Establishing new medical schools in diverse contexts: A novel conceptual framework for success.

BACKGROUND: Establishing a new medical school is a significant venture involving many complex political, social, economic, educational, and organisational considerations. The published literature on the process of establishing a new medical school is, however, under-developed with minimal empirical research and no explicit reference to theory. This research sought to address these gaps and establish an empirical and theoretical evidence-base for the process of new medical school establishment in diverse contexts, particularly medically under-served areas. METHODS: A Critical Realist Multiple Case Study was undertaken to examine the establishment of new medical schools across three continents. Data were collected between 2016 and 2018 through observational data gathered on site visits to three medical schools in medically under-served areas, relevant documents/audio-visual materials, and semi-structured interviews with key founding personnel. Data were analysed using the Critical Realist approach. Institutional Entrepreneurship theory was applied, adapted, and extended to explore and explain the phenomenon of new medical school establishment in diverse contexts. RESULTS: This study identifies eight critical success factors underpinning new medical school establishment. Framed as the Eight C's Framework (8CF), these factors include Context (field conditions), Catalysts (institutional entrepreneurs), Conducing (helping to bring about a particular situation or outcome), Collecting (resources), Connecting (relationships), Convincing (rationales), Challenges, and Consequences (outcomes). 8CF highlights that new medical schools are successfully established when Catalysts act within their Contexts to undertake the tasks of Conducing, Convincing, Collecting, and Connecting in order to produce desired Consequences and overcome Challenges. CONCLUSIONS: The Eight C's Framework is a theory-based, empirically supported framework that can be applied across different contexts to strategically guide the successful establishment of new medical schools. Founding leaders and stakeholders could use 8CF to ensure their establishment efforts are underpinned by theory and scholarship.

A Toolkit for Delirium Identification and Promoting Partnerships Between Carers and Nurses: A Pilot Pre-Post Feasibility Study.

BACKGROUND: Delirium is frightening for people experiencing it and their carers, and it is the most common hospital-acquired complication worldwide. Delirium is associated with higher rates of morbidity, mortality, residential care home admission, dementia, and carer stress and burden, yet strategies to embed the prevention and management of delirium as part of standard hospital care remain challenging. Carers are well placed to recognize subtle changes indicative of delirium, and partner with nurses in the prevention and management of delirium. OBJECTIVE: To evaluate a Prevention & Early Delirium Identification Carer Toolkit (PREDICT), to support partnerships between carers and nurses to prevent and manage delirium. DESIGN: A pre-post-test intervention and observation study. MAIN MEASURES: Changes in carer knowledge of delirium; beliefs about their role in partnering with nurses and intended and actual use of PREDICT; carer burden and psychological distress. Secondary measures were rates of delirium. PARTICIPANTS: Participants were carers of Indigenous patients aged 45 years and older and non-Indigenous patients aged 65 years and older. INTERVENTION: Nurses implemented PREDICT, with a view to provide carers with information about delirium and strategies to address caregiving stress and burden. KEY RESULTS: Participants included 25 carers (43% response rate) (n = 17, 68% female) aged 29-88 (M = 65, SD = 17.7 years). Carer delirium knowledge increased significantly from pre-to-post intervention (p = < .001; CI 2.07-4.73). Carers' intent and actual use of PREDICT was (n = 18, 72%; and n = 17, 68%). Carer burden and psychological distress did not significantly change. The incidence of delirium in the intervention ward although not significant, decreased, indicating opportunity for scaling up. CONCLUSION: The prevention and management of delirium are imperative for safe and quality care for patients, carers, and staff. Further comprehensive and in-depth research is required to better understand underlying mechanisms of change and explore facets of nursing practice influenced by this innovative approach.

Virtual Dementia-Friendly Communities (Verily Connect) Stepped-Wedge Cluster-Randomised Controlled Trial: Improving Dementia Caregiver Wellbeing in Rural Australia.

Caring for people living with dementia often leads to social isolation and decreased support for caregivers. This study investigated the effect of a Virtual Dementia-Friendly Rural Communities (Verily Connect) model on social support and demand for caregivers of people living with dementia. The co-designed intervention entailed an integrated website and mobile application, peer-support videoconference, and technology learning hubs. This mixed-methods, stepped-wedge, cluster-randomised controlled trial was conducted with 113 participants from 12 rural communities in Australia. Caregiver data were collected using MOS-SSS and ZBI between 2018 and 2020. The relationship between post-intervention social support with age, years of caring, years since diagnosis, and duration of intervention were explored through correlation analysis and thin plate regression. Google Analytics were analysed for levels of engagement, and cost analysis was performed for implementation. Results showed that caregivers' perception of social support (MOS-SSS) increased over 32 weeks (p = 0.003) and there was a marginal trend of less care demand (ZBI) among caregivers. Better social support was observed with increasing caregiver age until 55 years. Younger caregivers (aged <55 years) experienced the greatest post-intervention improvement. The greatest engagement occurred early in the trial, declining sharply thereafter. The Verily Connect model improved caregivers' social support and appeared to ease caregiver demand.

Partnering with carers in the management of delirium in general acute care settings: An integrative review.

OBJECTIVES: Delirium is a common, preventable condition. However, delirium is poorly recognised and often missed because symptoms are misinterpreted, and risk factors overlooked by health-care professionals. Carers usually have intimate knowledge about the person they care for. Therefore, they are well placed within care teams to implement delirium prevention strategies, identify symptoms and support the early diagnosis of delirium. The aim of this integrative review was to synthesise findings from the published research reporting on partnering with carers in the management of delirium in general acute care settings. METHODS: Five databases (Medline-EBSCO, PubMed, PsycINFO, ProQuest, CINAHL and SCOPUS) were searched to identify primary research regarding partnering with carers in the management of delirium in acute care settings, and results were synthesised. PRISMA guidelines were adhered to, and quality appraisal was conducted using the Mixed Methods Appraisal Tool. RESULTS: All seven studies reported that partnering with carers was a viable strategy in the management of delirium to maximise outcomes for people at risk of or experiencing delirium and that increasing carers' knowledge of delirium was key. The synthesis of findings also identified two themes: Increasing knowledge and Effective partnerships. CONCLUSIONS: A collaborative approach to increasing carers' and nurses' knowledge about the management of delirium, coupled with education on how to develop therapeutic nurse-carer relationships, is important for ongoing effective partnerships in the management of delirium. Good communication supported effective partnerships, which enabled both nurses and carers the opportunity to express their needs and concerns and negotiate collaborative involvement in the management of delirium.

Person-Centred, Culturally Appropriate Music Intervention to Improve Psychological Wellbeing of Residents with Advanced Dementia Living in Australian Rural Residential Aged Care Homes.

This quasi-experimental, nonrandomized intervention study reports the effect of person-centred, culturally appropriate music on psychological wellbeing of residents with advanced dementia in five rural residential aged care homes in Australia. Seventy-four residents attended in person-centred music sessions and culturally appropriate group sessions. Interest, response, initiation, involvement, enjoyment, and general reactions of the residents were assessed using the Music in Dementia Assessment Scale (MiDAS), and interviews and focus groups were conducted with aged care staff and musicians. The overall effect of person-centred sessions at two-time points were: during the intervention-351.2 (SD 93.5); and two-hours post intervention-315.1 (SD 98.5). The residents presented a moderate to high level of interest, response, initiation, involvement, and enjoyment during the session and at post-intervention. However, the MiDAS sub-categories' mean scores differed between the time-points: interest (t59 = 2.8, p = 0.001); response (t59 = 2.9, p = 0.005); initiation (t59 = 2.4, p = 0.019); and involvement (t59 = 2.8, p = 0.007), indicating a significant decline in the effect of person-centred music over time. Interestingly, during the period of time, most of the residents were observed with no exhibitions of agitation (87.5%), low in mood (87.5%), and anxiousness (70.3%), and with a presentation of relaxation (75.5%), attentiveness (56.5%), and smiling (56.9%). Themes from qualitative data collected regarding culturally appropriate group music sessions were behavioural change, meaningful interaction, being initiative, increased participation, and contentment. The findings suggest that the integration of music into care plans may reduce the residents' agitation and improve their emotional wellbeing in rural aged care homes.

Web-Based Technologies to Support Carers of People Living With Dementia: Protocol for a Mixed Methods Stepped-Wedge Cluster Randomized Controlled Trial.

BACKGROUND: Informal carers play a significant role in supporting people living with dementia; however, carers in rural areas are often isolated, with limited access to support services. Although dementia-friendly communities provide valued support for carers, access to them is limited as they are few and geographically dispersed. OBJECTIVE: This study's aim was to increase support and services for rural informal carers of people living with dementia by using information and communication technologies accessed through an integrated website and mobile app-the Verily Connect app. The objective of this protocol is to detail the research design used in a complex study that was situated in a challenging real-world setting integrating web-based and on-ground technology and communication. Therefore, it is anticipated that this protocol will strengthen the research of others exploring similar complex concepts. METHODS: A stepped-wedge, open-cohort cluster randomized controlled trial was conducted to implement Verily Connect across 12 rural Australian communities. The Verily Connect intervention delivered web-based, curated information about dementia, a localized directory of dementia services and support, group and individual chat forums, and peer support through videoconference. During the implementation phase of 32 weeks, Verily Connect was progressively implemented in four 8-weekly waves of 3 communities per wave. Usual care, used as a comparator, was available to carers throughout the study period. Participants and researchers were unblinded to the intervention. There were 3 cohorts of participants: carers, volunteers, and staff; participants were recruited from their communities. The primary outcome measure was perceived carer social support measured using the Medical Outcomes Study-Social Support Survey. Volunteers and staff provided feedback on their participation in Verily Connect as qualitative data. Qualitative data were collected from all cohorts of participants through interviews and focus groups. Process evaluation data were collected through interviews and memos written by research staff. Data on the costs of implementing Verily Connect were collected by the research team members and evaluated by a health economist. RESULTS: Between August 2018 and September 2019, a total of 113 participants were recruited. There were 37 (32.7%) carers, 39 (34.5%) volunteers, and 37 (32.7%) health service staff. The study was complex because of the involvement of multiple and varied communities of carers, volunteers, health service staff, and research team members originating from 5 universities. Web-based technologies were used as intervention strategies to support carers and facilitate the process of undertaking the study. CONCLUSIONS: The Verily Connect trial enabled the testing and further development of a web-based approach to increasing support for carers of people living with dementia across a diverse rural landscape in Australia. This protocol provides an example of how to conduct a pragmatic evaluation of a complex and co-designed intervention involving multiple stakeholders. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618001213235; https://tinyurl.com/4rjvrasf. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/33023.

Aging, care and dependency in multimorbidity: how do relationships affect older Bangladeshi women's use of homecare and health services?

Gender issues can create major barriers to healthcare utilization for older women with multimorbidity, especially in developing countries like Bangladesh. Elderly rural women in Bangladesh, are the poorest of the poor, and the women with multimorbidity live in a regulated family atmosphere. This study explored the relationship dimensions of older women with multimorbidity in homecare and their utilization of health services. To gain a deeper understanding of these complex issues, a qualitative case study was conducted. Semi-structured, in-depth interviews were conducted with 11 health staff and 22 older women with multimorbidity, living in three residential communities of the Sylhet District, Bangladesh. Our analysis used critical thematic discourse, a technique developed from Axel Honneth's recognition-and-misrecognition theory. Seven relationship dimensions have been identified, and grouped under three major themes: intimate affairs [marital marginalization and parent-children-in law dynamics]; alienation in community relationships [patriarchal sibling relationships, neighborhood challenges, and gender inequality in interactions]; and legal disconnections [ignorance of rights and missed communication]. Our findings revealed a lack of understanding of the women's multimorbid care needs and patriarchal marginalization in family. This lack of understanding together with poor peer-supports in healthcare is perpetuated by misrecognition of needs from service providers, resulting in a lack of quality and poor utilization of homecare and health services. Understanding the high needs of multimorbidity and complexities of older women's relationships can assist in policy decisions. This study deepens our understanding of the ways gender inequality intersects with cultural devaluation to reduce the well-being of older women in developing countries.

Volunteers' Support of Carers of Rural People Living with Dementia to Use a Custom-Built Application.

There is great potential for human-centred technologies to enhance wellbeing for people living with dementia and their carers. The Virtual Dementia Friendly Rural Communities (Verily Connect) project aimed to increase access to information, support, and connection for carers of rural people living with dementia, via a co-designed, integrated website/mobile application (app) and Zoom videoconferencing. Volunteers were recruited and trained to assist the carers to use the Verily Connect app and videoconferencing. The overall research design was a stepped wedge open cohort randomized cluster trial involving 12 rural communities, spanning three states of Australia, with three types of participants: carers of people living with dementia, volunteers, and health/aged services staff. Data collected from volunteers (n = 39) included eight interviews and five focus groups with volunteers, and 75 process memos written by research team members. The data were analyzed using a descriptive evaluation framework and building themes through open coding, inductive reasoning, and code categorization. The volunteers reported that the Verily Connect app was easy to use and they felt they derived benefit from volunteering. The volunteers had less volunteering work than they desired due to low numbers of carer participants; they reported that older rural carers were partly reluctant to join the trial because they eschewed using online technologies, which was the reason for involving volunteers from each local community.

"The odds were stacked against me": a qualitative study of underrepresented minorities in surgical training.

BACKGROUND: The Royal Australasian College of Surgeons (RACS) is expected to provide surgical care to a diverse patient population across Australia and New Zealand (ANZ). To improve the quality-of-care individuals receive, the surgical workforce must reflect the population it serves. Achieving diversity within RACS will strengthen therapeutic relationships with patients and promote an inclusive culture. This study investigates the perspectives of underrepresented minority (URM) trainees to highlight barriers for the selection and completion of the RACS Surgical Education and Training (SET) program. METHODS: This qualitative study used online, semi-structured, in-depth interviews of URM trainees. Participants were recruited by self-identification and were invited to participate based on inclusion criterion. Interviews took place between August and October 2020, were transcribed and de-identified. Framework analysis was used to identify themes. FINDINGS: Eight participants from four surgical specialities were interviewed, six from Australia and two from New Zealand. There were six female and two male participants. The findings identified barriers that were grouped into eight broad areas: discouragement; structural racism, discrimination and unconscious bias; language barriers; policies and procedures; lack of role models; homophobia; sexual harassment and women in surgery. CONCLUSION: The findings offer guidance to RACS and the surgical community to explore new strategies to improve the experience of URM SET trainees. While on a small scale, the study draws directly on the URMs' experiences to inform strategies addressing equity, diversity and inclusion. The aim is to produce a diverse surgical workforce that better delivers healthcare services to a diverse population.

The outcomes of a person-centered, non-pharmacological intervention in reducing agitation in residents with dementia in Australian rural nursing homes.

BACKGROUND: There is limited best- practice evidence to address behavioral and psychiatric symptoms for those with dementia in Australian rural nursing homes. This study aims to evaluate the outcomes of a person-centered, non-pharmacological dementia care model, 'Harmony in the Bush', based on the Progressively Lowered Stress Threshold principles and person-centered music in rural Australia. METHODS: A quasi-experimental (nonrandomized, pre-post) intervention study was conducted in five rural nursing homes in Queensland and South Australia. Seventy-four residents with dementia participated in this intervention study, which yielded a sample power of 80%. Eighty-seven staff completed the Caregiver Stress Inventory at pre-post four-weeks of intervention. Staff training workshops focused on the theory of the Progressively Lowered Stress Threshold principles and delivery of person-centered care plan with integrated music intervention. We used reported changes in agitation of the residents, measured using Cohen- Mansfield Agitation Inventory, and staff's caregiving stress, using Caregivers Stress Inventory. This study adheres to the CONSORT guidelines. RESULTS: Mean age of residents with dementia was 82.4 (7.7) years and 69% were females. The mean age of admission was 80.1(8.4) years. Baseline measures indicated that 32.7% had mild- severe pain and 30.5% reported mild-severe sadness. The results showed statistically significant decline in aggressive behaviors, physically non-aggressive behaviors, verbally agitated behavior and hiding and hoarding. There was similar reduction in staff stress in the domains of aggressive behaviors, inappropriate behaviors, resident safety, and resource deficiency. CONCLUSIONS: The Harmony in the Bush model is effective in reducing agitation among dementia residents with significant reduction in staff stress levels in nursing homes in rural Australia. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR) on 20/2/2018 (Registration No: ACTRN12618000263291p). https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374458.

Personalised music for residents with dementia in an Australian rural aged-care setting.

OBJECTIVE: Personalised music reportedly has a positive effect on behaviour and mood in people living with dementia. This intervention has not been conducted in low-resourced or rural aged-care settings. We evaluated the effect of a non-therapist-led personalised music listening intervention on residents with dementia and workplace culture in a rural aged-care facility in South Australia. DESIGN: Qualitative pilot study. SETTING: Rural aged-care home in South Australia. PARTICIPANTS: Ten residents with dementia and 15 aged-care staff participated in this study. INTERVENTIONS: Ten residents participated in an 8-week music program. Four focus groups were conducted with aged-care staff post-intervention. A thematic analysis was used to identify emerging themes. MAIN OUTCOME MEASURE: Personalised music positively influenced resident's behaviour and well-being, social interaction and the workplace environment and culture, and served as a useful tool for personalised care. RESULTS: Three themes emerged: quality of life, personalised care and better aged-care environment. Personalised music positively influenced resident's behaviour and well-being, social interaction and the workplace environment and culture, and served as a useful tool for personalised care. CONCLUSION: Personalised music program is an effective, low-cost intervention to improve quality of life and personalised care of residents living with dementia, staff well-being, and a workplace and culture in low-resourced or rural aged-care settings.

Towards personalized care: Factors associated with the quality of life of residents with dementia in Australian rural aged care homes.

Quality of dementia care improves with a personalized approach to aged care, and knowledge of the disease process and unique care needs of residents with dementia. A personalized model of care can have a significant impact on the overall organizational culture in aged care homes. However, the dimensions of personalized aged care relating to dementia often remain under-managed. We aim to explore the factors that shape the dimensions of personalized dementia care in rural nursing homes using qualitative data of a mixed-method 'Harmony in the Bush' dementia study. The study participants included clinical managers, registered nurses, enrolled nurses and care workers from five rural aged care homes in Queensland and South Australia. One hundred and four staff participated in 65 semi-structured interviews and 20 focus groups at three phases: post-intervention, one-month follow-up and three-months follow-up. A multidimensional model of nursing home care quality developed by Rantz et al. (1998) was used in data coding and analysis of the factors. Three key themes including seven dimensions emerged from the findings: resident and family [resident and family centeredness, and assessment and care planning]; staff [staff education and training, staff-resident interaction and work-life balance]; and organization [leadership and organizational culture, and physical environment and safety]. A lack of consideration of family members views by management and staff, together with poorly integrated, holistic care plan, limited resources and absence of ongoing education for staff, resulted in an ineffective implementation of personalized dementia care. Understanding the dimensions and associated factors may assist in interpreting the multidimensional aspects of personalized approach in dementia care. Staff training on person-centered approach, assessment and plan, and building relationships among and between staff and residents are essential to improve the quality of care residents receive.

Exploring interprofessional education and collaborative practice in Australian rural health services.

This article explores how work-based interprofessional education (IPE) influences collaborative practice in rural health services in Australia. Using a qualitative case study design, three rural hospitals were the focal point of the project. Marginal participant observations (98 hours) and semistructured interviews (n = 59) were undertaken. Participants were medical practitioners, nursing and midwifery professionals, physiotherapists, paramedics, social workers and administrative staff, who provided services in relation to each hospital. Data in the form of audio recordings and field notes, including researcher reflections were recorded over a three-year period. Whilst this study comprised of three phases, this article explores the extent to which collaborative practice was present or not before and after IPE. An inductive content analysis resulted in the following themes: Conceptualizing Collaborative Practice, Profession-Driven Education, and Professional Structures and Socialization. Community of practice theory is used to explore the barriers created through profession-based communities of practice.

Screening for burn-out in Australian medical students undertaking a rural clinical placement.

OBJECTIVE: To investigate Australian medical student burn-out during rural clinical placement. Second, to examine the association between perceived burn-out and rural career intent at the time of finishing their rural placement. DESIGN, SETTINGS AND PARTICIPANTS: The 2016 Federation of Rural Australian Medical Educators evaluation survey is a cross-sectional study of medical students from 17 Australian universities. Specifically, those medical students who completed a full academic year or more at a Rural Clinical School (RCS). Responses from 638 medical students from regional Australia were analysed in the study of all eligible 756 medical students (response rate 84.3%). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary objective was to determine self-reported burn-out (emotional exhaustion) in rural placements for medical students. Secondary outcome measures were designed to explore interactions with rural practice self-efficacy and rural intentions. Logistic regression models explored factors associated with burn-out. RESULTS: 26.5% of students reported experiencing burn-out during a rural placement. Factors associated with burn-out were female gender, rural origin, low preference for RCS, stress in the year prior to a rural clinical placement, perceived social isolation during rural placement and lower rural practice self-efficacy. Burn-out was not associated with rural career intentions. Social isolation and low rural self-efficacy were independently associated with burn-out during rural placement and together explained 10% of variance in burn-out (Model Nagelkerke R2=0.23). CONCLUSION: Burn-out during rural placement may be a consequence of stress prior to a medical school placement. Social isolation and rural self-efficacy are amendable factors to mitigate medical student burn-out during rural placements.

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.

Emergency rural obstetric transfers in South Australia: a review of the clinical and precipitating factors.

INTRODUCTION: The provision of critical management of obstetric emergencies is a vital service for rural women and their families. Emergency obstetric transfers are indispensable to reduce maternal and neonatal mortality and morbidity because local rural hospitals often do not have the resources or expertise to manage both maternal and neonatal outcomes. However, the transfer of a rural pregnant woman to a higher level, tertiary perinatal centre (TPC) is often stressful for the patient and costly for health services. Currently, little is known about the main reasons for obstetric transfers in rural South Australia, and there is even less information about the management of mothers and babies once they arrive at their destination. The present guidelines for informing the necessity of transferring from a rural or remote area to a TPC are unclear. This study aims to describe the clinical reasons for obstetric transfers from a rural area in South Australia and explore predictive factors of likelihood of delivery on transfer. Additionally, this study aims to determine the outcomes of transfers in terms of location of delivery, timing of delivery and to explore the association between delivery after transfer and clinical reasons for transfer. METHOD: All women from the Riverland region of South Australia who were transferred antenatally at >20 weeks gestational age for an acute admission to a TPC over a 5-year period were included in a retrospective review. Participants were determined from hospital coding data, and medical case notes were retrieved for all participants. The demographic and clinical data, including details of the emergency presentation and outcomes of women transferred to a tertiary hospital, were analysed with descriptive statistics (mean, standard deviation). A logistic regression was performed for predictive factors associated with delivery on transfer. RESULTS: A total of 160 patients were transferred antenatally. A minority of participants delivered on admission (35%). Of the women who were discharged undelivered, 43% eventually delivered at their rural hospital and the remainder delivered later in a tertiary hospital as part of a planned admission. The most common diagnoses for transfer were preterm labour, premature preterm rupture of membranes, antepartum haemorrhage and placental disorders. Delivery on transfer was associated with preterm premature rupture of membranes and pre-eclampsia. Likelihood of delivery on transfer was not increased with preterm gestation, cervical dilation or other presenting diagnosis. There was not an association of increased number of indications for transfer and likelihood of delivering after transfer. CONCLUSION: This study suggests that the rural doctor workforce in the Riverland region appears to be well skilled at identifying obstetric emergencies despite the lack of guidance around what constitutes a high risk perinatal situation. Furthermore, this study quantifies the number of women who would potentially require support services associated with rural perinatal transfers from this area. There was a comparatively lower rate of delivery on transfer and, as such, these women eventually delivered their babies either at their hospital of origin or returned to a metropolitan hospital as part of a planned admission for delivery. Further research is needed about the practical implications of transferring pregnant women to tertiary centres and clinical decision-making tools to improve this process.

The power of simulation: a large-scale narrative analysis of learners' experiences.

CONTEXT: Simulation-based education (SBE) includes a broad spectrum of simulation activities, which are individually well researched. An extensive literature reports on SBE methods, topics and modalities, but there are limited studies investigating how simulation as a holistic phenomenon promotes learning. This study seeks to identify the ways in which health professionals narrate powerful SBE experiences and through this to understand in what ways SBE may influence learning. METHODS: Three hundred and twenty-seven narratives about powerful learning through SBE were gathered from participants' online reflections from a national faculty development programme in SBE. Narrative and thematic analyses were conducted on included texts, using 'transformative learning theory' as a sensitising notion. RESULTS: Narratives were categorised into the following categories: progress (267/327 = 81%); transformation (25/327 = 8%); practice (27/328 = 8%); and humiliation (8/327 = 2%). Recurrent features across narrative categories were as follows: early experiences in training; dramatic scenarios; developing appreciation of SBE; highly emotional experiences; things that 'went wrong'; and ongoing reflection. Themes regarding mechanisms that supported learning were as follows: verisimilitude; feedback, debriefing and facilitation; observation of self and others; repetition of activities; and role-playing the patient. CONCLUSIONS: The results generally support the notion that SBE is experienced as a holistic phenomenon, rather than separate modalities. The narrative categories, recurrent features and learning themes tended to work across all simulation modalities, with the exception of 'being in the patient's shoes' being supported by role-play in particular. Although powerful experiences were not necessarily transformative ones, they often occurred at formative stages of training. There was a strong sense that things going wrong in simulation scenarios (and the associated emotions and reflection) were a key part of learning. This underlines SBE's potential role in helping learners see fallibility as part of professional practice.

Practice intentions at entry to and exit from medical schools aspiring to social accountability: findings from the Training for Health Equity Network Graduate Outcome Study.

BACKGROUND: Understanding the impact of selection and medical education on practice intentions and eventual practice is an essential component of training a fit-for-purpose health workforce distributed according to population need. Existing evidence comes largely from high-income settings and neglects contextual factors. This paper describes the practice intentions of entry and exit cohorts of medical students across low and high income settings and the correlation of student characteristics with these intentions. METHODS: The Training for Health Equity Network (THEnet) Graduate Outcome Study (GOS) is an international prospective cohort study tracking learners throughout training and ten years into practice as part of the longitudinal impact assessment described in THEnet's Evaluation Framework. THEnet is an international community of practice of twelve medical schools with a social accountability mandate. Data presented here include cross-sectional entry and exit data obtained from different cohorts of medical students involving eight medical schools in six countries and five continents. Binary logistic regression was used to create adjusted odds ratios for associations with practice intent. RESULTS: Findings from 3346 learners from eight THEnet medical schools in 6 countries collected between 2012 and 2016 are presented. A high proportion of study respondents at these schools come from rural and disadvantaged backgrounds and these respondents are more likely than others to express an intention to work in underserved locations after graduation at both entry and exit from medical school. After adjusting for confounding factors, rural and low income background and regional location of medical school were the most important predictors of intent to practice in a rural location. For schools in the Philippines and Africa, intention to emigrate was more likely for respondents from high income and urban backgrounds. CONCLUSIONS: These findings, from a diverse range of schools with social accountability mandates in different settings, provide preliminary evidence for the selection and training of a medical workforce motivated to meet the needs of underserved populations. These respondents are being followed longitudinally to determine the degree to which these intentions translate into actual practice.