Rationale and protocol for the Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study: a large-scale longitudinal investigation of graduate practice destinations.

INTRODUCTION: Inequitable distribution of health workforce limits access to healthcare services and contributes to adverse health outcomes. WHO recommends tracking health professionals from their points of entry into university and over their careers for the purpose of workforce development and planning. Previous research has focused on medical students and graduates' choice of practice location. Few studies have targeted nursing and allied health graduates' practice intentions and destinations. The Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study is investigating factors affecting Australian nursing and allied health students and graduates' choice of graduate practice location over the course of their studies and up to 10 years after graduation by linking multiple data sources, including routinely collected university administrative and professional placement data, surveys of students and graduates, and professional registration data. METHODS: By using a prospective cohort study design, each year a new cohort of about 2000 students at each participating university (Deakin University, Monash University and the University of Newcastle) is tracked throughout their courses and for 10 years after graduation. Disciplines include medical radiation practice, nursing and midwifery, occupational therapy, optometry, paramedicine, pharmacy, physiotherapy, podiatry and psychology. University enrolment data are collected at admission and professional placement data are collected annually. Students' practice destination intentions are collected via questions added into the national Student Experience Survey (SES). Data pertaining to graduates' practice destination, intentions and factors influencing choice of practice location are collected in the first and third years after graduation via questions added to the Australian Graduate Outcomes Survey (GOS). Additionally, participants may volunteer to receive a NAHGOT survey in the second and fourth-to-tenth years after graduation. Principal place of practice data are accessed via the Australian Health Practitioner Regulation Agency (Ahpra) annually. Linked data are aggregated and analysed to test hypotheses comparing associations between multiple variables and graduate practice location. RESULTS: This study seeks to add to the limited empirical evidence about factors that lead to rural practice in the nursing and allied health professions. This prospective large-scale, comprehensive study tracks participants from eight different health professions across three universities through their pre-registration education and into their postgraduate careers, an approach not previously reported in Australia. To achieve this, the NAHGOT study links data drawn from university enrolment and professional placement data, the SES, the GOS, online NAHGOT graduate surveys, and Ahpra data. The prospective cohort study design enables the use of both comparative analysis and hypothesis testing. The flexible and inclusive study design is intended to enable other universities, as well as those allied health professions not regulated by Ahpra, to join the study over time. CONCLUSION: The study demonstrates how the systematic, institutional tracking and research approach advocated by the WHO can be applied to the nursing and allied health workforce in Australia. It is expected that this large-scale, longitudinal, multifactorial, multicentre study will help inform future nursing and allied health university admission, graduate pathways and health workforce planning. Furthermore, the project could be expanded to explore health workforce attrition and thereby influence health workforce planning overall.

'It's mostly about the job' - putting the lens on specialist rural retention.

INTRODUCTION: Rural health services throughout the world face considerable challenges in the recruitment and retention of medical specialists. This research set out to describe the factors that contribute to specialist workforce retention and attrition in a health service in rural Tasmania, Australia. METHODS: This qualitative study utilised in-depth interviews with 22 medical specialists: 12 currently employed by the service and 10 who had left or intended to leave. Interview transcripts were thematically analysed to identify professional, social and location factors influencing retention decision-making. RESULTS: Professional and workplace factors were more important than social or location factors in retention decision-making. Tipping points were excessive workloads, particularly on-call work, difficult collegial relationships, conflict with management, offers of more appealing positions elsewhere, family pressure to live in a metropolitan area, educational opportunities for children and a lack of contract flexibility. Inequitable workload distribution and the absence of senior registrars contributed to burnout. Financial remuneration was not a primary factor in retention decision-making, however, there was acknowledgement of the need to ensure equitable pay scales, flexible employment contracts including statewide positions and increased CPD payments/leave. Specialists who had autonomy in determining their preferred work balance tended to stay, as did those who had family or developed social connections within the area, rural backgrounds and a preference for rural living. CONCLUSION: To improve specialist workforce retention, rural health services should ensure a professionally rewarding, harmonious work environment, without onerous out-of-hours demands and where specialists feel valued. Specialists should have autonomy over workloads, flexible contracts, appropriate financial remuneration and enhanced access to CPD. New specialists and their families should have additional support to assist with social integration.

The Australian Rural Clinical School (RCS) program supports rural medical workforce: evidence from a cross-sectional study of 12 RCSs.

INTRODUCTION: Many strategies have been implemented to address the shortage of medical practitioners in rural areas. One such strategy, the Rural Clinical School Program supporting 18 rural clinical schools (RCSs), represents a substantial financial investment by the Australian Government. This is the first collaborative RCS study summarising the rural work outcomes of multiple RCSs. The aim of this study was to combine data from all RCSs' 2011 graduating classes to determine the association between rural location of practice in 2017 and (i) extended rural clinical placement during medical school (at least 12 months training in a rural area) and (ii) having a rural background. METHODS: All medical schools funded under the RCS Program were contacted by email about participation in this study. De-identified data were supplied for domestic students about their gender, origin (rural background defined as having lived in an Australian Standard Geographic Classification-Remoteness Area (ASGC-RA) 2-5 area for at least 5 years since beginning primary school) and participation in extended rural clinical placement (attended an RCS for at least 1 year of their clinical training). The postcode of their practice location according to the publicly available Australian Health Practitioner Regulation Agency (AHPRA) register was collected (February to August 2017) and classified into rural and metropolitan areas using the ASGC 2006 and the more recent Modified Monash Model (MMM). The main outcome measure was whether graduates were working in a 'rural' area (ASGC categories RA2-5 or MMM categories 3-7) or 'metropolitan' area. Pearson's χ2 test was used to detect differences in gender, rural background and extended placement at an RCS between rural and metropolitan practice locations. Binary logistic regression was used to determine odds of rural practice and 95% confidence intervals (CIs) were calculated. RESULTS: Although data were received from 14 universities, two universities had not started collecting origin data at this point so were excluded from the analysis. The proportion of students with a rural background had a range of 12.3-76.6% and the proportion who had participated in extended RCS placement had a range of 13.7-74.6%. Almost 17% (16.6%) had a principal practice postcode in a rural area (according to ASGC), range 5.8-55.6%, and 8.3% had a principal practice postcode in rural areas (according to MMM 3-7), range 4.5-29.9%. After controlling for rural background, it was found that students who attended an RCS were 1.5 times more likely to be in rural practice (95%CI 1.2-2.1, p=0.004) using ASGC criteria. Using the MMM 3-7 criteria, students who participated in extended RCS placement were 2.6 times as likely to be practising in a rural location (95%CI 1.8-3.8, p<0.001) after controlling for rural background. Regardless of geographic classification system (ASGC, MMM) used for location of practice and of student background (metropolitan or rural), those students with an extended RCS had an increased chance of working rurally. CONCLUSION: Based on the combined data from three-quarters (12/16) of the Australian medical schools who had a graduating class in 2011, this suggests that the RCS initiative as a whole is having a significant positive effect on the regional medical workforce at 5 years post-graduation.

When death is imminent - documenting end-of-life decisions.

BACKGROUND: There has been widespread promotion of advance care planning in recent years, which is consistent with an ageing population and a greater awareness of patient self determination. METHODS: A review of medical records relating to hospital patient deaths and a separate review of emergency department admissions of patients aged 75 years or more in the same hospital. RESULTS: In the patient deaths sample, 77% of patients (median age 79 years), had their first documented end-of-life discussion 3 days before death. In the sample of emergency department admissions, 82% of patients (median age 83 years), had no documented end-of-life discussion or review by the time of discharge. Only two patients, both in the emergency department admissions group, had written advance care plans before admission. DISCUSSION: This study suggests that documented advance care plans are either not being prepared in the community or are not being communicated to acute care facilities. As a result, end-of-life care preferences are documented when death is imminent.

Occupational violence in general practice: a whole-of-practice problem. Results of a cross-sectional study.

OBJECTIVE: To examine the experiences of occupational violence in general practitioner (GP) and non-GP staff. Further objectives were to compare prevalence of violence in GP and non-GP staff and to examine levels of apprehension and perceptions of control over violence. DESIGN: Cross-sectional questionnaire-based study. SETTING: A network of research general practices, New South Wales, Australia. PARTICIPANTS: GPs and non-GP staff--receptionist, practice-management, nursing and allied health staff. MAIN OUTCOME MEASURE(S): Experience of occupational violence during the previous 12 months. Other outcomes examined were workplace apprehension regarding violence, perception of occupational violence as a problem in general practice, and perception of control over violence in the workplace. RESULTS: A total of 125 questionnaire replies were received (response rate 55%), 59.3% of GPs and 74.6% of non-GPs had experienced work-related violence during the previous 12 months. The difference was not significant (OR 0.65, 95% CI 0.20-2.06). Subjects in rural practices were more likely than those in urban practices to have experienced violence (OR 3.79, 95% CI 1.15-12.5). Personal experience of violence (OR 35.9, 95% CI 6.24-207) and a perception that violence is increasing (OR 8.33, 95% CI 1.89-36.6) were associated with apprehension regarding violence at work.

What evidence is there to support skill mix changes between GPs, pharmacists and practice nurses in the care of elderly people living in the community?

BACKGROUND: Workforce shortages in Australia are occurring across a range of health disciplines but are most acute in general practice. Skill mix change such as task substitution is one solution to workforce shortages. The aim of this systematic review was to explore the evidence for the effectiveness of task substitution between GPs and pharmacists and GPs and nurses for the care of older people with chronic disease. Published, peer reviewed (black) and non-peer reviewed (grey) literature were included in the review if they met the inclusion criteria. RESULTS: Forty-six articles were included in the review. Task substitution between pharmacists and GPs and nurses and GPs resulted in an improved process of care and patient outcomes, such as improved disease control. The interventions were either health promotion or disease management according to guidelines or use of protocols, or a mixture of both. The results of this review indicate that pharmacists and nurses can effectively provide disease management and/or health promotion for older people with chronic disease in primary care. While there were improvements in patient outcomes no reduction in health service use was evident. CONCLUSION: When implementing skill mix changes such as task substitution it is important that the health professionals' roles are complementary otherwise they may simply duplicate the task performed by other health professionals. This has implications for the way in which multidisciplinary teams are organised in initiatives such as the GP Super Clinics.

HPV vaccine catch up schedule - an opportunity for chlamydia screening.

The human papillomavirus (HPV) vaccine (Gardasil) catch up schedule in general practice is available until June 2009 to females not in school and under the age of 27 years. A course of three injections is given over 6 months. This provides a unique opportunity for sexual health screening in an age group where chlamydia screening is a priority.

Integrated models or mayhem? Lessons learnt from three integrated primary health care entities in regional New South Wales.

While "integration" may be a policy imperative at present, the reality of integrating services whilst managing the business of service delivery and best patient outcomes is both challenging and unfamiliar territory for most general practitioners. Recent policy changes in general practice have challenged traditional financial and governance models. This paper reviews three integrated general practice entities, all under the auspice of the University of Newcastle, for commonalities and concerns. A model was conceptualised and key factors identified and discussed. These factors included careful selection of partners, elucidation of the level of integration and the need for a lead champion to promote the changed environment. The financial and clinical governance systems needed to be clearly delineated, including the type and priority of service delivery intended. Integration is not a blanket solution but may be useful for patients with chronic and complex health problems. Being resource-intense, it may not be available or appropriate for all. The practical realities of workforce however, and the political and funding environment are likely to dictate how GP practices in the future embrace integration.

HPV vaccination - a paradigm shift in public health.

BACKGROUND: In 2006, the world's first quadrivalent human papillomavirus (HPV) vaccine (Gardasil) was made available to the Australian public. The quadrivalent HPV vaccine protects against cervical cancer, cervical abnormalities, and genital warts related to HPV types 6, 11, 16 and 18. General practitioners play a vital role in preventive medicine and as such should have a good understanding of the vaccine and its role in the primary prevention of cervical cancer and precancers. OBJECTIVE: This article provides an overview of the HPV vaccine including efficacy and safety as it relates to its approved use in Australia. DISCUSSION: The vaccine (Gardasil) is quadrivalent, providing protection against HPV types 6, 11, 16 and 18. These HPV types represent a significant burden on public health as they are responsible for 70% of cervical cancers, a substantial proportion of cervical abnormalities, and 90% of genital warts. The quadrivalent HPV vaccine (Gardasil) is indicated for females aged 9-26 years and males aged 9-15 years and should ideally be administered before the onset of sexual activity, however sexually active patients will also benefit.

Clinical service integration: a stocktake of the Australian experience.

Australia, in common with most developed countries, needs to reorientate its health system to meet the needs of the future. There is general acceptance that the current approach geared towards acute episodic care is no longer fit for purpose. This article explores the concept of integration in healthcare in Australia and specifically describes the role of clinicians over the last five years in brokering and supporting change in the way services are delivered.