationships may have potential to improve the transferability of IPE strategies to other contexts. A flowchart is presented to encourage authors to: (i) consider how to portray educators' collaborative relationships, and (ii) reflect on how these collaborative relationships may impact on the success, or otherwise, of their IPE projects.

When students from different professions are co-located: the importance of interprofessional rapport for learning to work together.

With increasing interest and research into interprofessional learning, there is scope to more deeply understand what happens when students from different professions live and study in the same location. This study aimed to explore the issue of co-location and its effects on how students learn to work with other professions. The setting for this study was a rural health education facility in Australia with close links to local health care and community services. Philosophical hermeneutics informed the research method. Interviews were undertaken with 29 participants, including students, academic educators and clinical supervisors in diagnostic radiography, medicine, nursing, nutrition and dietetics, pharmacy, physiotherapy, occupational therapy, and speech pathology. Photo-elicitation was used to facilitate participant engagement with the topic. The findings foreground the value of interprofessional rapport building opportunities for students learning to work together. Enabled by the proximity of different professions in shared educational, clinical and social spaces, interprofessional rapport building was contingent on contextual conditions (balance of professions, shared spaces and adequate time) and individual's interpersonal capabilities (being interested, being inclusive, developing interpersonal bonds, giving and receiving respect, bringing a sense of own profession and being patient-centred). In the absence of these conditions and capabilities, negative professional stereotypes may be inadvertently re-enforced. From these findings suggestions are made for nurturing interprofessional rapport building opportunities to enable students of different professions to learn to work together.

Collaboration across the health care and education interface: what is it like for teachers of children with traumatic brain injury?

For those involved in supporting and educating children with traumatic brain injury, the interface between health care and education is complex. This paper reports the findings of a study exploring how teachers of children with traumatic brain injury experience collaboration with health-care professionals. A phenomenological approach was used to understand teachers' experience of collaboration. Semi-structured interviews were undertaken with five teachers who taught children with traumatic brain injury in a regional area of Australia. The findings revealed that the experience of collaboration for teachers is characterised by moving through three national spaces (starting out in the interactive space, moving into a collaborative space and embracing the collaborative space). As they move through these spaces, teachers widen their self-sufficient practice horizon to develop reciprocity with health-care professionals. The findings from this study highlight a need for health-care professionals to be sensitive to, and aware of, teachers' familiarity with interdisciplinary collaboration, issues related to knowledge differentials and time constraints.

Allied Health Collaborative Practice Capability: A Coalescence of Capabilities.

Allied health professionals are key in collaborative practice in healthcare settings. To better inform allied health student preparation for collaborative practice, this research illuminated the nature of allied health collaborative practice capability. Literature and perceptions of allied health students and academics were examined using a philosophical hermeneutic approach. A literature text set was constructed from a range of health and health education related fields. An experiential text was constructed from two sources; focus groups with students and semi-structured interviews with academics. Through this research we identified a plurality of capabilities that coalesce to become allied health collaborative practice capability. These dimensions and capabilities are: contextual (adaptability, responsiveness and persistence), social (friendliness, openness and reciprocity), and individual (professional expertise, willingness and flexibility). Capabilities illuminated in this research included skills and qualities. The plurality and coalescence of capabilities identified in this research highlight the complex nature of collaborative practice capability. A challenge remains to bring the more tacit qualities and how they interact into focus so that they receive meaningful attention to inform practice development and education.

Collaboration: what is it like? - phenomenological interpretation of the experience of collaborating within rehabilitation teams.

Although a core component of many current health-care directions, interprofessional collaboration continues to challenge educators and health professionals. This paper aims to inform the development of collaborative practice by illuminating the experiences of collaborating within rehabilitation teams. The researchers focused on experiences that transcended team members' professional role categorizations in order to bring individuals and their lived experiences to the forefront. An inclusive view of "teams" and "collaboration" was adopted and the complexity and multifaceted nature of collaborating were explored through a hermeneutic phenomenological approach. Semi-structured interviews were used to gather data about experiences of collaborating in nine rehabilitation teams. Sixty-six team members across nine teams were interviewed. Eight interdependent dimensions, core to the experience of collaborating, emerged from the analysis of the data. Five dimensions expressed interpersonal dimensions of endeavor: engaging positively with other peoples' diversity; entering into the form and feel of the team; establishing ways of communicating and working together; envisioning together frameworks for patients' rehabilitation and effecting changes in people and situations. Three reviewing dimensions, reflexivity, reciprocity and responsiveness, operated across the endeavor dimensions. By identifying meaning structures of the experience of collaborating, this study highlights the importance of seeing beyond team members' professional affiliations and being aware of their contextualized interpersonal and activity-related collaborating capabilities.

Developing a meta-understanding of 'human aspects' of providing palliative care.

Objectives: Our intention was to develop a meta-understanding of the 'human aspects' of providing palliative care. Integral to developing this meta-understanding was recognising the individuality of people, their varied involvements, situations, understandings, and responses, and the difficulty in stepping back to get a whole view of this while being in the midst of providing palliative care. We intended for this meta-understanding to inform reflections and sense-making conversations related to people's changing situations and diverse needs. Methods: Using collaborative inquiry, this qualitative research was undertaken 'with' clinicians rather than 'on' them. Our team (n = 7) was composed of palliative care clinicians and researchers from a co-located rural health service and university. We explored our personal perceptions and experiences through a series of 12 meetings over 8 months. In addition, through five focus groups, we acccessed perceptions and experiences of 13 purposively sampled participants with a range of roles as carers and/or healthcare providers. Data were dialogically and iteratively interpreted. Findings: Our meta-understanding of 'human aspects' of providing palliative care, represented diagrammatically in a model, is composed of ATTRIBUTES OF HUMANITY and ACTIONS OF CARING. ATTRIBUTES OF HUMANITY are death's inevitability, suffering's variability, compassion's dynamic nature, and hope's precariousness. ACTIONS OF CARING include recognising and responding, aligning expectations, valuing relationships, and using resources wisely. The meta-understanding is a framework to keep multiple complex concepts 'in view' as they interrelate with each other. Significance of findings: Our meta-understanding, highlighting 'human aspects' of providing palliative care, has scope to embrace complexity, uncertainty, and the interrelatedness of people in the midst of resourcing, requiring, and engaging in palliative care. Questions are posed for this purpose. The non-linear diagrammatic representation of ATTRIBUTES OF HUMANITY and ACTIONS OF CARING facilitates multiple ways of engaging and revisiting palliative care situations or navigating changes within and across them.

Personalised written consultation summaries for patients: An 'up-close, in-depth, inside-out' exploration of a rheumatologist's patient-centred strategy.

OBJECTIVE: The importance of ensuring that patients understand and remember information from rheumatology consultations is well recognised. However, literature focuses on 'one-size-fits-all' information resources. In this qualitative study our 'upclose, in-depth, inside-out' exploration sought to understand the personalised written consultation summary, a rheumatologist's patient-centred strategy developed through ongoing reflection. METHODS: A research team of a rheumatologist, practice nurse, two patients, registrar and researcher used a participatory research approach, collaborative inquiry Semistructured interviews were undertaken with 29 patients. Data analysis was dialogical and iterative, moving from descriptive to conceptual. RESULTS: Implicit within the personalised written consultation summary were domains and actions of: INVOLVEMENT in the process (contributing to the content, clarifying and negotiating the content, being present as it is written), CONTINUITY of information (taking the summary, sharing it with others, storing it at home) and SECURITY for ongoing management (owning the summary, being reminded about management plans, having a basis for re-checking). CONCLUSION: Aligned with the findings are patient-centred intentions for health literacy, personal health information management and medication adherence. The second highlights an important theoretical basis for patient-centred rheumatology strategies beyond consultations. PRACTICE IMPLICATIONS: A model and reflective questions are presented to inform ongoing reflections about patient-centred information strategies.

Developing and maintaining collaborative practice: Exploring perspectives from dietetics and speech pathology about 'what works well'.

AIM: The aim was to support rich collaborative practice between two professions who frequently work together across both ordered and organic modes of collaboration. METHODS: This study uses a qualitative research approach of collaborative dialogical inquiry to explore the question 'From the perspective of dietitians and speech pathologists, "what works well" for developing and maintaining collaborative practice?' We deliberately chose a context where collaborative practice is evident, University Department of Rural Health (UONDRH). Participants in the research were academics and clinicians from dietetics and speech pathology. Data were sourced from our research reflections and focus group transcriptions. Analysis was dialogical and iterative. RESULTS: Beyond shared purpose, knowledge of roles and good communication, the notions of curiosity, willingness and momentum were at the core of 'what works well' for collaborative practice between dietitians and speech pathologists. Participant perspectives related to collaborative practice between these professions and beyond to other professions, and involved collaborative practice within and across healthcare organisations and a university setting. CONCLUSIONS: Our interpreted themes of curiosity, willingness and momentum for developing and maintaining collaborative practice highlight the importance of paying attention to the less visible and difficult to measure aspects of patient-centred care. Questions for reflection are suggested to inform the ongoing process of developing and maintaining our and others' collaborative practice.

Who, where, what and where to now? A snapshot of publishing patterns in Australian orthopaedic surgery.

BACKGROUND: Development of core research competency is a principle of orthopaedic surgical training in Australia. This paper aims to provide an objective snapshot of publications by Australian orthopaedic trainees and surgeons, to contribute to the discussion on how to identify and build on research capability in the Australian Orthopaedic Association (AOA). METHODS: By analysing journals with a journal impact factor >1 from 2009 to 2015, data were gathered to explore scientific journal publications by Australian orthopaedic surgeons and trainees in relation to who are the authors, what they are reporting and where they are publishing. RESULTS: One thousand five hundred and thirty-nine articles were identified with 134 orthopaedic trainees and 519 surgeons as authors. The publication rate for both trainees and surgeons was just over two in five. The majority of studies were of level three or four evidence (Oxford's Centre for Evidence-Based Medicine guidelines). Only 5% of trainee papers were published without surgeons' co-authorship. Eighty-six percent of papers published by surgeons did not involve a trainee. The rates of trainees publishing with other trainees were low. CONCLUSION: Only 5% of trainee papers were published without surgeons' co-authorship, highlighting the importance of surgeon mentorship in developing trainee research capability. The 86% of papers published by surgeons without trainee co-authorship raises the question of missed mentoring opportunities. Low rates of trainee co-authorship highlight potential for trainees to work together to support each other's research efforts. There is scope for more studies involving higher levels of evidence. This paper raises discussion points and areas for further exploration in relation to AOA trainee research capability.

Educators' Interprofessional Collaborative Relationships: Helping Pharmacy Students Learn to Work with Other Professions.

Similar to other professions, pharmacy educators use workplace learning opportunities to prepare students for collaborative practice. Thus, collaborative relationships between educators of different professions are important for planning, implementing and evaluating interprofessional learning strategies and role modelling interprofessional collaboration within and across university and workplace settings. However, there is a paucity of research exploring educators' interprofessional relationships. Using collaborative dialogical inquiry we explored the nature of educators' interprofessional relationships in a co-located setting. Data from interprofessional focus groups and semi-structured interviews were interpreted to identify themes that transcended the participants' professional affiliations. Educators' interprofessional collaborative relationships involved the development and interweaving of five interpersonal behaviours: being inclusive of other professions; developing interpersonal connections with colleagues from other professions; bringing a sense of own profession in relation to other professions; giving and receiving respect to other professions; and being learner-centred for students' collaborative practice. Pharmacy educators, like other educators, need to ensure that interprofessional relationships are founded on positive experiences rather than vested in professional interests.

Breastfeeding friendly workplace accreditation. Creating supportive workplaces for breastfeeding women.

The strategies of health promotion, as outlined in the World Health Organization's Ottawa Chapter of Health Promotion provide a good framework for a multifaceted approach to improving breastfeeding rates. The Australian Breastfeeding Association (ABA) utilises the full range of these health promotion strategies. Through the energy and commitment of the nationwide network of the association's volunteers, many beneficial breastfeeding initiatives have been implemented over the past few years. The aim of this paper is to describe one of these initiatives, the ABA's Breastfeeding Friendly Workplace Accreditation program (BFWA), within the context of health promotion. First, a summary of breastfeeding information will be presented, then the program will be described, the support it provides for breastfeeding mothers in the workplace will be outlined and the impact of BFWA since its implementation in 2002 will be examined.