Health Professions Educators' System-Oriented Roles as Educational Advocate, Quality Improver, and Broker.

INTRODUCTION: Health professionals have many facets to their educational role. Although the teaching and student support dimensions of health professionals' educational role are highly visible in the literature, other nontraditional elements are not. This study presents a broader conceptualization of health professionals' educational role, with a focus on the strategic dimensions of their role. METHODS: Participants were health professionals from different clinical backgrounds and teaching settings, with a formal role in education. Data were collected using a survey (n = 41) and interviews (n = 9), and this article focuses on reporting the qualitative findings of this study. Thematic analysis was used for data interpretation. RESULTS: Health professionals have three strategic dimensions to their educational role. The first strategic dimension is educational advocacy, which is aimed at championing education at different levels and parts of the educational system and building educational capacity. The second strategic dimension is educational quality improvement which is focused on shifting narratives around education and educational change in health service settings and leveraging educational evidence. The final strategic dimension is educational brokerage which is oriented at connecting clinical and educational communities and building trust and consensus. DISCUSSION: Beyond the microlevel of learning and teaching, health professionals engage in strategic work that is focused on the broader educational mission within health. Continuing professional development initiatives can empower health professionals to optimize these strategic and system-focused educational roles and responsibilities.

Supporting workforce practice change: protocol for a pilot study of a motivational interviewing virtual client software tool for health professionals.

INTRODUCTION: Motivating behavioural change during client consultations is of crucial importance across all health professions to address the growing burden of chronic conditions. Yet health professionals often lack the skills and confidence to use evidence-based counselling interventions to support clients' behavioural change and mobilise clients' resources and self-efficacy for change to address their long-term needs. AIMS: This pre-post pilot study will develop a motivational interviewing (MI) virtual client training tool for health professionals and test the effectiveness of the educational content and usability of the virtual client interaction. METHODS AND ANALYSIS: Postgraduate students across a range of health disciplines will be recruited. Data assessing attitudes towards preventive healthcare will be collected using a modified version of the Preventive Medicine Attitudes and Activities Questionnaire. Conversations with the virtual client will be analysed using the Motivational Interviewing Treatment Integrity code to assess changes in MI skills. The System Usability Scale will be used to assess the usability of the virtual client training tool. ETHICS AND DISSEMINATION: This protocol was approved by the Flinders University Social and Behavioural Research Ethics Committee in May 2019. The results of the pilot study will inform the development of an avatar-based mobile application consisting of MI teaching and interactions with a generic virtual client that can be easily adapted to multiple scenarios.

Exploring the relationship between body mass index, mental health and outcomes of a regional physiotherapy-led post-arthroplasty review clinic.

OBJECTIVE: To determine whether 12-month hip and knee outcomes of a regional arthroplasty clinic were comparable to results from metropolitan-based clinics, and to explore a possible relationship between body mass index and depression to identify groups at risk of not achieving optimal outcomes. DESIGN: A prospective observational study. SETTING: A regional physiotherapy-led post-arthroplasty review clinic. PARTICIPANTS: Patients after hip or knee replacement. INTERVENTIONS: Patients underwent either total hip or total knee joint arthroplasty. MAIN OUTCOME MEASURES: SF-12 Health Survey, Oxford Hip/Knee Scale, 10-minute walk test, knee range of motion, body mass index and the Hospital Anxiety and Depression Scale. RESULTS: Physical outcomes were comparable to those reported by metropolitan-based clinics. People with a high body mass index showed most improvement in the severity of depression compared to those with a lower body mass index. CONCLUSION: It is important to consider the long-term effects of obesity on arthroplasty outcomes.

Embedding and sustaining motivational interviewing in clinical environments: a concurrent iterative mixed methods study.

BACKGROUND: Motivational interviewing (MI) is internationally recognised as an effective intervention to facilitate health-related behaviour change; although, how it is best implemented and maintained in everyday clinical practice is not so clear. The aim of this study is to understand how MI as an intervention can be embedded and sustained in the clinical practice and learning environments. METHODS: A concurrent iterative mixed methodology was utilised. Data collection occurred in two parts: a scoping review to identify reported barriers and enablers to embedding and sustaining MI in healthcare settings, and a survey of health professionals at an international clinical educator workshop on the topic. Results from both methods were integrated at the analysis phase ('following a thread') to understand how MI is embedded and the fidelity sustained in the clinical environments. Complexity theory as a conceptualising framework was utilised. RESULTS: Eleven studies were included, and 30 health professionals were surveyed. Sustainability of MI at micro-clinical levels can be fostered through use of enabling technology, focus on patient-centred care, personnel development and process improvement. At the meso-organisational level, developing shared vision, creating opportunities and an organisational culture supportive of continuous learning are relevant issues. At the macro levels, adopting systems thinking and a learning organisation approach is important for sustaining MI. CONCLUSIONS: In addressing the recognised barriers to embedding and sustaining MI in health service provisions, clinical educators could potentially play a central role as change agents within and across the complex clinical system.

The clinical educator and complexity: a review.

BACKGROUND: Complexity science perspectives have helped in examining fundamental assumptions about learning and teaching in the health professions. The implications of complexity thinking for how we understand the role and development of the clinical educator is less well articulated. This review article outlines: the key principles of complexity science; a conceptual model that situates the clinical educator in a complex system; and the implications for the individual, organisation and the system. KEY FINDINGS: Our conceptual model situates the clinical educator at the centre of a complex and dynamic system spanning four domains and multiple levels. The four domains are: personal (encompassing personal/professional needs and expectations); health services (health agencies and their consumers); educational (educational institutions and their health students); and societal (local community/region and government). The system also comprises: micro or individual, meso or organisational, and macro or socio-political levels. CONCLUSION: Our model highlights that clinical educators are situated within a complex system comprising different agents and connections. It emphasises that individuals, teams and organisations need to recognise and be responsive to the unpredictability, interconnectedness and evolving nature of this system. Importantly, our article also calls for an epistemological shift from faculty development to capacity building in health professions education, aimed at developing individual, team, organisational and system capabilities to work with(in) complexity. Clinical educators are situated within a complex system comprising different agents and connections.

Early dynamic ultrasound for neonatal hip instability: implications for rural Australia.

BACKGROUND: Neonatal instability of the hip (NIH), where the femoral head can move away from the acetabulum, in the first weeks of life, is an important risk factor for developmental dysplasia of the hip (DDH). In rural areas in Australia, there is a recent trend to increased late diagnosis of DDH. Clinical screening of infant hips, a common practice in Australia, is experience dependent. Best practice early screening techniques are still debated with different techniques and timing used internationally. This systematic review examines early dynamic ultrasound (eDUS) screening for hip instability in the first 6 weeks after birth, and the early interventions informed by these findings and considers the findings for the context of rural Australia. METHODS: The Cochrane Library, Medline, CINAHL and PEDro were searched for original research or systematic reviews, and clinical studies 1998 to 2015 involving dynamic ultrasound. Critical Appraisal Skills Programme tools were used to appraise the studies. RESULT: Nineteen studies were included. Early Dynamic Ultrasound (DUS) is consistently described as a reliable assessment of NIH. Early DUS is recommended for risk factors including geographical areas of high prevalence. Approaches to early intervention of hips with excessive movement are somewhat discipline-related and include: primary prevention (advice), secondary prevention (abduction supports), and conservative management (removable splints). CONCLUSIONS: In the context of increased prevalence of DDH in rural Australia, contemporary evidence suggests that introduction of early DUS could provide rural infants with more effective screening than clinical examination alone. Targeted early advice about posturing and simple removable supports to abduct infant hips could prevent some cases of DDH in rural Australia.

Are Australian medical students being taught to teach?

BACKGROUND: The current global trend of growth in medical training is increasing the demand for the teaching and supervision of medical students and junior doctors. If well trained and supported, junior doctors and medical students represent an important teaching resource. Unfortunately, there is limited evidence available on whether Australian medical students are equipped with teaching skills. This study aimed to gain insight into the type and amount of teaching-skills training and peer-to-peer teaching present in Australian medical schools. METHODS: A survey of Australian medical schools was conducted between May and December 2014. An online 22-item questionnaire was sent to all 19 Australian medical schools. RESULTS: The response rate to the questionnaire was 100 per cent. Eleven Australian medical schools reported offering a teaching-skills programme, of which five were described as compulsory formal programmes. Eight schools did not offer such a programme, citing time restraints and other subjects taking higher priority. Formal peer-to-peer teaching opportunities were described by 17 schools, with 13 offering this electively. Two schools reported that they did not offer such opportunities because of time restraints, the belief that the quality of expert teaching is superior and because of a lack of staffing. The demand for the teaching and supervision of medical students and junior doctors is increasing CONCLUSIONS: Despite the increasing number of medical students and subsequently junior doctors in Australia, a minority of Australian medical schools report including a formal, compulsory teaching-skills programme. These results may imply a lost opportunity to use the positive effects of teaching-skills programmes, and are in line with studies from other countries.

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.

Towards equity and sustainability of rural and remote health services access: supporting social capital and integrated organisational and professional development.

BACKGROUND: Access to rural health services is compromised in many countries including Australia due to workforce shortages. The issues that consequently impact on equity of access and sustainability of rural and remote health services are complex. DISCUSSION: The purpose of this paper is to describe a number of approaches from the literature that could form the basis of a more integrated approach to health workforce and rural health service enhancement that can be supported by policy. A case study is used to demonstrate how such an approach could work. Disjointed health services are common in rural areas due to the 'tyranny of distance.' Recruitment and retention of health professionals in rural areas and access to and sustainability of rural health services is therefore compromised. Strategies to address these issues tend to have a narrow focus. An integrated approach is needed to enhance rural workforce and health services; one that develops, acknowledges and accounts for social capital and social relations within the rural community.

Literature review of teaching skills programs for junior medical officers.

OBJECTIVE: The aim of this review was to assess the current evidence regarding the efficacy of teaching skills programs for junior medical officers. We aimed to compare and contrast these results with findings from previous literature reviews, the last of which were published in 2009. METHODS: In order to capture studies since the last published literature reviews, five databases and grey literature were searched for publications from January 2008 to January 2015. A search for literature reviews without using the timeframe limitation was also performed. RESULTS: The search from January 2008 to January 2015 resulted in the inclusion of 12 studies. Five systematic reviews of the topic were found which included 39 individual studies that were also analysed. Nearly all studies reported positive effects. Twenty nine studies reported change in attitudes, 28 reported modification in knowledge, 28 reported change in behaviour, 6 reported change in the organisation and two reported change in program participant's students. There were substantial threats of bias present. CONCLUSIONS: The literature reviewed demonstrated many positive effects of teaching skills programs, which supports their utilization. However, high level outcomes need to be evaluated over longer periods of time to establish their true impact. An organisation specific approach to these programs needs to occur using sound course design principles, and they need to be reported in evaluation trials that are designed with robust methodology.

The 'rural pipeline' and retention of rural health professionals in Europe's northern peripheries.

The major advance in informing rural workforce policy internationally over the past 25 years has been the recognition of the importance of the 'rural pipeline'. The rural pipeline suggests that people with 'rural origin' (who spent some childhood years in rural areas) and/or 'rural exposure' (who do part of their professional training in rural areas) are more likely to select rural work locations. What is not known is whether the rural pipeline also increases the length of time professionals spend in rural practice throughout their careers. This paper analyses data from a survey of rural health professionals in six countries in the northern periphery of Europe in 2013 to examine the relationship between rural origin and rural exposure and the intention to remain in the current rural job or to preference rural jobs in future. Results are compared between countries, between different types of rural areas (based on accessibility to urban centres), different occupations and workers at different stages of their careers. The research concludes that overall the pipeline does impact on retention, and that both rural origin and rural exposure make a contribution. However, the relationship is not strong in all contexts, and health workforce policy should recognise that retention may in some cases be improved by recruiting beyond the pipeline.

Retention policies for allied health professionals in rural areas: a survey of private practitioners.

INTRODUCTION: Retention of rehabilitation therapists (RTs) in rural areas is a growing problem in rural Australia. Current literature demonstrates that private allied health professionals in general remain longer in rural areas than those working in the public sector. However, government focus to enhance retention has been on those employed in the public sector, offering private practitioners little incentive to stay rural. There has been an absence of policy commitment to attracting private professionals to rural areas or offering rural practitioners options for mixing private and public service. This study aimed to explore the thoughts and perceptions of private RTs in rural areas concerning their incorporation into broader rural health policies and concomitant programs. METHODS: An online survey was sent to a purposively chosen sample of RTs in rural Victoria. Participants were selected from publicly available internet listings and were contacted via email. Possible participants were limited to those who had an email address and to those on three available professional lists (physiotherapy, occupational therapy and speech pathology). The survey consisted of 29 questions: eight related to the perceived place that practitioners in rural areas occupy; eight related to their professional practice; seven related to retention policies; two related to education and training; and four were demographic questions. RESULTS: A total of 72 RTs completed the survey and were included in the analysis (40% response rate). The overwhelming majority of respondents were in favour of having partnerships between private and public practice in rural and regional areas and of governments developing programs to facilitate such partnerships. In total, 26% of respondents currently worked in some form of partnership with public agencies. There was also a reasonable response to the use of government incentives to retain and attract private practitioners to rural and regional areas. CONCLUSIONS: The results of this research indicate that many private RTs in Victoria perceived their greater involvement in the delivery of public health in rural areas in a positive manner.

Why did they leave and what can they tell us? Allied health professionals leaving rural settings.

The aim of this paper is to explore the lack of retention of allied health professionals in rural areas in Victoria, Australia. A structured telephone interview was used to elicit responses from 32 allied health professionals from south-west, central-west and north-east Victoria about their working experiences and reasons for resignation. The data revealed that work experiences in rural areas can be summarised within three domains: organisational, professional and personal/community. Under the organisational domain the participants were mainly focussed on the way in which their work arrangements require them to be both more generalist in their approach to day-to-day work, and more expansive in shouldering management style functions in the workplace. Under the professional domain there were three major issues; clinical, career and education/training. The personal/community domain focussed on issues to do with their affinity for their workplace as well as their location in a rural place. The attempts by government to address some of the leading factors for retention of allied health professionals are perhaps too narrowly focussed on the public sector and could encompass a wider approach.

Supporting self-management of chronic health conditions: common approaches.

OBJECTIVE: The aims of this paper are to provide a description of the principles of chronic condition self-management, common approaches to support currently used in Australian health services, and benefits and challenges associated with using these approaches. METHODS: We examined literature in this field in Australia and drew also from our own practice experience of implementing these approaches and providing education and training to primary health care professionals and organizations in the field. RESULTS: Using common examples of programs, advantages and disadvantages of peer-led groups (Stanford Courses), care planning (The Flinders Program), a brief primary care approach (the 5As), motivational interviewing and health coaching are explored. CONCLUSIONS: There are a number of common approaches used to enhance self-management. No one approach is superior to other approaches; in fact, they are often complimentary. PRACTICE IMPLICATIONS: The nature and context for patients' contact with services, and patients' specific needs and preferences are what must be considered when deciding on the most appropriate support mode to effectively engage patients and promote self-management. Choice of approach will also be determined by organizational factors and service structures. Whatever self-management support approaches used, of importance is how health services work together to provide support.

The association of levels of physical activity with metabolic syndrome in rural Australian adults.

BACKGROUND: Physical activity (PA) reduces risk factors related to metabolic syndrome. Rurality influences the way people incorporate physical activity into daily life. The aim of this study is to determine the association of PA level with metabolic syndrome in a rural Australian population. The influence of adiposity on these associations is also investigated. METHODS: Three cross-sectional population health surveys were conducted in south-east Australia during 2004-2006 using a random population sample (n = 1563, participation rate 49%) aged 25-74 years. PA was assessed via a self-administered questionnaire, and components of the metabolic syndrome via anthropometric measurements taken by specially trained nurses and laboratory tests. RESULTS: Approximately one-fifth of participants were inactive in leisure-time and over one-third had metabolic syndrome (men 39%, women 33%; p = 0.022). There was an inverse association between level of PA and metabolic syndrome (p < 0.001). Men who were inactive in leisure-time were more than twice as likely and women more than three times as likely to have metabolic syndrome compared with those having high PA. Body mass index (BMI) is a mediating factor in the association between level of PA and metabolic syndrome. CONCLUSION: Some PA is better than none if adults, particularly women, are to reduce their risk of metabolic syndrome and associated vascular diseases. Specialised interventions that take rurality into consideration are recommended for adults who are inactive.

From student to therapist: follow up of a first cohort of Bachelor of Occupational Therapy students.

AIM: This study aimed to investigate the perception of graduate students on their preparation for practice, at 7 months post graduation. METHOD: Using an anonymous postal questionnaire, 18 respondents (58% response rate) provided data on the nature of current employment, the experience as a graduate therapist, and perceptions of their undergraduate experience in preparing them for practice. RESULTS: Fifty percent of the respondents were practising in a rural environment. There was a significant positive relationship between respondents perception of their curriculum and fieldwork experiences and their preparation for practice (rho = 0.52, p < 0.05, and rho = 0.55, p < 0.05, respectively). Of the fieldwork experiences, respondents rated block placements as more beneficial to practice than non-traditional placements. However, a correlational analysis showed the non-traditional placement was significantly related to preparation for practice (rho = 0.54, p < 0.05). On a seven-point Likert scale, respondents rated themselves from 5.2 to 5.7 for perceived self-competence as a newly graduated practitioner with community-based graduates having the higher rating. Confidence in clinical decision-making was rated 5.0 to 5.6 with community-based graduates having higher rating. Respondents reported a positive perception that the undergraduate program prepared them to enter the workforce and practise as an occupational therapist (mean ratings 5.5 to 6.2). CONCLUSION: Respondents felt adequately prepared to enter the occupational therapy profession and workforce. Strengths and weaknesses in their preparation are discussed as well as the need for further research.

Workload capacity measures for estimating allied health staffing requirements.

Workforce planning methodologies for the allied health professions are acknowledged as rudimentary despite the increasing importance of these professions to health care across the spectrum of health services settings. The objectives of this study were to (i) identify workload capacity measures and methods for profiling allied health workforce requirements from a systematic review of the international literature; (ii) explore the use of these methods in planning workforce requirements; (iii) identify barriers to applying such methods; and (iv) recommend further action. Future approaches to workforce planning were explored through a systematic review of the literature, interviews with key stakeholders and focus group discussions with representatives from the different professional bodies and health agencies in Victoria. Results identified a range of methods used to calculate workload requirements or capacity. In order of increasing data demands and costliness to implement, workload capacity methods can be broadly classified into four groups: ratio-based, procedure-based, categories of care-based and diagnostic or casemix-based. Despite inherent limitations, the procedure-based measurement approach appears to be most widely accepted. Barriers to more rigorous workforce planning methods are discussed and future directions explored through an examination of the potential of casemix and mixed-method approaches.

Exploring the barriers and enablers to attendance at rural cardiac rehabilitation programs.

OBJECTIVE: The objectives of this study were to: (i) identify local barriers and enablers to the uptake of hospital-based cardiac rehabilitation (CR) programs, and (ii) identify preferred alternatives for the delivery of CR. DESIGN: A questionnaire administered by local CR coordinators and focus groups facilitated by the research team. SETTING: Six regional hospitals in south-west Victoria offering hospital-based CR programs. PARTICIPANTS: Patients and their carers referred to and eligible for local CR programs; health professionals working within local CR programs. MAIN OUTCOMES MEASURES: CR attendees and decliners demographics, patient and health professional perceived factors which contribute to enabling hospital-based CR attendance, patient and health professional perceived barriers to CR attendance, and receptiveness and preferences for alternative modes of CR delivery. RESULTS: This study identified distance to travel to hospital-based CR programs the only statistically significant factor in determining uptake of CR. Easy access to transport (63%) and to a lesser extent family support (49%) and work flexibility (43%) were the primary enablers to attendance. Of the 97 study participants, 38% were receptive to alternative CR methods such as programs in outlying communities, evening facility-based programs, home and GP based programs, telephone support and a patient manual/workbook. CONCLUSIONS: The results of this study provide valuable information for designing strategies to increase utilisation and improve patient acceptability of existing hospital-based CR programs. It provides a basis for pilot testing alternative modes of CR program delivery for cardiac patients in rural areas unable to access hospital-based CR.

Rethinking policies for the retention of allied health professionals in rural areas: a social relations approach.

OBJECTIVE: Retaining allied health professionals in rural areas is a recognised problem. Generally the literature has concentrated on three elements: practitioner needs, community needs and organisational needs. There has been little attempt to focus other types of social relations in which health practitioner retention and recruitment takes place. The aim of this paper is to question the present dominant hierarchical approach taken in relation to the retention of allied health professionals in rural localities. METHODS: The data derives from a survey in Southwest Victoria, Australia. The sample was purposive rather than representative as it was intended to be exploratory in nature rather than definitive. RESULTS: The data indicates that there is a greater tendency for allied health professionals in private practice to be retained in rural areas than those in the public sector. CONCLUSION: The paper concludes by raising some questions about the pertinence of present models for regional health initiatives since they are locked into a bureaucratic model where relationships are hierarchical and asymmetrically controlled.