What does it mean to be an allied health professional working in rural Aotearoa New Zealand? A qualitative study.

OBJECTIVE: Building health services and workforce that are both well supported and fit for purpose is a key consideration for improving health outcomes in rural populations. Achieving this requires an understanding of the roles and practice characteristic of each professional group, including allied health professionals. This study explores what it means to be an allied health professional practicing in rural Aotearoa New Zealand. DESIGN: A qualitative study design was used, involving individual semi-structured interviews with 13 rural allied health professionals in the Otago and Northland regions. The interviews explored participants journey into rural practice, their experiences working rurally, and their views on rural practice. FINDINGS: Four main themes were derived: Identity; Connectedness; Expectations; and Providing Care. DISCUSSION: Proud of being rural, these allied health professionals are immersed within their community, intertwining their professional and personal identities. The unique nature of this dual identity while empowering for some, can also isolate rural allied health professionals from their professional bodies and urban peers. This leads to a sense of vulnerability and feeling undervalued and invisible. In response, rural allied health professionals choose to form strong connections to their local interprofessional team and their community. The connections they forge, and the breadth of their skills cumulate to enable allied health professionals to provide dynamic and responsive health services for their rural communities. CONCLUSION: This study provides the first insight into experiences and perspectives of allied health professionals within rural Aotearoa New Zealand. Despite the challenges, a sense of pride is associated with practicing rurally for allied health professionals.

A retrospective observational study examining interhospital transfers from six New Zealand rural hospitals in 2019.

OBJECTIVE: The aim of this study was to identify the percentage of patients that were transferred from rural hospitals and who received an investigation or intervention at an urban hospital that was not readily available at the rural hospital. METHODS: A retrospective observational study. DESIGN: Patients were randomly selected and clinical records were reviewed. Patient demographic and clinical information was collected, including any interventions or investigations occurring at the urban referral hospital. These were compared against the resources available at the rural hospitals. SETTING: Six New Zealand (NZ) rural hospitals were included. PARTICIPANTS: Patients that were transferred from a rural hospital to an urban hospital between 1 Jan 2019 and 31 December 2019 were included. MAIN OUTCOME MEASURES: The primary outcome measure was the percentage of patients who received an investigation or intervention that was not available at the rural hospital. RESULTS: There were 584 patients included. Overall 73% of patients received an intervention or investigation that was not available at the rural hospital. Of the six rural hospitals, there was one outlier, where only 37% of patients transferred from that hospital received an investigation or intervention that was not available rurally. Patients were most commonly referred to general medicine (23%) and general surgery (18%). Of the investigations or interventions performed, 43% received a CT scan and 25% underwent surgery. CONCLUSIONS: Most patients that are transferred to urban hospitals receive an intervention or investigation that was not available at the rural hospital.

The place of rural hospitals in New Zealand's health system: an exploratory qualitative study.

INTRODUCTION: In Aotearoa New Zealand (NZ) there is a knowledge gap regarding the place and contribution of rural hospitals in the health system. New Zealanders residing in rural areas have poorer health outcomes than those living in urban areas, and this is accentuated for Maori, the Indigenous people of the country. There is no current description of rural hospital services, no national policies and little published research regarding their role or value. Around 15% of New Zealanders rely on rural hospitals for health care. The purpose of this exploratory study was to understand national rural hospital leadership perspectives on the place of rural hospitals in the NZ health system. METHODS: A qualitative exploratory study was undertaken. The leadership of each rural hospital and national rural stakeholder organisations were invited to participate in virtual semi-structured interviews. The interviews explored participants' views of the rural hospital context, the strengths and challenges they faced and how good rural hospital care might look. Thematic analysis was undertaken using a framework-guided rapid analysis method. RESULTS: Twenty-seven semi-structured interviews were conducted by videoconference. Two broad themes were identified, as follows. Theme 1, 'Our place and our people', reflected the local, on-the-ground situation. Across a broad variety of rural hospitals, geographical distance from specialist health services and community connectedness were the common key influencers of a rural hospital's response. Local services were provided by small, adaptable teams across broad scopes and blurred primary-secondary care boundaries, with acute and inpatient care a key component. Rural hospitals acted as a conduit between community-based care and city-based secondary or tertiary hospital care. Theme 2, 'Our positioning in the wider health system', related to the external wider environment that rural hospitals worked within. Rural hospitals operating at the margins of the health system faced multiple challenges in trying to align with the urban-centric regulatory systems and processes they were dependent on. They described their position as being 'at the end of the dripline'. In contrast to their local connectedness, in the wider health system participants felt rural hospitals were undervalued and invisible. While the study found strengths and challenges common to all NZ rural hospitals, there were also variations between them. CONCLUSION: This study furthers understanding of the place of rural hospitals in the NZ healthcare system as seen through a national rural hospital lens. Rural hospitals are well placed to provide an integrative role in locality service provision, with many already long established in performing this role. However, context-specific national policy for rural hospitals is urgently needed to ensure their sustainability. Further research should be undertaken to understand the role of NZ rural hospitals in addressing healthcare inequities for those living in rural areas, particularly for Maori.

Doing without the residential component of a blended postgraduate rural medical programme during the 2020 COVID-19 pandemic in New Zealand: student perspectives.

AIM: Rural-targeted postgraduate medical training is a key factor associated with entering rural practice. Rural health professionals often experience geographical and professional isolation, which can impact their training and education. In New Zealand, during the 2020 COVID-19 pandemic, an established distance postgraduate rural medical programme replaced its in-person residentials with virtual workshops. This study aimed to gain insights into the student experience of the virtual workshops, with emphasis on exploring the effects of the absence of an in-person component. METHOD: Qualitative exploratory design. All students who had completed a semester one 2020 University of Otago rural postgraduate module were invited by email to participate. Fifteen semi-structured interviews were conducted by video-conference. A thematic analysis was conducted using a general inductive approach. RESULTS: Three themes captured the main issues. 1. Making sure everyone is in the same boat: the key roles of an in-person component were identified as consolidation of learning, benchmarking and connectedness. 2. Learning but not connecting: virtual workshops were well facilitated, allowed continuation of study and the convenience of staying home, however connectedness faded. 3. We've got to keep a human touch in a digital age: looking beyond the pandemic, opportunities for streamlining virtual content were identified, however there was concern around diminished communication and cultural aspects of learning and the absent connection with rural health services and communities. CONCLUSION: A virtual workshop is valuable in the COVID-19 environment but does not replace an in-person component of a distance postgraduate training programme for rural medicine.

A scope of practice that works 'out here': exploring the effects of a changing medical regulatory environment on a rural New Zealand health service.

INTRODUCTION: In 2008, the Medical Council of New Zealand recognised rural hospital medicine as a vocational scope of practice. The aim was to provide training and professional development standards for medical practitioners working in New Zealand's rural hospitals and to encourage quality systems to become established in rural hospitals. Hokianga Health in New Zealand's far north is an established integrated health service that includes a rural hospital and serves a largely Māori community. The aim of this study was to explore how the new scope had affected health practitioners and the health service at Hokianga Health. METHODS: A case study design was used, employing qualitative methods. Documentary analysis was undertaken tracking change and development at Hokianga Health. Twenty-six documents (10 from within and 16 from outside Hokianga Health) were included in the analysis. Eleven face-to-face semi-structured interviews were conducted with employees of Hokianga Health. The interviews explored participants' views of the rural hospital medicine scope. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately. RESULTS: Four themes capturing the main issues were identified: (1) 'What I do': articulating the scope of medical practice at Hokianga, (2) 'What we do': the role of the hospital at Hokianga, (3) 'On the fringes', and (4) Survival. With changing regulatory policy an established part of Hokianga Health practice, the hospital aspect was outside the scope of general practice. This mismatch created a vulnerability for individual doctors and threatened the hospital service. The new scope filled the gap, rural hospital medicine together with general practice now covering the whole practice scope at Hokianga Health. With the introduction of the rural hospital medicine scope and the accompanying national definition of a rural hospital came a sense of belonging and increased connectedness, Hokianga Health and its practitioners realigning with the new scope, its policies, processes and language. The new scope brought for the first time a specific focus on the inpatient and emergency care aspects of practice at Hokianga and with this validation of the hospital aspect of the medical practitioners work. The critical importance of a fit-for-purpose scope and rural-specific postgraduate training programs in minimising inequity of care and opportunity for rural communities was emphasised. The importance of benchmarking with its associated costs was also highlighted. The main challenges identified related to the real (as well as potential) increased regulatory requirements of two separate scopes of practice for practitioners and a small rural health service working across primary and secondary care. CONCLUSION: In better equipping medical practitioners for rural hospital work and strengthening hospital systems and standards, the rural hospital medicine scope has met its intentions at Hokianga Health. The rural hospital medicine pathway is a necessary partial solution to rural medical practitioners maintaining a broad skill set. Continued flexibility is required in training programs in order to meet a range of different practitioner and rural health service needs.

Point-of-care ultrasound for FAST and AAA in rural New Zealand: quality and impact on patient care.

INTRODUCTION: Point-of-care ultrasound (POCUS) has the potential to improve access to diagnostic imaging for rural communities. This article evaluates the sensitivity and specificity, impact on patient care, quality and safety of two common POCUS examinations - focused assessment with sonography in trauma (FAST) and aortic aneurysm (AAA) - in the rural context. METHODS: This study is a subgroup analysis of a larger study into POCUS in rural New Zealand. Twenty-eight physicians in six New Zealand rural hospitals, with limited access to formal diagnostic imaging, completed a questionnaire before and after POCUS scans to assess the extent to which it altered diagnostic certainty and patient disposition (discharge v admission to rural hospital v transfer to urban hospital). The investigators and a specialist panel reviewed images for technical quality and accuracy of interpretation, and patient clinical records, to determine accuracy of the POCUS findings and their impact on patient care. RESULTS: For FAST and AAA scans respectively, sensitivities were 75% and 100%, and specificities 100% and 93%; rural doctors correctly interpreted their POCUS images for 97% and 91% of scans. The proportions of scans that had either a 'significant' or 'major' impact on patient care were 17% and 31%. POCUS resulted in the disposition being de-escalated for 15% and 10% of patients and escalated for 5% and 3% of patients. CONCLUSIONS: In the rural context, POCUS AAA is a reliable 'rule out' test for ruptured abdominal aortic aneurysm and FAST scan has a role as a 'rule in' test for solid organ injury. These findings are consistent with larger studies in the emergency medicine literature.

The impact of the introduction of a point-of-care haematology analyser in a New Zealand rural hospital with no onsite laboratory.

INTRODUCTION: Hokianga Hospital is a small rural hospital in the far north of New Zealand serving a predominantly Maori population of 6500. The hospital, an integral part of a comprehensive primary healthcare service, provides continuous acute in-hospital and emergency care. Point-of-care (POC) biochemistry has been available at the hospital since 2010 but there is no onsite laboratory. This study looked at the impact of introducing a POC haematology benchtop analyser at Hokianga Hospital. METHODS: This was a mixed methods study conducted at Hokianga Hospital over 4 months in 2016. Quantitative and qualitative components and a cost-benefit analysis were combined using an integrative process. Part I: Doctors working at Hokianga Hospital completed a form before and after POC haematology testing, recording test indication, differential diagnosis, planned patient disposition and impact on patient treatment. Part II: Focus group interviews were conducted with Hokianga Hospital doctors, nurses and a cultural advisor. Part III: An analysis of cost versus tangible benefits was conducted. RESULTS: Part I: A total of 97 POC haematology tests were included in the study. Of these, 97% were undertaken in the setting of the acute clinical presentation and 72% were performed out of hours. The average number of differential diagnoses reduced from 2.43 pre-test to 1.7 post-test, (χ2 tests p<0.05). There was a significant reduction in the number of patients transferred and an increase in the number of patients discharged home (χ2 tests p<0.05). Part II: Three main themes were identified: impact on patient management, challenges and the commitment to 'make it work'. POC haematology had a positive impact on patient management and clinician confidence mainly by increasing diagnostic certainty. The main challenges related to the hidden costs of implementing the analyser and its associated quality assurance program in a remote-from-laboratory setting. Part III: Tangible cost-benefit analysis showed a clear cost saving to the health system as a whole. CONCLUSIONS: This is the first published study evaluating the impact of haematology POC testing on acute clinical care in a rural hospital with no onsite laboratory. Timely access to a full blood count POC improves clinical care and addresses inequity. There was an overall reduction in healthcare costs. The study highlighted the hidden costs of implementing POC systems and their associated quality assurance programs in a remote-from-laboratory context.

Kete pikau: A basket of knowledge - 'guidelines from back home'.

From the perspective of one rural New Zealand Maori community involved in a health service research study, this article describes 'Te Tomokanga' - an established local Maori model of engagement. This model served as an essential guide for researchers coming into the community and at the same time, enabled the community to take ownership of the research process. This may have applicability to research in rural Indigenous communities elsewhere.

Point-of-care ultrasound in rural New Zealand: Safety, quality and impact on patient management.

OBJECTIVE: To evaluate the safety, quality and impact of point-of-care ultrasound on patient management when performed by rural generalist doctors. DESIGN: Cross-sectional descriptive study. SETTING: Six rural small hospitals serving a range of communities in rural New Zealand. PARTICIPANTS: All generalist doctors practising ultrasound in the study hospitals. MAIN OUTCOME MEASURES: Technical quality, accuracy, impact on diagnostic certainty, patient disposition and overall patient care. RESULT: Participants correctly interpreted 90% of images and a similar percentage of point-of-care ultrasound findings when compared with the results of formal imaging or the final diagnosis. In total, 87% of scans contributed to the diagnostic process, changing the diagnostic probability. There was a 4% overall reduction in the number of patients needing hospital admission or transfer to an urban base hospital. The overall impact on patient care was positive for 71% of point-of-care ultrasound scans. Three percent of scans had the potential for patient harm. CONCLUSION: Rural generalists' practise a broad scope of point-of-care ultrasound that, when used as a part of the full clinical assessment, has a positive impact on patient care, improving diagnostic certainty and reducing the need for hospital admission and inter-hospital transfer. There are challenges in learning and maintaining the skills needed to practise a high standard of point-of-care ultrasound in this context. Further consideration needs to be given to the development safe scopes of practice, training, credentialing and quality assurance.

A targeted rural postgraduate education programme - linking rural doctors across New Zealand and into the Pacific.

This article describes the University of Otago Rural Postgraduate medical programme, established in 2002 to provide a targeted rural education option for medical practitioners working in rural and remote areas of New Zealand. With both faculty and participants dispersed throughout New Zealand and the Cook Islands embedded in day to day rural clinical practice, this programme uniquely reflects the national and international clinical networks it has been developed to support. It now provides the academic component of two vocational training programmes: the New Zealand Rural Hospital Medicine Training Programme and The Cook Islands General Practice Training Programme. We describe the journey the Rural Postgraduate programme has taken over the last decade: the opportunities, learnings and challenges. The programme is continuing to expand and is creating a growing community of rural and remote practitioners throughout New Zealand and the Pacific.

Training generalist doctors for rural practice in New Zealand.

Targeted postgraduate training increases the likelihood young doctors will take up careers in rural generalist medicine. This article describes the postgraduate pathways that have evolved for these doctors in New Zealand. The Cairns consensus statement 2014 defined rural medical generalism as a scope of practice that encompasses primary care, hospital or secondary care, emergency care, advanced skill sets and a population-based approach to the health needs of rural communities. Even as work goes on to define this role different jurisdictions have developed their own training pathways for these important members of the rural healthcare workforce. In 2002 the University of Otago developed a distance-taught postgraduate diploma aimed at the extended practice of rural general practitioners (GPs) and rural hospital medical officers. This qualification has evolved into a 4-year vocational training program in rural hospital medicine, with the university diploma retained as the academic component. The intentionally flexible and modular nature of the rural hospital training program and university diploma allow for a range of training options. The majority of trainees are taking advantage of this by combining general practice and rural hospital training. Although structured quite differently the components of this combined pathway looks similar to the Australian rural generalist pathways. There is evidence that the program has had a positive impact on the New Zealand rural hospital medical workforce.

The impact of a rural scanner in overcoming urban versus rural disparities in the utilisation of computed tomography.

OBJECTIVE: In 2008, Oamaru Hospital became the second rural hospital in New Zealand to install a computed tomography (CT) scanner. This article assesses the impact of this on local CT scanning rates. DESIGN: Observational: review of radiology department data. SETTING: Rural hospital imaging services. PARTICIPANTS: CT scanning patients residing in Otago region during the study period. INTERVENTIONS: There is no intervention in this observational study. MAIN OUTCOME MEASURES: CT scanning rates and waiting times before and after the introduction of the rural scanner. RESULTS: Prior to the scanner being commissioned, there was a significant urban versus rural disparity in CT utilisation. Residents in the neighbouring urban centre were 1.4 times more likely to access CT (33.2 (95% confidence interval (CI) 32.2-34.2) versus 23.0 (95% CI 21.0-25.1) scans per 1000 residents per annum). Twenty months after the scanner was commissioned, the rate for the rural community had almost doubled to 45.6 (95% CI 43.0-48.2) and was 1.2 times greater than for the urban community. This difference was not sustained, and rural and urban communities had similar CT scanning rates in 2011 and 2012. Mean waiting time for residents in the rural community fell from 21.1 (95% CI 17.1-25.2) days prior to the scanner to 6.7 (95% CI 5.6-7.8) days after the scanner was commissioned. CONCLUSIONS: On-site CT increased the rural scanning rate, corrected the rural-urban disparity and reduced waiting times without apparent over servicing.

He Aroka Uruta. Rural health provider perspectives of the COVID-19 vaccination rollout in rural Aotearoa New Zealand with a focus on Maori and Pasifika communities: a qualitative study.

Introduction From a coronavirus disease (COVID-19) pandemic perspective, Aotearoa New Zealand (NZ) rural residents formed an at-risk population, and disparities between rural and urban COVID-19 vaccination coverage have been found. Aim To gain insight into factors contributing to the urban-rural COVID-19 vaccination disparity by exploring NZ rural health providers' experiences of the vaccine rollout and pandemic response in rural Maori and Pasifika communities. Methods Rural health providers at four sites participated in individual or focus group semi-structured interviews exploring their views of the COVID-19 vaccine rollout. Thematic analysis was undertaken using a framework-guided rapid analysis method. Results Twenty interviews with 42 participants were conducted. Five themes were identified: Pre COVID-19 rural situation, fragile yet resilient; Centrally imposed structures, policies and solutions - urban-centric and Pakeha focused; Multiple logistical challenges - poor/no consideration of rural context in planning stages resulting in wasted resource and time; Taking ownership - rural providers found geographically tailored, culturally anchored and locally driven solutions; Future directions - sustained investment in rural health services, including funding long-term integrated (rather than 'by activity') health services, would ensure success in future vaccine rollouts and other health initiatives for rural communities. Discussion In providing rural health provider perspectives from rural areas serving Maori and Pasifika communities during the NZ COVID-19 vaccine rollout, the importance of the rural context is highlighted. Findings provide a platform on which to build further research regarding models of rural health care to ensure services are designed for rural NZ contexts and capable of meeting the needs of diverse rural communities.

Te Paatu o Te Ao Hurihuri - pandemic-related virtual adaptation of an established marae-based workshop for rural doctors: a qualitative study.

Introduction Due to COVID-19 pandemic restrictions in Aotearoa New Zealand, an established remote community marae-based workshop (a component of a postgraduate rural medical programme) was converted into a virtual platform. Aim The aim of this study was to explore student and teacher experiences of this virtual adaptation with focus on cultural aspects. Methods A qualitative exploratory study was undertaken that involved document review and qualitative interviews. Students and teachers were invited to participate. Semi-structured interviews were conducted. Thematic analysis was undertaken using a framework-guided rapid analysis method. The two participant groups' data were analysed concurrently but separately. Results Students found the virtual workshop valuable in furthering their knowledge of Maori culture, cross-cultural communication skills and health inequities in rural clinical practice. Through the innovative efforts of their teachers, they felt some sense of connection with the remote locality and its people. Teachers were able to impart knowledge, connect and keep everyone culturally safe through their commitment and adaptability. However, moving to a virtual platform meant compromise to the cultural experience for students and loss of sharing the learning and experience with their place and their people. Discussion In the event of a further pandemic or other emergency situation, where strong established relationships exist, replacing an in-person remote marae-based workshop with a virtual workshop, while limited, is achievable and has value. When urban tertiary institutions partner with remote Maori communities to deliver virtual teaching, caution is needed in ensuring sustained transparency in priorities and expectations to avoid further exacerbations of power imbalance and resulting loss of value.

Defining catchment boundaries and their populations for Aotearoa New Zealand's rural hospitals.

Introduction There is considerable variation in the structure and resources of New Zealand (NZ) rural hospitals; however, these have not been recently quantified and their effects on healthcare outcomes are poorly understood. Importantly, there is no standardised description of each rural hospital's catchment boundary and the characteristics of the population living within this area. Aim To define and describe a catchment population for each of New Zealand's rural hospitals. Methods An exploratory approach to developing catchments was employed. Geographic Information Systems were used to develop drive-time-based geographic catchments, and administrative health data (National Minimum Data Set and Primary Health Organisation Data Set) informed service utilisation-based catchments. Catchments were defined at both the Statistical Area 2 (SA2) and domicile levels, and linked to census-based population data, the Geographic Classification for Health, and the area-level New Zealand Index of Socioeconomic Deprivation (NZDep2018). Results Our results highlight considerable heterogeneity in the size (max: 57 564, min: 5226) and characteristics of populations served by rural hospitals. Substantial differences in the age structure, ethnic composition, socio-economic profile, 'remoteness' and projected future populations, are noted. Discussion In providing a standardised description of each rural hospital's catchment boundary and its population characteristics, the considerable heterogeneity of the communities served by rural hospitals, both in size, rurality and socio-demographic characteristics, is highlighted. The findings provide a platform on which to build further research regarding NZ's rural hospitals and inform the delivery of high-quality, cost-effective and equitable health care for people living in rural NZ.

The allied health workforce of rural Aotearoa New Zealand: a scoping review.

Introduction The allied health workforce is a crucial, if at times poorly visible, component of modern healthcare systems. The services provided by allied health professionals may be particularly important for underserved populations, including rural and remote communities. Aim To determine what is currently known through research about the allied health workforce in rural Aotearoa New Zealand. Method A scoping review of diverse sources of literature from Aotearoa New Zealand was obtained from seven databases (July 2011-July 2021). Results Eighty-nine articles were identified, of which 10 met the inclusion criteria; nine empirical studies and one narrative review. The included research fell into two main categories: geographic workforce distribution (n = 8), and the role of the rural allied health workforce (n = 2). Discussion The paucity of research that meets the criteria for inclusion makes it difficult to draw conclusions about the allied health workforce in rural Aotearoa New Zealand. There is a focus in both the international rural allied health literature and the Aotearoa New Zealand rural medical and nursing literature on: measuring geographic workforce distribution; and rural-specific training. This suggests that these issues are important to the rural workforce. Similar research is needed in Aotearoa New Zealand to inform policy and ensure the rural allied health workforce reaches its full potential in improving health outcomes for rural New Zealanders.

New Zealand postgraduate medical training by distance for Pacific Island country-based general practitioners: a qualitative study.

Introduction New Zealand health training institutions have an important role in supporting health workforce training programmes in the Pacific Region. Aim To explore the experience of Pacific Island country-based doctors from the Cook Islands, Niue, and Samoa, studying in New Zealand's University of Otago distance-taught Rural Postgraduate programme. Methods Document analysis (16 documents) was undertaken. Eight semi-structured interviews were conducted with Pacific Island country-based students. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately, followed by a process to converge and corroborate findings. Results For Pacific Island countries with no previous option for formal general practice training, access to a recognised academic programme represented a milestone. Immediate clinical relevance and applicability of a generalist medical curriculum with rural remote emphasis, delivered mainly at a distance, was identified as a major strength. Although technologies posed some issues, these were generally easily solved. The main challenges identified related to the provision of academic and other support. Traditional university support services and resources were campus focused and not always easily accessed by this group of students who cross educational pedagogies, health systems and national borders to study in a New Zealand programme. Study for individuals worked best when it was part of a recognised and supported Pacific in-country training pathway. Discussion The University of Otago's Rural Postgraduate programme is accessible, relevant and achievable for Pacific Island country-based doctors. The programme offers a partial solution for training in general practice for the Pacific region. Student experience could be improved by tailoring and strengthening support services and ensuring their effective delivery.

New Zealand's rural hospitals in 2021: findings from an exploratory questionnaire survey.

Introduction There is a gap in our knowledge of the place and contribution of rural hospitals in the New Zealand health system. There is no current description of rural hospital services, no national policies and little published research regarding their value. Aim To explore rural hospital leader perspectives of the role of rural hospitals. Methods An on-line survey of rural hospital leaders conducted to capture perspectives on areas including facility nomenclature; access and equity; funding and the health reforms. Results Fifty-five rural hospital leaders representing 19/24 rural hospitals responded. 'Rural Hospital' was the most common term used to describe facilities with 80% of respondents indicating this as their preferred term. Other descriptive terms varied widely from primary through to secondary care. Respondents indicated that the loss of rural hospital in-patient beds would be unacceptable to communities (median 0, IQR 0, 1). Scores on questions about 'range of services' (median 7, IQR 6, 8), 'accessibility' (median 7, IQR 6, 8) and how rural hospitals were addressing health equity (median 6, IQR 5, 7) were variable. The process for allocating funds to rural hospitals was perceived as lacking transparency (median 3, IQR 2, 5). National strategy and 'local governance and control' were both rated as important (median 9, IQR 7, 10 and median 9, IQR, 8, 10) for a rural hospital's future. Discussion By capturing a collective national rural hospital leadership voice, this study facilitates the understanding of the rural hospital concept. The findings inform subsequent research needed to gain a clearer picture of New Zealand rural hospital provision.

Point-of-Care Haematology Analyser Quality Assurance Programme: a rural nursing perspective.

BACKGROUND AND CONTEXT Rural health services without an onsite laboratory lack timely access to haematology results. Set in New Zealand's far north, this paper provides a rural nursing perspective on how a health service remote from a laboratory introduced a haematology analyser suitable for point-of-care use and established the associated quality assurance programme. ASSESSMENT OF PROBLEM Five broad areas were identified that could impact on successful implementation of the haematology analyser: quality control, staff training, physical resources, costs, and human resource requirements. RESULTS Quality control testing, staff training and operating the haematology analyser was more time intensive than anticipated. Finding adequate physical space for placement and operation of the analyser was challenging and costs per patient tests were higher than predicted due to low volumes of testing. STRATEGIES FOR IMPROVEMENT Through a collaborative team approach, a modified quality assurance programme was agreed on with the supplier and regional point-of-care testing co-ordinator, resulting in a reduced cost per test. The supplier provided dedicated hours of staff training. Allocated time was assigned to run point-of-care testing quality assurance. LESSONS Having access to laboratory tests can reduce inequalities for rural patients, but natural enthusiasm to introduce new point-of-care technologies and devices needs to be tempered by a thorough consideration of the realities on the ground. Quality assurance programmes need to fit the locality while being overseen and supported by laboratory staff knowledgeable in point-of-care testing requirements. Associated costs need to be sustainable in both human and physical resources.