Nurse rostering: understanding the current shift work scheduling processes, benefits, limitations, and potential fatigue risks.

BACKGROUND: Implementing appropriate shift work schedules can help mitigate the risk of sleep impairment and reduce fatigue of healthcare workers, reducing occupational health and safety risks. In Australia, the organisation has a responsibility to make sure all reasonable measures are taken to reduce fatigue of staff. Therefore, it is important to assess what the current rostering processes is for staff responsible for creating the rosters for nurses. AIM: The aims of the project were to understand (1) who creates the rosters and what the process is, (2) what training and knowledge these staff have in establishing rostering schedules that optimise the sleep and wellbeing of staff, and (3) what the benefits and limitations are of current rostering practices. METHODS: Findings were generated through semi-structured interviews, using cluster coding to form categories. Twenty four nurses responsible for rostering staff were interviewed from three different sites in Victoria (one metropolitan and two regional/rural hospitals). Data was analysed using selected grounded theory methods with thematic analysis. RESULTS: The common themes that came out of the interviews were that rostering staff were under prepared, unaware of fatigue and safety guidelines and polices from governing bodies and had not received any education or training before taking on the role. The most common rostering style was self-rostering, where staff could submit preferences. However, there were concerns about staff fatigue but were divided as to who should be responsible, with many saying it was up to staff to preference shifts that they could cope with. The final theme was cultural barriers to change. CONCLUSION: While self-rostering resulted in staff having more freedom and flexibility,  shift preferences may be influenced more so by a need to fit with lifestyle rather than to minimise fatigue and increase safety in the workplace. Greater consideration of the impact of shift work schedules on fatigue is required to ensure that the layers of clinical governance in health care organisations minimise the risk of occupation health and safety issues for employees delivering direct patient care.

Sleep and fatigue management strategies: How nurses, midwives and paramedics cope with their shift work schedules-a qualitative study.

AIMS: To understand the benefits and challenges of shift work, and the coping strategies used by nurses, midwives and paramedics to manage the impact of shift work on sleep and fatigue from shift work. DESIGN: A single case study with embedded units. METHODS: Twenty-seven participants were interviewed exploring their shift work experiences, coping strategies used to improve sleep, and what their recommendations are for improving shift work management. Interviews were completed between November and December 2022. RESULTS: Participants enjoyed the lifestyle, flexibility and financial rewards offered by working shift work. However, fatigue and sleep deprivation undermined these benefits, as it impacted their ability to enjoy social and family events. There were also concerns of long-term health consequences of shift work and delivery of care. Changes to rostering practices and sleep and shift work education were common recommendations. CONCLUSION: This study provides insights on how healthcare professionals manage sleep and fatigue due to shift work and the inadequate support. There is absence of adequate policies, processes and training at an organizational, academic and personal level on how to best manage sleep and fatigue when working shift work. Future research is needed to explore how to equip healthcare shift workers with the skills to successfully manage their schedules to mitigate the negative impact that poor sleep and fatigue has on the health and safety of themselves and their patients. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Understanding the specific challenges of shift work and how workers manage their shift work schedules is critical for improving the health and safety of themselves and their patients. This study identified that there is insufficient training regarding sleep and shift work management strategies, potentially leading to occupational health and safety concerns. Further education and training to equip staff with the necessary information, training and guidance to staff on how to reduce fatigue risk is required. PATIENT OR PUBLIC CONTRIBUTION: This study involved healthcare shift workers in semi-structured interviews. Data gathered from a previous survey that participants were involved in helped shape the interview topics and the study design.

Differences in shift and work-related patterns between metropolitan and regional/rural healthcare shift workers and the occupational health and safety risks.

OBJECTIVES: To explore if there are differences in shift patterns and work-related factors between metropolitan and regional/rural healthcare shift workers and their risk of poor sleep and mental health. Furthermore, explore whether these factors impact on medical errors, workplace and car/near car accidents. DESIGN: A cross-sectional study. SETTING: An anonymous online survey of healthcare shift workers in Australia. PARTICIPANTS: A total of 403 nurses, midwives and paramedics completed the survey. MAIN OUTCOME MEASURES: Sample characteristics, employment location, shift work-related features, sleep and mental health measurements, workplace accidents, medical errors and car/near car accident post shift. RESULTS: Regional/rural healthcare shift workers were significantly older, had more years' experience, worked more nights, on-call and hours per week. Those in metropolitan areas took significantly longer (minutes) to travel to work, had higher levels of anxiety, increased risk of shift work disorder, reported significantly more workplace accidents and were more likely to have a car/near car accident when commuting home post shift. Both groups reported ~25% having a medical error in the past year. Workplace accidents were related to more on-call shifts and poor sleep quality. Medical errors were associated with fewer years' experience, more evening shifts and increased stress. Car accidents were associated with metropolitan location and increased depression. CONCLUSION: Differences in work-related factors between metropolitan and regional/rural healthcare shift workers were observed. Some of these factors contributed to occupational health and safety risks. Further exploration is needed to understand how to reduce occupational health and safety risks, and improve employee and patient safety both in both regional/rural and metropolitan areas.

Diabetes Distress and Associations With Demographic and Clinical Variables: A Nationwide Population-Based Registry Study of 10,186 Adults With Type 1 Diabetes in Norway.

OBJECTIVE: To estimate diabetes distress prevalence and associations with demographic and clinical variables among adults with type 1 diabetes in Norway. RESEARCH DESIGN AND METHODS: In this nationwide population-based registry study, the 20-item Problem Areas in Diabetes (PAID-20) questionnaire was sent to 16,255 adults with type 1 diabetes. Linear regression models examined associations of demographic and clinical variables with distress. RESULTS: In total, 10,186 individuals (62.7%) completed the PAID-20, with a mean score of 25.4 (SD 18.4) and 21.7% reporting high distress. Respondents endorsed worrying about the future and complications as the most problematic item (23.0%). Female sex, younger age, non-European origin, primary education only, unemployment, smoking, continuous glucose monitoring use, more symptomatic hypoglycemia, reduced foot sensitivity, treated retinopathy, and higher HbA1c were associated with higher distress. CONCLUSIONS: Diabetes distress is common among adults with type 1 diabetes and associated with clinically relevant factors, underlining that regular care should include efforts to identify and address distress.

Maternal Circadian Disruption from Shift Work and the Impact on the Concentration of Melatonin in Breast Milk.

Background and Objective: Melatonin in breast milk exhibits a 24-hour circadian rhythm, present in nighttime breast milk but nearly undetectable in daytime breast milk. Shift work can disrupt the circadian timing of individuals, evident in changes in melatonin in saliva and urine samples. However, it is unknown whether these changes are also reflected in breast milk from a shift working mother. The aim of this study was to investigate whether maternal circadian rhythm disturbance from shift work impacts the melatonin concentration in breast milk. Materials and Methods: Breast milk and saliva samples were collected from 11 shift working mothers at four timepoints across five consecutive days. This included during their day shift or nonworkdays to act as a control, night shift, subsequent night shifts and postnight shift. Where possible, pre- and postfeed collections were also undertaken. Samples were grouped into four-time intervals: 12-6:30 am, 7-11:30 am, 12-6:30 pm, 7-11:30 pm, and melatonin levels (picogram per milliliter) in the breast milk and saliva samples were analyzed. Results: There was a significant decrease in breast milk melatonin (p = 0.026) at the 12-6:30 am time interval on subsequent night shifts, compared with control days. However, there was no overall time and shift type interaction effect (p = 0.70). In addition, no observed difference in melatonin levels was found in saliva samples, or when comparing pre- and postfeed breast milk. Breast milk melatonin however was found to be significantly higher compared with saliva (p > 0.001), at all but one time interval. Conclusion: The findings suggest that there is a potential effect of maternal circadian rhythm disruption from shift work on breast milk melatonin levels. This is an important step in exploring the role of maternal circadian timing and the effect on breast milk composition. Expansion of this research and exploration of other circadian rhythm misalignment sleep disorders on breast milk is highly recommended.

Psychosocial Outcomes Among Users and Nonusers of Open-Source Automated Insulin Delivery Systems: Multinational Survey of Adults With Type 1 Diabetes.

BACKGROUND: Emerging research suggests that open-source automated insulin delivery (AID) may reduce diabetes burden and improve sleep quality and quality of life (QoL). However, the evidence is mostly qualitative or uses unvalidated, study-specific, single items. Validated person-reported outcome measures (PROMs) have demonstrated the benefits of other diabetes technologies. The relative lack of research investigating open-source AID using PROMs has been considered a missed opportunity. OBJECTIVE: This study aimed to examine the psychosocial outcomes of adults with type 1 diabetes using and not using open-source AID systems using a comprehensive set of validated PROMs in a real-world, multinational, cross-sectional study. METHODS: Adults with type 1 diabetes completed 8 validated measures of general emotional well-being (5-item World Health Organization Well-Being Index), sleep quality (Pittsburgh Sleep Quality Index), diabetes-specific QoL (modified DAWN Impact of Diabetes Profile), diabetes-specific positive well-being (4-item subscale of the 28-item Well-Being Questionnaire), diabetes treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire), diabetes distress (20-item Problem Areas in Diabetes scale), fear of hypoglycemia (short form of the Hypoglycemia Fear Survey II), and a measure of the impact of COVID-19 on QoL. Independent groups 2-tailed t tests and Mann-Whitney U tests compared PROM scores between adults with type 1 diabetes using and not using open-source AID. An analysis of covariance was used to adjust for potentially confounding variables, including all sociodemographic and clinical characteristics that differed by use of open-source AID. RESULTS: In total, 592 participants were eligible (attempting at least 1 questionnaire), including 451 using open-source AID (mean age 43, SD 13 years; n=189, 41.9% women) and 141 nonusers (mean age 40, SD 13 years; n=90, 63.8% women). Adults using open-source AID reported significantly better general emotional well-being and subjective sleep quality, as well as better diabetes-specific QoL, positive well-being, and treatment satisfaction. They also reported significantly less diabetes distress, fear of hypoglycemia, and perceived less impact of the COVID-19 pandemic on their QoL. All were medium-to-large effects (Cohen d=0.5-1.5). The differences between groups remained significant after adjusting for sociodemographic and clinical characteristics. CONCLUSIONS: Adults with type 1 diabetes using open-source AID report significantly better psychosocial outcomes than those not using these systems, after adjusting for sociodemographic and clinical characteristics. Using validated, quantitative measures, this real-world study corroborates the beneficial psychosocial outcomes described previously in qualitative studies or using unvalidated study-specific items.

Rapid Versus Slow Cooling Pasteurization of Donor Breast Milk: Does the Cooling Rate Effect Melatonin Reduction?

Background and Objective: There is a question as to whether melatonin levels in breast milk are impacted by the cooling rate postpasteurization. Past research that has used in the Australian donor bank's breast milk Holder Pasteurization technique has reported varying findings regarding melatonin levels postpasteurization. Where breast milk was cooled slowly, a significant reduction in breast milk melatonin levels was observed. Conversely, where a rapid cooling method was used, there was no significant reduction in melatonin levels. The aim of this study was to investigate whether the cooling process between the different pasteurization techniques impact on melatonin levels in breast milk postpasteurization. Materials and Methods: Twenty-seven nighttime breast milk samples were collected, with each sample divided into three; one remained unpasteurized, one was pasteurized and rapidly cooled to 4°C, and the other was pasteurized and cooled slowly to 4°C. Results: Melatonin levels were significantly reduced in both the rapidly cooled and slow cooled breast milk samples when compared to their unpasteurized counterpart (p < 0.001). There was no significant difference in melatonin levels between the two cooling methods (p = 0.91). Conclusion: This study showed that both the rapid and cooling pasteurization processes had a similar reduction in melatonin levels in breast milk. However, even after pasteurization melatonin was still present. Therefore, it is recommended that donor banks still take into consideration circadian timing hormones such as melatonin and the time of day breast milk is expressed.

Young children's perspectives on treatment and care: A qualitative study using narrative and play-based interviewing.

PURPOSE: To explore young children's (age 3-6 years) own experiences and perceptions of treatment and care when living with a chronic illness. DESIGN AND METHODS: The study employed a qualitative research design using a narrative and play-based interview approach. Individual face-to-face, narrative and play-based interviews were conducted with eight young children age 3-6 years with type 1 diabetes or cystic fibrosis. The play sessions took place at the home of the children and were video recorded. Interpretative phenomenological analysis was used to analyse the data and frame the study. RESULTS: Our analysis identified six main themes: 1. Children understood illness through their bodily experience of treatment and care, 2. Children's experience of care and treatment ranged from a feeling of powerlessness to a sense of agency, 3. Children depended on their parents to provide comfort, advocacy and protection, 4. Children's perceptions of treatment and care were inherently related to their experiences of familiarity, interpersonal relationships and trust, 5. Children with type 1 diabetes did not perceive that they played an active role during consultations, and 6. Children associated medical treatment with receiving tangible rewards or positive feedback. CONCLUSION: Children expressed a need to feel safe and build agency. They experienced this through participation and interpersonal relationships with healthcare professionals. PRACTICE IMPLICATIONS: We should prioritize the establishment and implementation of age-appropriate psychosocial care practices that support young children in participating, forming relationships, and building trust.

Rethinking the distribution of sleep services: discrepancy of obstructive sleep apnoea in rural compared with metropolitan men in Australia - a large national survey.

INTRODUCTION: Geographical location is increasingly recognised as a contributor to health inequity, with barriers including travel distances and a shortage of healthcare services. Individuals living in rural areas are known to have increased illness and comorbidities. Obstructive sleep apnoea (OSA) is one such illness. OSA is a condition where a person repeatedly pauses breathing while asleep due to their airways becoming wholly or partially blocked, and it is associated with various chronic diseases. Exploration into the effects of these barriers on OSA is limited. This study explores the proportion of diagnosed and undiagnosed OSA in men living in rural compared to metropolitan areas. METHODS: This was a cross-sectional, secondary analysis of the Australian Ten to Men dataset. The present study looked at men aged over 18 years diagnosed with OSA in their lifetime from wave 2 (n=10 513) and wave 3 (n=7262) of the dataset. Wave 2 data were collected between November 2015 and May 2016, and wave 3 between July 2020 and February 2021. RESULTS: In wave 2, a higher proportion of rural men were diagnosed with OSA than metropolitan men (OR, 1.47, 95%CI 1.22-1.78, p<0.001), but not regional men. In addition, a significantly higher proportion of men in rural areas were at risk for OSA than metropolitan men (37.7% v 32.6%, p<0.0001). However, men living rurally were older, had higher BMI and lower socioeconomic status. Location was no longer a significant predictor of OSA after controlling for age, BMI and socioeconomic status. In wave 3, rate of diagnosis of OSA during the lifetime was no longer significantly associated with location (p=0.057) or being diagnosed with OSA in the previous 12 months (p=0.062). CONCLUSION: This study highlights the need to ensure adequate services in rural areas, given the higher proportion of men diagnosed with, or at risk of, OSA in rural areas. OSA is also associated with an increase risk of comorbidities such as heart disease, hypertension and diabetes, which are diseases also seen more prevalently in rural men. Rethinking the distribution of healthcare services will go some way to addressing this problem.

Feasibility and acceptability of 'low-intensity mental health support via a telehealth-enabled network' for adults with type 1 and type 2 diabetes: the LISTEN pilot study.

BACKGROUND: This study examined the feasibility and acceptability of the low-intensity mental health support via telehealth-enabled network (LISTEN) intervention, for adults with diabetes, facilitated by diabetes health professionals (HPs). METHODS: LISTEN training. Three HPs participated in three half-day online workshops and applied their learnings during training cases (maximum four). Competency was assessed with a validated tool and achieved 'satisfactory' ratings for three consecutive sessions. LISTEN pilot. A single-group, pre-post study (up to four LISTEN sessions) with online assessments at baseline, post-intervention, and 4-week follow-up. Eligible participants were adults with type 1 or type 2 diabetes, with diabetes distress, but excluded if they had moderate/severe depressive and/or anxiety symptoms. Feasibility was assessed via recruitment and session completion rates. Acceptability was assessed with post-intervention self-report data. Changes in diabetes distress and general emotional well-being from baseline (T1) were explored at post-intervention (T2) and at 4-week follow-up (T3). RESULTS: Two HPs achieved competency (median training case sessions required: 7) and progressed to deliver LISTEN in the pilot study. In the pilot, N = 16 adults (Med [IQR] age: 60 [37-73] years; 13 women) with diabetes participated (median sessions per participant: 2). Twelve participants (75%) completed the post-intervention assessment (T2): 92% endorsed the number of sessions offered as 'just right', 75% felt comfortable talking with the HP, and 67% were satisfied with LISTEN. Perceived limitations were the structured format and narrow scope of problems addressed. Diabetes distress scores were lower post-intervention. CONCLUSIONS: This pilot demonstrates the feasibility of training HPs to deliver LISTEN, and the acceptability and potential benefits of LISTEN for adults with diabetes. The findings highlight adaptations that may enhance the delivery of, and satisfaction with, LISTEN that will be tested in a hybrid type 1 effectiveness-implementation trial.

Habitual Physical Activity of People with or at Risk of Diabetes-Related Foot Complications.

Regular physical activity is an important component of diabetes management. However, there are limited data on the habitual physical activity of people with or at risk of diabetes-related foot complications. The aim of this study was to describe the habitual physical activity of people with or at risk of diabetes-related foot complications in regional Australia. Twenty-three participants with diabetes from regional Australia were recruited with twenty-two participants included in subsequent analyses: no history of ulcer (N = 11) and history of ulcer (N = 11). Each participant wore a triaxial accelerometer (GT3X+; ActiGraph LLC, Pensacola, FL, USA) on their non-dominant wrist for 14 days. There were no significant differences between groups according to both participant characteristics and physical activity outcomes. Median minutes per day of moderate-to-vigorous physical activity (MVPA) were 9.7 (IQR: 1.6-15.7) while participants recorded an average of 280 ± 78 min of low-intensity physical activity and 689 ± 114 min of sedentary behaviour. The sample accumulated on average 30 min of slow walking and 2 min of fast walking per day, respectively. Overall, participants spent very little time performing MVPA and were largely sedentary. It is important that strategies are put in place for people with or at risk of diabetes-related foot complications in order that they increase their physical activity significantly in accordance with established guidelines.

High-Temperature Pasteurization Used at Donor Breast Milk Banks Reduces Melatonin Levels in Breast Milk.

Background and Objective: Donor human milk banks are used when breast milk directly from mothers is unavailable or insufficient. Breast milk contains melatonin, which exhibits a 24-hour pattern. Melatonin promotes sleep onset and is barely detected in daytime milk but rises in the evening and peaks early in the morning. Melatonin supports the development of an infant's own circadian rhythm and is important for neurodevelopment. Currently, donor banks pasteurize breast milk using a Holder Pasteurization (HoP) technique where breast milk is treated at a high temperature (+62°) for 30 minutes before cooling to eliminate any pathogens before it is given to infants. It is not known how the pasteurization process affects the melatonin levels in breast milk. The aim of this study was to investigate whether the pasteurization process reduces melatonin levels in breast milk. Materials and Methods: Ten night-time breast milk samples were collected and each divided into two groups; one group remained unpasteurized and the other group was pasteurized using the HoP technique. Results: Melatonin levels between the unpasteurized and pasteurized groups were compared. Results showed that there was a significant reduction after pasteurization (mean ± standard deviation = 51.92 pg/mL ± 19.54 versus 39.66 pg/mL ± 13.05, p = 0.01). Conclusions: It is important to understand that pasteurization can reduce melatonin levels in breast milk because this hormone is considered important to support the neurodevelopment of infants, especially those born preterm. Further focus on the effect of pasteurization techniques on melatonin in donor breast milk is warranted.

Low-Intensity mental health Support via a Telehealth Enabled Network for adults with diabetes (LISTEN): protocol for a hybrid type 1 effectiveness implementation trial.

BACKGROUND: Mental health problems are common among people with diabetes. However, evidence-based strategies for the prevention and early intervention of emotional problems in people with diabetes are lacking. Our aim is to assess the real-world effectiveness, cost-effectiveness, and implementation of a Low-Intensity mental health Support via a Telehealth Enabled Network (LISTEN), facilitated by diabetes health professionals (HPs). METHODS: A hybrid type I effectiveness-implementation trial, including a two-arm parallel randomised controlled trial, alongside mixed methods process evaluation. Recruited primarily via the National Diabetes Services Scheme, Australian adults with diabetes (N = 454) will be eligible if they are experiencing elevated diabetes distress. Participants are randomised (1:1 ratio) to LISTEN-a brief, low-intensity mental health support program based on a problem-solving therapy framework and delivered via telehealth (intervention) or usual care (web-based resources about diabetes and emotional health). Data are collected via online assessments at baseline (T0), 8 weeks (T1) and 6 months (T2, primary endpoint) follow-up. The primary outcome is between-group differences in diabetes distress at T2. Secondary outcomes include the immediate (T1) and longer-term (T2) effect of the intervention on psychological distress, general emotional well-being, and coping self-efficacy. A within-trial economic evaluation will be conducted. Implementation outcomes will be assessed using mixed methods, according to the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Data collection will include qualitative interviews and field notes. DISCUSSION: It is anticipated that LISTEN will reduce diabetes distress among adults with diabetes. The pragmatic trial results will determine whether LISTEN is effective, cost-effective, and should be implemented at scale. Qualitative findings will be used to refine the intervention and implementation strategies as required. TRIAL REGISTRATION: This trial has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN: ACTRN12622000168752) on 1 February, 2022.

Preliminary Exploration into the Impact of Mistimed Expressed Breast Milk Feeding on Infant Sleep Outcomes, Compared to Other Feeding Patterns.

Background and Objective: The presence and fluctuation of melatonin in breast milk during the night and day may be providing sleep timing information to infants, thereby supporting/enabling the development of their own circadian cycle. If this is the case, then it is important that infants consume breast milk according to the time of day it is produced. However, breast milk is not always consumed at the "right" time. The aim of this study was to investigate whether consuming mistimed expressed breast milk impacts infant sleep compared with other feeding types. Methods: A total of 329 mothers completed an online anonymous survey. Mothers were grouped into one of five groups; direct breastfed only, formula only, express mistimed, express-timed, and combined breastfed/formula fed. Results: Cross-sectional analysis showed mistimed expressed breast milk was significantly associated with delayed sleep onset of the infant (p < 0.001), but direct breastfed infants had significantly more awakenings at night (p < 0.001). Conclusions: The findings from this study suggest a potential effect of mistimed expressed breast milk consumption on an infant's circadian rhythm, affecting some aspects of their sleep. This is an important first step in exploring mistimed feeding on infant sleep outcomes and provides preliminary evidence that warrants future research.

Different Behavior-Change Messaging Techniques Do Not Increase Customers' Hand Sanitization Adherence During the COVID-19 Pandemic: A Natural Behavioral Study.

Introduction: Hand hygiene is an integral public health strategy in reducing the transmission of COVID-19, yet the past research has shown hand hygiene practices among the public is sub-optimal. This study aimed to (1) quantify hand sanitization rates among the public to minimize the transmission of COVID-19 and (2) evaluate whether different public health messaging, based on various behavior-change theories influences hand hygiene behavior in a natural setting. Methods: An observational, naturalistic study design was used with real-time customer activity data recorded against hand sanitizer usage in a regional hardware store. Primary outcome from the study was to measure the usage ratio by counting the amount of activity versus usage of hand sanitizer per hour against individual messages based on their behavioral change technique (BCT). Results: There was no significant difference between the baseline message and any of the intervention messages [F(16,904) = 1.19, p = 0.279] or between BCT groups [F(3,906) = 1.33, p = 0.263]. Post hoc tests showed no significant difference between messages (social comparison, p = 0.395; information, p = 1.00; and action planning, p = 1.00). Conclusion: This study showed that even during a pandemic, hand hygiene usage rates in a public setting were similar to the past studies and that compliance did not shift dependent on the public message displayed. This raises questions on whether requirements imposed on businesses to provide hand sanitizer to patrons are an ineffective and maybe an unnecessary economic burden. A measured approach to risk and behavioral analysis surrounding the use of hand sanitizer in a pandemic is suggested as a better approach to inform public policy on the value of hand sanitizer.

Does undertaking rural placements add to place of origin as a predictor of where health graduates work?

OBJECTIVE: To determine the work location (metropolitan, regional, rural and remote) of graduates in nursing, allied health and oral health disciplines who complete their professional training, end-to-end training, in a regional or rural area noting the potential inclusion of a metropolitan-based placement for speciality practice not available in rural or regional Victoria. METHODS: We tracked the place of employment from the Australian Health Practitioners Regulation Agency (AHPRA) of all graduates from a regional/rural tertiary education provider. The student home address at enrolment, locations where they undertook all placements and their current place of work were described using an objective geographical model of access, the Modified Monash Model. RESULTS: Seventy-five per cent of 5506 graduates were located in the AHPRA database. About one third of graduates were working in metropolitan areas, 1/3 in regional cities and 1/3 in rural areas. Students' origin accounted for 1/3 of variance in current workplace location. The more placement days students completed in regional/ rural areas was also a significant predictor of working in a regional or rural area. CONCLUSION: End-to-end training in regional/rural areas is an effective approach to retaining a regional/rural workforce. Student origin is a strong predictor of working rural or regionally, as is undertaking placements in rural areas. This suggests that priority for rural/ regional student placements should be given to students in end-to-end regional/ rural programs and students from a regional/ rural background.

Web-based intervention to reduce psychological barriers to insulin therapy among adults with non-insulin-treated type 2 diabetes: study protocol for a two-armed randomised controlled trial of 'Is insulin right for me?'.

INTRODUCTION: Psychological barriers to insulin therapy are associated with the delay of clinically indicated treatment intensification for people with type 2 diabetes (T2D), yet few evidence-based interventions exist to address these barriers. We describe the protocol for a randomised controlled trial (RCT) examining the efficacy of a novel, theoretically grounded, psychoeducational, web-based resource designed to reduce psychological barriers to insulin among adults with non-insulin treated T2D: 'Is insulin right for me?'. METHODS AND ANALYSIS: Double-blind, parallel group RCT. A target sample of N=392 participants (n=196/arm) will be randomised (1:1) to 'Is insulin right for me?' (intervention) or widely available online resources (control). Eligible participants include adults (18-75 years), residing in Australia, currently taking oral hypoglycaemic agents to manage T2D. They will be primarily recruited via invitations and reminders from the national diabetes registry (from a purposefully selected sample of N≥12 000). EXCLUSION CRITERIA: experience of self-administered injectable; previously enrolled in pilot RCT; 'very willing' to start insulin as baseline. Outcomes will be assessed via online survey at 2 weeks and 6 months. Primary outcome between-group: difference in mean negative Insulin Treatment Appraisal Scores (ITAS negative) at 2-week and 6-month follow-up. SECONDARY OUTCOMES: between-group differences in mean positive insulin appraisals (ITAS positive) and percentage difference in intention to commence insulin at follow-up time points. All data analyses will be conducted according to the intention-to-treat principle. ETHICS AND DISSEMINATION: Deakin University Human Research Ethics Committee (2020-073). Dissemination via peer-reviewed journals, conferences and a plain-language summary. TRIAL REGISTRATION NUMBER: ACTRN12621000191897; Australian and New Zealand Clinical Trials Registry.

Open-source automated insulin delivery: international consensus statement and practical guidance for health-care professionals.

Open-source automated insulin delivery systems, commonly referred to as do-it-yourself automated insulin delivery systems, are examples of user-driven innovations that were co-created and supported by an online community who were directly affected by diabetes. Their uptake continues to increase globally, with current estimates suggesting several thousand active users worldwide. Real-world user-driven evidence is growing and provides insights into safety and effectiveness of these systems. The aim of this consensus statement is two-fold. Firstly, it provides a review of the current evidence, description of the technologies, and discusses the ethics and legal considerations for these systems from an international perspective. Secondly, it provides a much-needed international health-care consensus supporting the implementation of open-source systems in clinical settings, with detailed clinical guidance. This consensus also provides important recommendations for key stakeholders that are involved in diabetes technologies, including developers, regulators, and industry, and provides medico-legal and ethical support for patient-driven, open-source innovations.

'Is insulin right for me?': Feasibility of a pilot randomised controlled trial and acceptability of a web-based intervention to reduce psychological barriers to insulin therapy among adults with type 2 diabetes.

AIMS: Acceptable and accessible interventions are needed to address 'psychological insulin resistance', which is a common barrier to insulin uptake among adults with type 2 diabetes (T2D). Our aim was to test the feasibility of a randomised controlled trial (RCT) study design and acceptability of a theoretically grounded, psycho-educational, web-based resource to reduce negative insulin appraisals among adults with T2D. METHODS: A double-blinded, parallel group, two-arm pilot RCT (1:1), comparing intervention with active control (existing online information about insulin). Eligible participants were Australian adults with T2D, taking oral diabetes medications. EXCLUSION CRITERIA: prior use of injectable medicines; being 'very willing' to commence insulin. Primary outcomes: study feasibility (recruitment ease, protocol fulfilment, attrition, data completeness); secondary outcomes: intervention acceptability (intervention engagement, user feedback) and likely efficacy (negative Insulin Treatment Appraisal Scale [ITAS] scores at follow-up). Online surveys completed at baseline and 2 weeks. RESULTS: During 4-week recruitment, 76 people expressed interest: 51 eligible and 35 enrolled (intervention = 17, control = 18; median[interquartile range] age = 62[53, 69] years; 17 women). Protocol fulfilment achieved by 26 (74%) participants (n = 13 per arm), with low participant attrition (n = 6, 17%). Intervention acceptability was high (>80% endorsement, except format preference = 60%). ITAS negative scores differed between-groups at follow-up (M diff = -6.5, 95% confidence interval: -10.7 to -2.4), favouring the intervention. CONCLUSIONS: This novel web-based resource ("Is insulin right for me?") is acceptable and associated with a likely reduction in negative insulin appraisals, relative to existing resources. This pilot shows the study design is feasible and supports conduct of a fully powered RCT.