An Exploratory Study Of Factors Influencing Pakistani Physicians' Retention And Resettlement Career Decisions.

Background: The recruitment, retention and migration of health workers is a global phenomenon. The literature shows push factors associated with leaving rural areas and developing countries in general are explored in depth. However importantly, some health workers behave differently and decide to stay in or return to a developing country. Less is known about the reasons/ pull factors of this groups' decision making. Methods: This paper aims to explore the perceptions of Pakistani physicians regarding their career decisions to remain in their country, or resettle back after working abroad for some time. Thirteen Pakistani physicians were interviewed via telephones who were working in Pakistan and Australia. Results: The motivation for Pakistani physicians to remain or resettle back into their country stems from the perceived better quality of life in Pakistan compared to the better standard of life overseas. Other reasons include a perceived differentiation between locals and non-locals abroad and the availability of a permanent job in Pakistan. Conclusion: The main factors that contributed to Pakistani physicians' retention and resettlement decisions were mostly personal and family or societal factors and there was a minimal role for professional or health system related factors in their career decisions, except for the availability of permanent jobs in Pakistan.

Models and Interventions to Promote and Support Engagement of First Nations Women with Maternal and Child Health Services: An Integrative Literature Review.

BACKGROUND: Studies show that participation in maternal and child health (MCH) services improves health outcomes for First Nations families. However, accessing MCH services can be associated with fear, anxiety, and low attendance at subsequent appointments. OBJECTIVE: To identify the existing knowledge of models/interventions that support engagement of First Nations women with MCH services in the child's first five years. METHODS: An integrative review was undertaken of full-text, peer-reviewed journal articles and grey literature, which were analysed to identify barriers and enabling factors that influenced the engagement of First Nations families with MCH services. RESULTS: Enabling factors that influenced the engagement with MCH services included service models/interventions that are timely and appropriate, and effective integrated community-based services that are flexible, holistic, culturally strong, and encourage earlier identification of risk and further assessment, intervention, referral, and support from the antenatal period to the child's fifth birthday. Barriers to engagement included inefficient communication, lack of understanding, cultural differences between the client and the provider, poor continuity of care, limited flexibility of service delivery to meet individual needs, and a health care model that does not recognise the importance of the social determinants of health and wellbeing. DISCUSSION: Timely, effective, holistic engagement with First Nations women during their child's first 2000 days, which respects their culture and facilitates genuine partnerships built on co-design and shared decision making with the indigenous community, needs to be an essential part of the MCH service model if health care providers seek to practice within First Nations communities. CONCLUSION: Improving engagement with MCH services is important for First Nations families, nursing practice, and public health.

Motivational Factors Influencing Retention of Village Health Workers in Rural Communities of Bhutan.

Village health workers (VHWs) are the first contact extending vital health services to unreached and underserved communities in Bhutan. VHWs truly embody the principles of primary health care and are effective catalysts in promoting community health. This study identifies and confirms factors motivating VHWs to remain in the health care system. This is a quantitative study with a cross-sectional survey design. Two-stage cluster sampling was used with VHWs from 12 districts representing 3 regions of Bhutan. Data were collected using pretested semistructured questionnaires. Confirmatory factor analysis was used for data analysis. Findings reveal a 4-factor model of motivations among VHWs that includes social, personal, job related, and organizational factors. Among these, the social factor most significantly motivates VHWs to remain in the health care system. VHW motivation can be further fostered by providing a holistic combination of financial and nonfinancial incentives that recognize intrinsic needs and empower innate altruism.

Leadership and management competencies required for Bhutanese primary health care managers in reforming the district health system.

OBJECTIVE: This study aims to identify the required management competencies, current competency levels, and strategies for improving the management competencies of Bhutanese primary health care (PHC) managers. METHODS: A quantitative method with a cross-sectional survey using self-administered questionnaires. This study recruited 339 PHC managers across Bhutan. The data were analyzed using statistical software. RESULTS: This study identified three competency domains and seven key sub-domain competencies. People domain was perceived to be the highest required competency with a mean score of 4.2376, followed by execution (4.1851), and the transformation (4.0501) domains. For the seven key sub-domains, the communication sub-domain (4.3220) was perceived as the highest required competency, followed by professionalism (4.2967), managing change (4.1776), relationship building (4.1686), analytical thinking (4.1091), leadership (4.0980), and innovative thinking (3.9794). The current competency levels of PHC managers in domains and sub-domain competencies were the people domain (3.7322), execution (3.6471), and the transformation (3.5554). For the sub-domains, communication (3.8092), professionalism (3.7939), relationship building (3.6603), analytical thinking (3.6396), leadership (3.5805), managing change (3.5723), and innovative thinking (3.4543). CONCLUSION: Findings of Bhutan health managers' competencies are consistent with the findings of other international contexts. This study suggests that agencies responsible for health system need to focus more on the competencies defined by the study to positively influence health leadership and management development interventions.

Identifying and confirming demotivating factors for village health workers in rural communities of Bhutan.

BACKGROUND: Bhutan achieved over 95% of health coverage through its primary health care network and geared towards achieving and ensuring Universal Health Coverage. About 62.2% of the Bhutanese people are rural dwellers, living in villages. Village health workers (VHWs) are essential for primary health care delivery at the community level in order to bridge the gap between the health care system and the communities. However, increasing numbers of VHWs leaving the health care system remain a challenge for Bhutan. This study intends to find existing problems of motivation and retention among VHWs in Bhutan and to devise appropriate strategies for making effective policy interventions. METHODS: This quantitative study with a cross-sectional survey design aims to determine demotivating factors. One stage cluster sampling technique was applied for VHWs from 12 districts in three regions. Data were collected by the trained enumerators using a pre-tested semi-structured questionnaire. RESULTS: The Confirmatory factor analysis identified and confirmed a four-factor model of demotivation among VHWs in Bhutan. Among the four factors, the social factor was the main factor for VHWs leaving the health care system. However, the holistic combination of both financial and non-financial motivator needs to be taken into consideration. The content analysis revealed six areas of recommendation for improving motivation and retention among VHWs. CONCLUSION: The study concluded that managers and policymakers must give more emphasis to non-financial motivators through the holistic approach to existing altruism and intrinsic needs.

The role of rural nurse managers in supporting new graduate nurses in rural practice.

AIM: To investigate the nature and timing of support available to new graduate nurses within a rural transition to practice programme. BACKGROUND: For new graduates in rural practice successful transition is complicated by the unique role of the rural nurse, staff ratios and resources within rural environments. Little is known about the support needs of graduates working in rural health services, or who is best placed to provide support during their transition. METHOD: This was a qualitative case study, using individual interviews with new graduate nurses at 3, 6 and 9 months milestones during a 12-month rural transition to practice programme plus interviews with experienced rural nurses who were employed in rural health agencies where the new graduate nurses were employed. RESULTS: Graduates in rural health services rely on nurse unit managers and nurse managers for feedback, support and debriefing, provision of emotional support, advocacy, openness, encouragement and protection from organisational requests and demands during the transition to rural nursing practice. CONCLUSIONS: Nurse managers play an important role in rural health services in the provision of support for new graduate nurses. IMPLICATIONS FOR NURSING MANAGEMENT: As clinical leaders rural nurse managers and nurse unit managers, have an important role in facilitating the successful entry and retention of new graduate nurses into the rural nursing workforce.

Happy to help/happy to be here: Identifying components of successful clinical placements for undergraduate nursing students.

INTRODUCTION: The clinical placement learning environment is a critical component of nursing education where Australian nursing students spend a minimum of 800h. Identifying components of successful clinical placements for undergraduate nursing students is therefore paramount. PURPOSE: To assess nursing students' views of the learning environment during clinical placement with an emphasis on the pedagogical atmosphere, leadership style of the ward manager, and premises of nursing on the unit or ward. MATERIAL AND METHODS: The study used Clinical Learning Environment, Supervision and nurse teacher (CLES+T) questionnaire to examine 150 final year undergraduate students' perceptions of the clinical placement learning environment. The questionnaire was anonymous and completed by the students at the end of their clinical placement. The statistical program SPSS v22 was used. Principal components analysis (PCA) for data reduction was run on the 42-question section of the first dimension ('pedagogical atmosphere on the ward') of the questionnaire that measured the perceptions of the learning environment of the clinical placement of the 150 final-year undergraduate nursing students. The comments sections of the factors were subjected to interpretive content analysis to create the themes for the two components. RESULTS: Principle Component Analysis revealed two components that had eigenvalues greater than one: 'Happy to Help' Component 1 and 'Happy to be Here' Component 2. These components were statistically significant (p<0.0005), using Bartlett's Test of Sphericity indicating that the data was likely factorizable. These components scored higher than any other related factors. CONCLUSIONS: Student nurses value a welcoming workplace where staff and educators are happy to help and have a positive attitude to student presence on the wards. More than any other factors these ward-based factors appear to have the strongest influence on student satisfaction.

Venous access: the patient experience.

INTRODUCTION: The evolution of venous access via peripheral cannulation, particularly in relation to the risks and the benefits of this procedure, is reported widely in the literature. However, there is limited research specific to the patient experience of undergoing venous access. AIM: The intent of this qualitative study was to understand patients' experience of venous access, with the aim of bringing forth their voices about the experiences of repeated venous access/cannulation attempts. METHODOLOGY: This qualitative study used a hermeneutic phenomenological approach to explore the experiences of 15 participants in two rural oncology units in Australia. The participants had experienced repeated peripheral cannulation in order to receive chemotherapy. Study participants were asked to describe what it was like for them to be repeatedly cannulated. Data were collected via audiotaped individual interviews, the participants' stories were transcribed and analysed thematically. OUTCOMES: Themes emerged from the participants' stories that provided insights into their perceptions of the experience of being cannulated and the decision-making processes regarding how and where the procedure occurred. The findings suggest that a holistic approach to care was often missing causing the participants to feel vulnerable. Gaining insight into their experiences led to a greater understanding of the impact of this procedure on patients and the need to improve care through encouraging more collaborative decision-making processes between clinicians and patients. CONCLUSION: The implications for policy and practice focus on improving patient outcomes via procedural governance and education, with the intent of translating the findings from this research into evidence-based practice.

An Integrative Review of Enablement in Primary Health Care.

OBJECTIVES: To review how enablement is conceptualized and practiced in primary health care and to explore the factors that influence patient enablement in this setting. METHOD: A narrative integrative literature review was undertaken. RESULTS: Twenty-four articles specifically relating to enablement in primary health care were identified. Three literature reviews, 4 qualitative studies, and 17 quantitative studies were included in the analysis. CONCLUSIONS: In the primary health care setting, the concept of enablement is well defined as an outcome measure of quality. The literature exploring the practice of enablement is sparse, but 2 randomized controlled trials suggest enablement is linked to better outcomes for patients with asthma and diabetes. Primary factors influencing enablement included the practitioners' open communication style, the degree to which the practitioner is patient centered, and longer consultations. Other factors found to be associated with enablement were the presenting health issue, general state of health, ethnicity, the patient's own coping strategies and degree of independence, and socioeconomic status. The association between enablement and patients' expectations and satisfaction is less clear. The majority of research on enablement was carried out among general practitioners. Further research into the degree to which patients are enabled by a wider range of health care providers is needed. Additional qualitative research would provide a deeper understanding of the attributes of enablement in the primary health care setting.

Supporting new graduate nurses making the transition to rural nursing practice: views from experienced rural nurses.

AIMS AND OBJECTIVES: To present the findings from the experienced rural nurse participants of a larger study that explored the transitional experiences of newly graduated nurses making the role transition in rural health care facilities in Australia. BACKGROUND: There are specific and unique aspects of rural nursing practice that influence the nature and timing of support for new graduate nurses that have not been explored or acknowledged as influencing the new graduate nurses' experience of transition. Specifically, the difficulties and challenges that experienced rural nurses face in providing effective and timely support for new graduate nurses who are making the transition to rural nursing practice is yet to be explored. DESIGN: Using a qualitative case study framework, this study specifically aimed to investigate and describe the nature and timing of support required during the transition to nursing practice that is specific for the rural context and capacity. METHODS: Individual in-depth interviews were conducted with 16 experienced rural nurses who, at the time of the study, worked with new graduate nurses in the rural practice environment. RESULTS: The findings from this study showed that the provision of timely on-ward support for new graduates making the transition to rural nursing practice is affected and influenced by the skill mix and staffing allocation within the rural environment. As well, there is a lack of awareness by rural nurses of how to meet the on-ward support needs of new graduate nurses. CONCLUSIONS: This study has identified the specific and unique aspects of the rural nurse's role and responsibilities for which the new graduate nurse requires incremental learning and intensive clinical support. RELEVANCE TO CLINICAL PRACTICE: The findings can be used by rural health services and experienced rural registered nurses to assist in implementing adequate and timely support for new graduate nurses.

The support needs of new graduate nurses making the transition to rural nursing practice in Australia.

AIMS AND OBJECTIVES: The aim of this paper is to present the findings from the new graduate nurse participants of a larger study that explored the transitional experiences of newly graduated nurses making the role transition in rural health care facilities in Australia. BACKGROUND: Evidence indicates that workload, skill mix and organizational pressures are still of concern for new nursing graduates within the Australian context and internationally. Many graduates are expected by employers to have high levels of independence, well developed problem solving abilities and be able to assume management and leadership responsibilities early in their graduate year. DESIGN: An exploratory, descriptive, qualitative case study design was utilised to determine the particular support needs over time that would assist with a safe transition to the rural nursing workforce. The aims of the study were to: (1) Explore the new graduate nurses' perceptions and experience of the nature and timing of support throughout their Transition to Practice Program in a rural setting; (2) Identify the functional elements of rural graduate nurse transition programs and develop guidelines that will assist in the design of Transition to Practice Programs that match the rural context and capacity. METHODS: A purposive sample of 15 new graduate nurses who had commenced a 12 month Transition to Practice Program within a rural health facility from northern New South Wales, Australia, participated in this study. In-depth individual interviews with the new graduate nurses were conducted at time intervals of three to four months, six to seven months and 10 to 11 months. RESULTS: One of the key findings of this study is that as the new graduate nurse making the transition to professional rural nursing practice moves along the transition continuum, there are particular and unique aspects of the rural nurse's role and responsibilities for which the new graduate nurse will require specific learning support during their transition. CONCLUSIONS: When the new graduate moves from the role of the student to the less familiar role of professional practitioner, it is important that a rural Transition to Practice Program offers an incrementally staged workload and responsibilities that recognises the graduate's beginning nurse status. RELEVANCE TO CLINICAL PRACTICE: The study contributes new knowledge to the discussion of issues concerning support mechanisms for new graduate nurses as they make the transition to rural nursing practice.

Reviewing Tribunal cases and nurse behaviour: putting empathy back into nurse education with Bloom's taxonomy.

Recent events in the UK and Australia have shown how poor patient outcomes are achieved when the behaviour of nurses lacks empathy. The UK's Francis Inquiry and the Keogh Report both call for an increase in the 'caring and compassion' of health care workers. A review of cases presented to the nurses' disciplinary tribunal in New South Wales' (Australia) also suggests that the majority of complaints against nurses in this jurisdiction is the result of callousness or lack of empathy. Such events reinforce the need for nurse educators to support nursing students to develop the affective attributes of caring and empathy. This paper considers how to raise the awareness of undergraduate students as a first step to developing empathy by using Bloom's Taxonomy of Educational Objectives; and includes a description of how to facilitate interactions with undergraduate nursing students about caring with empathy. Enculturating empathy is an evidence-based method of increasing compassionate care in health organisations generally.

Perceptions from the front line: professional identity in mental health nursing.

In the context of a growing population of people experiencing mental illness worldwide, mental health nurses are a crucial workforce. Their recruitment and retention, however, is in decline. Drawing on qualitative data obtained from interviews with mental health nurses (MHN) in Victoria, Australia, the paper employs a range of concepts from role theory to explore professional identity within mental health nursing. The data highlight three key issues in relation to the future recruitment and retention of MHN: (i) the ambiguity of the MHN role; (ii) the weak definition and lack of understanding of the scope of the MHN role by nursing students; and (iii) a lack of communication about MHN as a profession to a wider audience. These findings indicate three avenues through which recruitment and retention in mental health nursing could be improved: (i) public communication; (ii) training and educating of the next generation of MHN; and (iii) more accurately defining the role of the MHN.

Identifying challenges and barriers in the delivery of primary healthcare at the district level: a study in one Thai province.

In 2001, the universal health coverage policy was adopted by Thailand with primary healthcare (PHC) as the major focus of the policy. In order to understand the structural and institutional factors affecting the implementation of PHC in rural Thailand, a qualitative study, utilising individual interviews with national and provincial policy decision makers, community health directors, heads of hospital primary care units, chiefs of district health offices, heads of health centres and community representatives, from one rural province was undertaken. Findings showed that the sustainability of PHC service provision under the administration of community hospitals is problematic as barriers exist at the policy and operational levels and access to PHC for all citizens may not be achieved until these barriers are addressed. Furthermore, although PHC needs to be acknowledged and implemented by all stakeholders within the health industry and government, the roles and responsibilities of the stakeholders in health services management at the district level need to be clarified.

Experiences of families who help young rural men with emergent mental health problems in a rural community in New South Wales, Australia.

A qualitative study was conducted in rural New South Wales, Australia, to understand the barriers to help-seeking among young rural men with emergent mental health problems. Participants who had real life experiences of these problems within their families were interviewed. Themes emerged from the data which explained some barriers to early intervention. Despite these barriers, families had developed skills in helping and in providing early mental health help to their sons. The findings of this study showed that a substantial burden on the emotional and social integrity of the family, combined with diminished psychological well-being, caused some parents to question how long they could cope before they reached 'the end of their strings'. This downward spiralling trajectory of mental health and well-being for both the young men and their families has implications for clinical practice. Current models of mental health service delivery do not adequately capture the early help-seeking dynamics of young rural men and their families. A more flexible approach is needed to identify and help the family and the young men, without the pre-requisite for a formal medical diagnosis. Future research should involve health and well-being solution focused service delivery.

Stereotyping stigma: undergraduate health students' perceptions at handover.

The World Health Organization (WHO) has recognized that errors in communication are one of the leading causes of adverse patient outcomes. Consequently, the WHO developed the High 5s Project to review, among other variables, handover of patients between shifts, professionals, and organizations. Seven countries were involved in the initial project. Australia responded by using the ISOBAR (Identify, Situation, Observations, Background, Agreed plan, and Read-back) tool as a template. However, none of the countries involved considered the social and emotional effects of handover on the staff or patients, although research has demonstrated that attitudes and values can be handed over from one nurse to another during this process. This article shows how the nurse who hands over care from one shift to the next can transfer stigma and labeling and offers suggestions for nurse educators and clinicians to apply national standards and core values to clinical practice and education.

Lessons from understanding the role of community hospital director in Thailand: clinician versus manager.

In 2001, Thailand adopted the Universal Health Coverage (UHC) policy. This policy focuses on primary health care (PHC), with the aim of reforming the Thai health system to provide health services to all, regardless of a person's ability to pay. The community hospital director (CHD) is the middle manager of the provincial health system and the leader of the district health system of Thailand. In recent reforms the emphasis for improving efficiency lies with changes in the provision of primary health services at the community level and this entails understanding the role of the CHD. A qualitative study, utilizing individual interviews and a focus group discussion, was undertaken in order to understand the factors affecting the implementation of rural health care in Thailand. Findings identified several barriers that limit the role of the CHD and a major result of the study was recognition of the dual role of the CHD as both clinician and manager. This study concluded that the goal of the UHC policy in providing equity of access to PHC to all citizens may not be achieved unless the role of CHDs is supported with training in health management and PHC and is supported by the government.

The thai-Australian alliance: developing a rural health management curriculum by participatory action research.

In 2006, the Thai National Health Security Office and the Ministry of Public Health, through the Nakhonratchasima Provincial Health Office in Thailand, asked the Thai-Australian Health Alliance to identify competencies and skills for a health management curriculum for health professionals working in primary healthcare in rural Thailand. The study was conducted in Nakhonratchasima province, Thailand, utilizing questionnaires, focus group discussions and an intensive 3-day workshop involving a purposive sample of 35 participants drawn from various sectors in the health industry. Findings identified the core curriculum competencies and skills required by rural doctors, nurses and public health officers. Critical issues regarding continuing education for health professionals in primary healthcare were also examined. This study found that a primary healthcare approach should include the principles of sustainability and capacity building, and incorporate team-based, interprofessional and long-term continuous learning.

Using a voice-centered relational method of data analysis in a feminist study exploring the working world of nursing unit managers.

In this article, we discuss the application of a data analysis method used in a feminist study that explored the working world of nursing unit managers in Australia. The decision to use a voice-centered relational approach to the data was based on a desire to delve into the working world of nursing unit managers and uncover the layers within the narratives that specifically related to their perceptions of themselves, their world, and the context in which they work. Throughout this article, the focus is on how this method was applied to uncover multiple layers of meaning within the data, rather than on the researchers' and participants' roles in the coconstruction of interview data. An excerpt from an interview transcript is used to illustrate how the stories of the participants were explored using this method.