The Rural Hand Therapy Project - providing hand therapy services closer to home.

CONTEXT: Hand therapy optimises functional use of the hand and arm after injury and is an expert area of practice for occupational therapists (OTs) and physiotherapists. In rural Australia, patients frequently travel to metropolitan or larger regional centres for initial hand surgery and rehabilitation. However, rural patients' access to follow-up hand therapy after the initial phase of care is impacted by several factors such as transport options, distance, staff shortages and availability of therapists skilled in hand therapy. To ensure service equity, these challenges require consideration of an alternative model of care that can be provided in rural areas. The aim of this project was to develop a shared care model that would better support rural OTs and rural patients in accessing follow-up hand therapy services closer to home. ISSUE: Two part-time accredited hand therapists (herein referred to as clinical leads) were employed in 2019-2020 to investigate a suitable model of care. Consultation with key stakeholders identified the following core issues: barriers, enablers, processes and intervention, and technology and resources. These findings were combined with recommendations from the literature to develop a model of service delivery: the Rural Hand Therapy Project (RHTP). Under the RHTP, eligible rural patients with complex hand conditions were either seen for their initial appointment, or had their referral screened, by a clinical lead at the regional hospital (Toowoomba Hospital, Queensland). During this process, a detailed handover to the rural OT was completed. Weekly case conferences with a clinical lead were available to all rural clusters. Rural patient cases remained open at the regional hospital for at least 3 months to allow patients to be easily seen by a clinical lead, face to face, or via telehealth (with the rural OT) if needed. The clinical leads also served as the primary contact for any clinical questions from rural OTs. Additionally, the clinical leads provided support and professional development to rural OTs based on the mix of patient cases at the time. LESSONS LEARNED: The RHTP clinical leads were involved in both initial assessment and ongoing intervention for 56% of rural hand therapy patients. The provision of videoconference occasions of service increased from 1% to 8%. Although a low response rate impaired therapist evaluation, an unexpected positive outcome of the RHTP was its flexibility to respond temporarily during rural staff crises and provide vital patient care. The RHTP model of care has shown promise in addressing the challenges faced by rural patients in accessing follow-up hand therapy services closer to home. Further research has been initiated to inform care at a local level. By sharing the model of RHTP, it is hoped that the equity of hand therapy service provision can be increased to improve patient outcomes in other rural and remote localities.

Understanding the Lives of Aboriginal and Torres Strait Islander Women with Traumatic Brain Injury from Family Violence in Australia: A Qualitative Study Protocol.

Globally, there is growing recognition of the connection between violence and head injuries. At present, little qualitative research exists around how surviving this experience impacts everyday life for women, particularly Aboriginal and Torres Strait Islander women. This project aims to explore the nature and context of these women's lives including living with the injury and to identify their needs and priorities during recovery. This 3-year exploratory project is being conducted across three Australian jurisdictions (Queensland, Northern Territory, and New South Wales). Qualitative interviews and discussion groups will be conducted with four key groups: Aboriginal and Torres Strait Islander women (aged 18+) who have acquired a head injury through family violence; their family members and/or carers; and hospital staff as well as government and non-government service providers who work with women who have experienced family violence. Nominated staff within community-based service providers will support the promotion of the project to women who have acquired a head injury through family violence. Hospital staff and service providers will be recruited using purposive and snowball sampling. Transcripts and fieldnotes will be analysed using narrative and descriptive phenomenological approaches. Reflection and research knowledge exchange and translation will be undertaken through service provider workshops.

"I Don't Think It's on Anyone's Radar": The Workforce and System Barriers to Healthcare for Indigenous Women Following a Traumatic Brain Injury Acquired through Violence in Remote Australia.

Aboriginal and Torres Strait Islander women experience high rates of traumatic brain injury (TBI) as a result of violence. While healthcare access is critical for women who have experienced a TBI as it can support pre-screening, comprehensive diagnostic assessment, and referral pathways, little is known about the barriers for Aboriginal and Torres Strait Islander women in remote areas to access healthcare. To address this gap, this study focuses on the workforce barriers in one remote region in Australia. Semi-structured interviews and focus groups were conducted with 38 professionals from various sectors including health, crisis accommodation and support, disability, family violence, and legal services. Interviews and focus groups were audiotaped and transcribed verbatim and were analysed using thematic analysis. The results highlighted various workforce barriers that affected pre-screening and diagnostic assessment including limited access to specialist neuropsychology services and stable remote primary healthcare professionals with remote expertise. There were also low levels of TBI training and knowledge among community-based professionals. The addition of pre-screening questions together with professional training on TBI may improve how remote service systems respond to women with potential TBI. Further research to understand the perspectives of Aboriginal and Torres Strait Islander women living with TBI is needed.

Evaluation of an occupational therapy led Paediatric Burns Telehealth Review Clinic: exploring the experience of family/carers and clinicians.

INTRODUCTION: Children with deep-partial or full-thickness burns often require complicated post-surgical care and rehabilitation, including specialist occupational therapy (OT) intervention, to achieve optimal outcomes. Those from rural and remote areas rarely have access to these services and must travel to a tertiary referral hospital to access follow-up, placing them at higher risk of complications and poorer outcomes. The OT-Led Paediatric Burn Telehealth Review (OTPB) Clinic, based at Townsville University Hospital in northern Queensland, Australia, was set up to address this inequity. The aim of this study was to investigate the experience of both family members and clinicians in using the OTPB Clinic. METHODS: A qualitative approach, guided by interpretive phenomenology, was used. Eight family members and six clinicians participated in semi-structured interviews conducted by phone or telehealth. Thematic analysis was used to identify key themes. RESULTS: Four major themes were derived through thematic analysis: continuity of care, family-centred care, technology and building of rural capacity. CONCLUSION: Family and clinicians confirm benefits of a telehealth service for delivering care to rural and remote children after burn injury. The results show this expanded-scope, OT-led telehealth model provides quality patient-centred and expert clinical advice within local communities and builds the skill and capacity of local clinicians. Areas for service enhancement were uncovered. This telehealth model can be translated to other clinical subspecialties across Australia.

Development of an occupational-therapy-led paediatric burn telehealth review clinic.

CONTEXT: Burns are a common injury in children. Rural and remote children with burn injuries are disadvantaged if their burns require hospitalisation and specialist rehabilitation. Most specialist burn rehabilitation is provided in regional or metropolitan cities by a multidisciplinary team. Therefore, rural and remote burn patients are required to travel to access these services. This project aimed to develop an Occupational Therapy (OT)-Led Paediatric Burn Telehealth Review Clinic (OTPB Clinic) at Townsville University Hospital (TUH) to provide ongoing rehabilitation to rural and remote children after burn injury closer to home. ISSUES: Local audits identified inequitable service delivery to children from rural and remote areas after burn injury. A project officer was appointed to develop the OTPB Clinic, including comprehensive guidelines to support sustainability. An expanded scope role was undertaken by the treating OT, and allied health assistants were engaged to promote efficient service delivery. LESSONS LEARNED: The OTPB Clinic commenced in 2017 and was evaluated using patient satisfaction surveys and number of clinical encounters pre- and post-implementation. During the implementation period, 28 rural or remote paediatric burn patients were reviewed. Review frequency increased from 20-week to 8-week intervals. Travel time was reduced by approximately 12 hours per appointment. Families identified numerous benefits of the clinic including continuity of care and reduced time away from work. Less than 4% of patients required re-engagement with paediatric surgeons for surgical intervention. The model has the potential to be transferred to other tertiary referral burns services.

How are allied health notes used for inpatient care and clinical decision-making? A qualitative exploration of the views of doctors, nurses and allied health professionals.

BACKGROUND: Inpatient care is dependent upon the effective transfer of clinical information across multiple professions. However, documented patient clinical information generated by different professions is not always successfully transferred between them. One obstacle to successful information transfer may be the reader's perception of the information, which is framed in a particular professional context, rather than the information per se. OBJECTIVE: The aim of this research was to investigate how different health professionals perceive allied health documentation and to investigate how clinicians of all experience levels across medicine, nursing and allied health perceive and use allied health notes to inform their decision-making and treatment of patients. METHOD: The study used a qualitative approach. A total of 53 speech pathologists, nurses, doctors, occupational therapists, dieticians and social workers (8 males; 43 females) from an Australian regional tertiary hospital participated in eleven single discipline focus groups, conducted over 4 months in 2012. Discussions were recorded and transcribed verbatim and coded into themes by content analysis. FINDINGS: Six themes contributing to the efficacy of clinical information transference emerged from the data: day-to-day care, patient function, discharge and discharge planning, impact of busy workloads, format and structure of allied health documentation and a holistic approach to patient care. DISCUSSION: Other professions read and used allied health notes albeit with differences in focus and need. Readers searched for specific pieces of information to answer their own questions and professional needs, in a process akin to purposive sampling. Staff used allied health notes to explore specific aspects of patient function but did not obtain a holistic picture. CONCLUSION: Improving both the relationship between the various health professions and interpretation of other professions' documented clinical information may reduce the frequency of communication errors, thereby improving patient care.

Hand therapy services for rural and remote residents: Results of a survey of Australian occupational therapists and physiotherapists.

OBJECTIVE: The aim of this study was to explore how interventions were provided to meet the needs of rural/remote residents who have had a traumatic hand injury, including the coordination of services between rural/remote and metro/regional therapists. Barriers to providing services, use of technology and professional support provided to therapists in rural/remote areas were also explored. DESIGN: Cross-sectional survey. SETTING: Metropolitan/regional and rural/remote public health facilities in Australia. PARTICIPANTS: Occupational therapists and physiotherapists who provide hand therapy to rural/remote patients. MAIN OUTCOME MEASURE: Quantitative and qualitative questionnaire responses analysed with descriptive statistics and inductive analysis. RESULTS: There were 64 respondents out of a possible 185. Over half of rural/remote respondents provided initial splinting and exercise prescriptions, and over 85% reported that they continued with exercise protocols. Videoconferencing technology for patient intervention and clinical review was used by 39.1% respondents. Barriers to providing services in rural/remote locations included transport, travelling time, limited staff, and lack of expert knowledge in hand injuries or rural/remote health care. Four major themes emerged from the open-ended questions: working relationships, patient-centred care, staff development and education, and rural and remote practice. CONCLUSION: The use of technology across Australia to support rural/remote patient intervention requires attention to achieve equity and ease of use. Flexible and realistic goals and interventions should be considered when working with rural/remote patients. A shared care approach between metropolitan/regional and rural/remote therapists can improve understanding of rural/remote issues and provide support to therapists. Further research is recommended to determine the suitability of this approach when providing hand therapy to rural/remote residents.

The experience of medical and rehabilitation intervention for traumatic hand injuries in rural and remote North Queensland: a qualitative study.

INTRODUCTION: This research explored the experience of receiving medical and rehabilitation intervention for rural and remote residents in North Queensland, Australia who had experienced a traumatic hand injury. This study contributes to larger project that seeks to propose a model of service delivery to rural and remote residents who have sustained a traumatic injury. METHODS: Utilising an interpretive phenomenological research design, data was gathered through in-depth, semi-structured interviews. Fifteen participants were recruited into this study and questions were designed to explore the experience of receiving medical and rehabilitation intervention following a traumatic hand injury for residents in rural and remote areas of North Queensland. RESULTS: The major themes that emerged were experience of medical intervention, experience of rehabilitation, travel, and technology. Participants felt that medical practitioners had a lack of local knowledge and were concerned that delays in medical intervention resulted in ongoing impairment. They reported following the exercise program they were given, often modifying it to fit with their daily routine. Metropolitan therapists appeared to have limited understanding of issues relevant to rural and remote lifestyles. There was, quite often, no occupational therapist or physiotherapist at their local facility due to staff turnover, and, when available, they had limited experience in hand injuries. The distance and cost of travel to appointments were of significant concern. The use of telehealth or telerehabilitation received a mixed response. CONCLUSION: Findings highlight the concerns regarding the provision of healthcare to rural and remote residents following a traumatic hand injury. These results provide the basis for recommendations surrounding the development of programs and service delivery models to address diverse needs in rural and remote areas.

The experience of living with a traumatic hand injury in a rural and remote location: an interpretive phenomenological study.

INTRODUCTION: The aim of this research study was to gain an understanding of how rural and remote residents in North Queensland, Australia, engaged in work, activities of daily living tasks and social activities following a traumatic hand injury. Findings from a previous retrospective survey with these participants revealed that patients experienced difficulties such as pain for many years after their injury; however, because of the survey methodology, the voices of participants were not heard. This study contributes to a larger project that seeks to propose a model of service delivery to rural and remote residents who have sustained a traumatic injury. METHODS: Utilising an interpretive phenomenological research design, data were gathered through in-depth, semistructured interviews. Fifteen participants were recruited into this study and questions were designed to explore the experience of having a traumatic hand injury in rural and remote areas of North Queensland. RESULTS: The thematic analysis indicated five major themes: injury and impairment, pain, occupation and activity, and resilience. Participants reported that having a hand injury often caused further injury due to the impairment. The pain experienced could be 'all consuming' yet participants reported 'pushing through' this pain to complete daily tasks. Participants reported that they would 'go mad' if they did not work and highlighted the importance of activity in their recovery. Participants felt grateful at having their hand and thought towards the future. Being self-reliant was important but they were willing to accept support from others when needed. CONCLUSIONS: Incorporating activity and occupation in rehabilitation programs as opposed to focusing on strict protocols is an important consideration in the recovery process of rural and remote residents. In particular, engaging in activity and occupation was an important part of managing the pain associated with the hand trauma. This research also found that participants demonstrated resilient qualities while recovering from a traumatic hand injury. Health professionals who work with people from a rural and remote location with a traumatic hand injury should consider a treatment model that encourages active patient participation, identifying collaborative treatment goals that align with the values of people living in rural and remote locations. Education regarding the high risk of further injury due to the nature of, and exposure to, the type of work and activity in rural and remote locations is also recommended.

Does a DVD improve compliance with home exercise programs for people who have sustained a traumatic hand injury? Results of a feasibility study.

PURPOSE: This feasibility study sought to determine if compliance and understanding of a home exercise program following a traumatic hand injury is improved when patients are provided with a DVD and a brochure when compared to using brochures only. METHOD: Patients who presented with a traumatic hand injury and commenced on a hand therapy protocol were randomly assigned into two groups. The control group received brochures while the experimental group were provided with exercise instructions on DVD as well as brochures. Compliance was measured through the use of exercise diaries, clinic attendance, a checklist to measure correctness and understanding of exercises and a follow-up survey. RESULTS: No significant improvement was found in the mean exercise compliance score (p = 0.344) between the intervention and control groups. From the survey results almost half of all participants reported that pain interfered in their ability to perform their home exercises and a third acknowledged that time limited their ability to perform their exercises. CONCLUSION: Findings demonstrate the multidimensional nature of compliance. The provision of DVD technology, while not shown to cause a statistically significant change in overall compliance, did help improve understanding of exercises; as such DVDs could be utilised as part of a program that facilitates the patient--therapist relationship. IMPLICATIONS FOR REHABILITATION: Limited time and level of pain are highlighted as reasons for non compliance with exercise and treatment programs. The use of DVDs can improve understanding and execution of exercises and can be part of a treatment program that facilitates increased patient therapist contact for rural and remote clients.

A critical review of the evidence on the use of videotapes or DVD to promote patient compliance with home programmes.

PURPOSE: The purpose of this paper is to critically review published research in order to evaluate the evidence surrounding the provision of video or DVD technology to promote patient compliance with home exercise or health programmes. METHOD: A literature search of the MEDLINE, CINAHL and Cochrane databases was undertaken. Critical appraisal of selected studies was undertaken using a previously validated tool. Inclusion criteria were: research related to DVD or videotape technology to improve compliance; published in peer-reviewed journals and full-text English language articles. Compliance was the main outcome measure. RESULTS: Eleven eligible studies were reviewed. All but one, which used a before-after design, were randomised controlled trials. Study quality tended medium to high in the critical appraisal scoring system, but an overall low quality on the Jadad score for randomisation; with only one study from 11 scoring well on both these measures. Research into the use of video or DVD showed mainly positive effects on compliance; however, methodological issues limit clinical applicability. CONCLUSIONS: Future well-designed randomised controlled trials with adequate sample sizes and reliable outcome measures will provide clearer evidence into the effectiveness of this technology in improving home exercise or health programme compliance, particularly for rural and remote populations.

The functional impact of a traumatic hand injury on people who live in rural and remote locations.

PURPOSE: This study aimed to gain an understanding of the functional impact of a traumatic hand injury on a rural and remote Australian population. METHOD: A retrospective, exploratory design was used. Patients who had experienced a traumatic hand injury were samples and were treated at the occupational therapy department at a major regional Australian hospital between January 2003 and February 2007 (n = 198). A mail-out survey was utilized, with 65 respondents included in the study. Questions focused on the impact on specific areas of occupational performance and on compliance to home exercises. The upper extremity functional index was also incorporated in the survey. RESULTS: The results revealed that almost 90% of survey respondents had residual difficulties as a result of the traumatic hand injury. The overall impact these difficulties have on 'day-to-day' life was moderate to extreme for over half of the respondents. In the areas of occupational performance, the most affected were work and leisure with less impact reported in self-care and rest. Comments were at times contrary with closed question data, with many respondents expressing relative satisfaction with their outcome despite highlighting the functional difficulties. CONCLUSION: A significant impact on occupational performance has been highlighted, which reflects common issues within this rural and remote population. Confirmation of the extent of these identified issues within the larger rural and remote Australian population will contribute to the formulation of policy and consequent improvements in health for this traditionally underserved population.