University staff perspectives on determinants of high-quality health professions student placements in regional, rural and remote Australia: protocol for a mixed-method study.

INTRODUCTION: In rural areas, work-integrated learning in the form of health student placements has several potential benefits, including contributing to student learning, enhancing rural health service capacity and attracting future rural health workforce. Understanding what constitutes a high-quality rural placement experience is important for enhancing these outcomes. There is no current standardised definition of quality in the context of rural health placements, nor is there understanding of how this can be achieved across different rural contexts. This study is guided by one broad research question: what do university staff believe are the determinants of high-quality health professions student placements in regional, rural and remote Australia? METHODS AND ANALYSIS: This study will adopt a convergent mixed-method design with two components. Component A will use explanatory sequential mixed methods. The first phase of component A will use a survey to explore determinants that contribute to the development of high-quality health student placements from the perspective of university staff who are not employed in University Departments of Rural Health and are involved in the delivery of health student education. The second phase will use semistructured interviews with the same stakeholder group (non-University Department of Rural Health university staff) to identify the determinants of high-quality health student placements. Component B will use a case study Employing COnceptUal schema for policy and Translation Engagement in Research mind mapping method to capture determinants that contribute to the development of high-quality health student placements from the perspective of University Department of Rural Health university staff. ETHICS AND DISSEMINATION: The University of Melbourne Human Ethics Committee approved the study (2022-23201-33373-5). Following this, seven other Australian university human research ethics committees provided external approval to conduct the study. The results of the study will be presented in several peer-review publications and summary reports to key stakeholder groups.

Identifying features of quality in rural placements for health students: scoping review.

OBJECTIVES: To explore and synthesise the evidence relating to features of quality in rural health student placements. DESIGN: Scoping review. DATA SOURCES: MEDLINE, CINAHL, Embase, ProQuest, Informit, Scopus, ERIC and several grey literature data sources (1 January 2005 to 13 October 2020). STUDY SELECTION: The review included peer-reviewed and grey literature from Organisation for Economic Co-operation and Development listed countries that focused on quality of health student placements in regional, rural and remote areas. DATA EXTRACTION: Data were extracted regarding the methodological and design characteristics of each data source, and the features suggested to contribute to student placement quality under five categories based on a work-integrated learning framework. RESULTS: Of 2866 resulting papers, 101 were included for data charting and content analysis. The literature was dominated by medicine and nursing student placement research. No literature explicitly defined quality in rural health student placements, although proxy indicators for quality such as satisfaction, positive experiences, overall effectiveness and perceived value were identified. Content analysis resulted in four overarching domains pertaining to features of rural health student placement quality: (1) learning and teaching in a rural context, (2) rural student placement characteristics, (3) key relationships and (4) required infrastructure. CONCLUSION: The findings suggest that quality in rural health student placements hinges on contextually specific features. Further research is required to explore these findings and ways in which these features can be measured during rural health student placements.

A day treatment program for adults with eating disorders: staff and patient experiences in implementation.

BACKGROUND: Eating disorders are serious conditions which are increasing in prevalence internationally. The causes of these conditions are complex and incompletely understood, and clinical presentations can vary over time. The complexity of these conditions can also complicate treatment. Therefore, stepped care treatment comprising a hierarchy of interventions, including access to day treatment programs (DTPs), is recommended. While studies have examined patient outcomes and provided narrative accounts of these programs, no published studies describe DTP development. This study aims to address this gap by examining development and implementation of a DTP from service providers and patients' perspectives. METHODS: This study utilised a mixed-methods design to examine the design and implementation of a publicly funded, closed group DTP in Australia. Data from service records and documents were analysed, alongside interviews with patients and interview and focus groups with service providers conducted between June 2016 and July 2017. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed using the Framework Approach. RESULTS: Seventeen service providers (n = 4 in managerial and n = 13 clinical positions, with clinical experience of 3 months to 20 years) and 11 patients (100% F, 17-33 years) were interviewed. The service providers reported that implementation was a stressful undertaking due to tight timeframes to achieve multiple tasks. Patients had diverse opinions regarding the DTP content and the group treatment experience. Despite this, all patients reported benefits from attending the DTP, varying from improvements in mood, weight gain, development of personal skills and strengths, to living independently. For further benefit, patients suggested that programs could be shaped and targets towards differing patient groups, with fewer breaks throughout treatment. CONCLUSIONS: Designing and implementing a DTP is a challenge and can be a time-intensive undertaking, however the result can be beneficial for both service providers and patients. The closed group format was beneficial in creating a supportive environment, though may have led to increases in additional eating disordered behaviours. While the current structure of this DTP may require reconsideration, organisations considering implementing a new DTP may find usefulness in the overall design described in this study, alongside learning from the issues experienced.

Dietitians' opinions regarding refeeding syndrome, clinical guidelines and extended scope of practice.

AIM: Refeeding syndrome (RFS) prevalence rates vary across studies depending on the criteria used for assessment and identification. For registered dietitians, the assessment and management of RFS is highly reliant on daily serum electrolyte values; however, registered dietitians working within Australia do not currently possess laboratory test ordering privileges. We aimed to examine the opinions of registered dietitians regarding RFS identification, management and guidelines and the option of using extended scope of practice to order electrolyte monitoring autonomously. METHODS: A multi-method action research approach was used, incorporating two projects. The first was a survey examining Australian registered dietitians' (n = 187) opinions regarding RFS identification, management and guidelines, and autonomous electrolyte monitoring. To establish if results were similar internationally, an interview was conducted with 22 registered dietitians working within 10 different countries. Data were analysed using chi-square tests and thematic analysis. RESULTS: Australian registered dietitians (75%) identify patients at risk of RFS at a high rate of more than once per fortnight, with 74% reporting that they have previously worked with a patient diagnosed with RFS. Results varied internationally, with respondents from eight countries reporting that RFS is a problem within acute care versus respondents from five countries having never treated a patient with RFS. The majority (≥89%) of registered dietitians desire new guidelines and the option to order patient electrolyte monitoring autonomously. CONCLUSIONS: Our findings suggest that more stringent tools for the identification of RFS are necessary. There was limited uniformity across countries, and updated practice guidelines are needed.

A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients with Eating Disorders.

BACKGROUND: Patients with eating disorders (EDs) are often considered a high-risk population to refeed. Current research advises using "start low, go slow" refeeding methods (∼1,000 kcal/day, advancing ∼500 kcal/day every 3 to 4 days) in adult patients with severe EDs to prevent the development of refeeding syndrome (RFS), typically characterized by decreases in serum electrolyte levels and fluid shifts. OBJECTIVE: To compare the incidence of RFS and related outcomes using a low-calorie protocol (LC) (1,000 kcal) or a higher-calorie protocol (HC) (1,500 kcal) in medically compromised adult patients with EDs. DESIGN: This was a retrospective pre-test-post-test study. PARTICIPANTS/SETTING: One hundred and nineteen participants with EDs, medically admitted to a tertiary hospital in Brisbane, Australia, between December 2010 and January 2017, were included (LC: n=26, HC: n=93). The HC refeeding protocol was implemented in September 2013. MAIN OUTCOME MEASURES: Differences in prevalence of electrolyte disturbances, hypoglycemia, edema, and RFS diagnoses were examined. STATISTICAL ANALYSIS PERFORMED: χ2 tests, Kruskal-Wallis H test, analysis of variance, and independent t tests were used to compare data between the two protocols. RESULTS: Descriptors were similar between groups (LC: 28±9 years, 96% female, 85% with anorexia nervosa, 31% admitted primarily because of clinical symptoms of exacerbated ED vs HC: 27±9 years, 97% female, 84% with anorexia nervosa, 44% admitted primarily because of clinical symptoms of exacerbated ED, P>0.05). Participants refed using the LC protocol had higher incidence rates of hypoglycemia (LC: 31% vs HC: 10%, P=0.012), with no statistical or clinical differences in electrolyte disturbances (LC: 65% vs HC: 45%, P=0.079), edema (LC: 8% vs HC: 6%, P=0.722) or diagnosed RFS (LC: 4% vs HC: 1%, P=0.391). CONCLUSIONS: A higher-calorie refeeding protocol appears to be safe, with no differences in rates of electrolyte disturbances or clinically diagnosed RFS and a lower incidence of hypoglycemia. Future research examining higher-calorie intakes, similar to those studied in adolescent patients, may be beneficial.

The accuracy and consistency of nutrition care process terminology use in cases of refeeding syndrome.

AIM: Using standardised terminology in acute care has encouraged consistency in patient care and the evaluation of outcomes. As such, the Nutrition Care Process (NCP) and Nutrition Care Process Terminology (NCPT) may assist dietitian nutritionists in the delivery of high quality nutrition care worldwide; however, limited research has been conducted examining the consistency and accuracy of its use. We aimed to examine the NCPT that dietitian nutritionists would use to formulate a diagnostic statement relating to refeeding syndrome (RFS). METHODS: A multimethod action research approach was used, incorporating two projects. The first was a survey examining Australian dietitian nutritionists' (n = 195) opinions regarding NCPT use in cases of RFS. To establish if results were similar internationally, an interview was then conducted with 22 dietitian nutritionists working within 10 different countries. RESULTS: 'Imbalance of nutrients' was only identified as a correct code by 17% of respondents in project 1. No mention of this term was made in project 2. Also 86% of respondents incorrectly selected more than one diagnostic code. The majority of respondents (80%, n = 52/65) who incorrectly selected 'Malnutrition', without also selecting 'Imbalance of nutrients', selected 'reduce intake' as an intervention, suggesting some misunderstanding in the requirement for interrelated diagnoses, interventions and goals. CONCLUSIONS: Our findings demonstrate that there is limited accuracy and consistency in selecting nutritional diagnostic codes in relation to RFS. Respondents also demonstrated limited knowledge regarding appropriate application of the NCP and NCPT. Implementation practices may require further refinement, as accurate and consistent use is required to procure the benefits of standardised terminology.