A Toolkit for Delirium Identification and Promoting Partnerships Between Carers and Nurses: A Pilot Pre-Post Feasibility Study.

BACKGROUND: Delirium is frightening for people experiencing it and their carers, and it is the most common hospital-acquired complication worldwide. Delirium is associated with higher rates of morbidity, mortality, residential care home admission, dementia, and carer stress and burden, yet strategies to embed the prevention and management of delirium as part of standard hospital care remain challenging. Carers are well placed to recognize subtle changes indicative of delirium, and partner with nurses in the prevention and management of delirium. OBJECTIVE: To evaluate a Prevention & Early Delirium Identification Carer Toolkit (PREDICT), to support partnerships between carers and nurses to prevent and manage delirium. DESIGN: A pre-post-test intervention and observation study. MAIN MEASURES: Changes in carer knowledge of delirium; beliefs about their role in partnering with nurses and intended and actual use of PREDICT; carer burden and psychological distress. Secondary measures were rates of delirium. PARTICIPANTS: Participants were carers of Indigenous patients aged 45 years and older and non-Indigenous patients aged 65 years and older. INTERVENTION: Nurses implemented PREDICT, with a view to provide carers with information about delirium and strategies to address caregiving stress and burden. KEY RESULTS: Participants included 25 carers (43% response rate) (n = 17, 68% female) aged 29-88 (M = 65, SD = 17.7 years). Carer delirium knowledge increased significantly from pre-to-post intervention (p = < .001; CI 2.07-4.73). Carers' intent and actual use of PREDICT was (n = 18, 72%; and n = 17, 68%). Carer burden and psychological distress did not significantly change. The incidence of delirium in the intervention ward although not significant, decreased, indicating opportunity for scaling up. CONCLUSION: The prevention and management of delirium are imperative for safe and quality care for patients, carers, and staff. Further comprehensive and in-depth research is required to better understand underlying mechanisms of change and explore facets of nursing practice influenced by this innovative approach.

Establishing new medical schools in diverse contexts: A novel conceptual framework for success.

BACKGROUND: Establishing a new medical school is a significant venture involving many complex political, social, economic, educational, and organisational considerations. The published literature on the process of establishing a new medical school is, however, under-developed with minimal empirical research and no explicit reference to theory. This research sought to address these gaps and establish an empirical and theoretical evidence-base for the process of new medical school establishment in diverse contexts, particularly medically under-served areas. METHODS: A Critical Realist Multiple Case Study was undertaken to examine the establishment of new medical schools across three continents. Data were collected between 2016 and 2018 through observational data gathered on site visits to three medical schools in medically under-served areas, relevant documents/audio-visual materials, and semi-structured interviews with key founding personnel. Data were analysed using the Critical Realist approach. Institutional Entrepreneurship theory was applied, adapted, and extended to explore and explain the phenomenon of new medical school establishment in diverse contexts. RESULTS: This study identifies eight critical success factors underpinning new medical school establishment. Framed as the Eight C's Framework (8CF), these factors include Context (field conditions), Catalysts (institutional entrepreneurs), Conducing (helping to bring about a particular situation or outcome), Collecting (resources), Connecting (relationships), Convincing (rationales), Challenges, and Consequences (outcomes). 8CF highlights that new medical schools are successfully established when Catalysts act within their Contexts to undertake the tasks of Conducing, Convincing, Collecting, and Connecting in order to produce desired Consequences and overcome Challenges. CONCLUSIONS: The Eight C's Framework is a theory-based, empirically supported framework that can be applied across different contexts to strategically guide the successful establishment of new medical schools. Founding leaders and stakeholders could use 8CF to ensure their establishment efforts are underpinned by theory and scholarship.

Aging, care and dependency in multimorbidity: how do relationships affect older Bangladeshi women's use of homecare and health services?

Gender issues can create major barriers to healthcare utilization for older women with multimorbidity, especially in developing countries like Bangladesh. Elderly rural women in Bangladesh, are the poorest of the poor, and the women with multimorbidity live in a regulated family atmosphere. This study explored the relationship dimensions of older women with multimorbidity in homecare and their utilization of health services. To gain a deeper understanding of these complex issues, a qualitative case study was conducted. Semi-structured, in-depth interviews were conducted with 11 health staff and 22 older women with multimorbidity, living in three residential communities of the Sylhet District, Bangladesh. Our analysis used critical thematic discourse, a technique developed from Axel Honneth's recognition-and-misrecognition theory. Seven relationship dimensions have been identified, and grouped under three major themes: intimate affairs [marital marginalization and parent-children-in law dynamics]; alienation in community relationships [patriarchal sibling relationships, neighborhood challenges, and gender inequality in interactions]; and legal disconnections [ignorance of rights and missed communication]. Our findings revealed a lack of understanding of the women's multimorbid care needs and patriarchal marginalization in family. This lack of understanding together with poor peer-supports in healthcare is perpetuated by misrecognition of needs from service providers, resulting in a lack of quality and poor utilization of homecare and health services. Understanding the high needs of multimorbidity and complexities of older women's relationships can assist in policy decisions. This study deepens our understanding of the ways gender inequality intersects with cultural devaluation to reduce the well-being of older women in developing countries.

The outcomes of a person-centered, non-pharmacological intervention in reducing agitation in residents with dementia in Australian rural nursing homes.

BACKGROUND: There is limited best- practice evidence to address behavioral and psychiatric symptoms for those with dementia in Australian rural nursing homes. This study aims to evaluate the outcomes of a person-centered, non-pharmacological dementia care model, 'Harmony in the Bush', based on the Progressively Lowered Stress Threshold principles and person-centered music in rural Australia. METHODS: A quasi-experimental (nonrandomized, pre-post) intervention study was conducted in five rural nursing homes in Queensland and South Australia. Seventy-four residents with dementia participated in this intervention study, which yielded a sample power of 80%. Eighty-seven staff completed the Caregiver Stress Inventory at pre-post four-weeks of intervention. Staff training workshops focused on the theory of the Progressively Lowered Stress Threshold principles and delivery of person-centered care plan with integrated music intervention. We used reported changes in agitation of the residents, measured using Cohen- Mansfield Agitation Inventory, and staff's caregiving stress, using Caregivers Stress Inventory. This study adheres to the CONSORT guidelines. RESULTS: Mean age of residents with dementia was 82.4 (7.7) years and 69% were females. The mean age of admission was 80.1(8.4) years. Baseline measures indicated that 32.7% had mild- severe pain and 30.5% reported mild-severe sadness. The results showed statistically significant decline in aggressive behaviors, physically non-aggressive behaviors, verbally agitated behavior and hiding and hoarding. There was similar reduction in staff stress in the domains of aggressive behaviors, inappropriate behaviors, resident safety, and resource deficiency. CONCLUSIONS: The Harmony in the Bush model is effective in reducing agitation among dementia residents with significant reduction in staff stress levels in nursing homes in rural Australia. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR) on 20/2/2018 (Registration No: ACTRN12618000263291p). https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374458.

Personalised music for residents with dementia in an Australian rural aged-care setting.

OBJECTIVE: Personalised music reportedly has a positive effect on behaviour and mood in people living with dementia. This intervention has not been conducted in low-resourced or rural aged-care settings. We evaluated the effect of a non-therapist-led personalised music listening intervention on residents with dementia and workplace culture in a rural aged-care facility in South Australia. DESIGN: Qualitative pilot study. SETTING: Rural aged-care home in South Australia. PARTICIPANTS: Ten residents with dementia and 15 aged-care staff participated in this study. INTERVENTIONS: Ten residents participated in an 8-week music program. Four focus groups were conducted with aged-care staff post-intervention. A thematic analysis was used to identify emerging themes. MAIN OUTCOME MEASURE: Personalised music positively influenced resident's behaviour and well-being, social interaction and the workplace environment and culture, and served as a useful tool for personalised care. RESULTS: Three themes emerged: quality of life, personalised care and better aged-care environment. Personalised music positively influenced resident's behaviour and well-being, social interaction and the workplace environment and culture, and served as a useful tool for personalised care. CONCLUSION: Personalised music program is an effective, low-cost intervention to improve quality of life and personalised care of residents living with dementia, staff well-being, and a workplace and culture in low-resourced or rural aged-care settings.

Exploring interprofessional education and collaborative practice in Australian rural health services.

This article explores how work-based interprofessional education (IPE) influences collaborative practice in rural health services in Australia. Using a qualitative case study design, three rural hospitals were the focal point of the project. Marginal participant observations (98 hours) and semistructured interviews (n = 59) were undertaken. Participants were medical practitioners, nursing and midwifery professionals, physiotherapists, paramedics, social workers and administrative staff, who provided services in relation to each hospital. Data in the form of audio recordings and field notes, including researcher reflections were recorded over a three-year period. Whilst this study comprised of three phases, this article explores the extent to which collaborative practice was present or not before and after IPE. An inductive content analysis resulted in the following themes: Conceptualizing Collaborative Practice, Profession-Driven Education, and Professional Structures and Socialization. Community of practice theory is used to explore the barriers created through profession-based communities of practice.

The power of simulation: a large-scale narrative analysis of learners' experiences.

CONTEXT: Simulation-based education (SBE) includes a broad spectrum of simulation activities, which are individually well researched. An extensive literature reports on SBE methods, topics and modalities, but there are limited studies investigating how simulation as a holistic phenomenon promotes learning. This study seeks to identify the ways in which health professionals narrate powerful SBE experiences and through this to understand in what ways SBE may influence learning. METHODS: Three hundred and twenty-seven narratives about powerful learning through SBE were gathered from participants' online reflections from a national faculty development programme in SBE. Narrative and thematic analyses were conducted on included texts, using 'transformative learning theory' as a sensitising notion. RESULTS: Narratives were categorised into the following categories: progress (267/327 = 81%); transformation (25/327 = 8%); practice (27/328 = 8%); and humiliation (8/327 = 2%). Recurrent features across narrative categories were as follows: early experiences in training; dramatic scenarios; developing appreciation of SBE; highly emotional experiences; things that 'went wrong'; and ongoing reflection. Themes regarding mechanisms that supported learning were as follows: verisimilitude; feedback, debriefing and facilitation; observation of self and others; repetition of activities; and role-playing the patient. CONCLUSIONS: The results generally support the notion that SBE is experienced as a holistic phenomenon, rather than separate modalities. The narrative categories, recurrent features and learning themes tended to work across all simulation modalities, with the exception of 'being in the patient's shoes' being supported by role-play in particular. Although powerful experiences were not necessarily transformative ones, they often occurred at formative stages of training. There was a strong sense that things going wrong in simulation scenarios (and the associated emotions and reflection) were a key part of learning. This underlines SBE's potential role in helping learners see fallibility as part of professional practice.

Emergency rural obstetric transfers in South Australia: a review of the clinical and precipitating factors.

INTRODUCTION: The provision of critical management of obstetric emergencies is a vital service for rural women and their families. Emergency obstetric transfers are indispensable to reduce maternal and neonatal mortality and morbidity because local rural hospitals often do not have the resources or expertise to manage both maternal and neonatal outcomes. However, the transfer of a rural pregnant woman to a higher level, tertiary perinatal centre (TPC) is often stressful for the patient and costly for health services. Currently, little is known about the main reasons for obstetric transfers in rural South Australia, and there is even less information about the management of mothers and babies once they arrive at their destination. The present guidelines for informing the necessity of transferring from a rural or remote area to a TPC are unclear. This study aims to describe the clinical reasons for obstetric transfers from a rural area in South Australia and explore predictive factors of likelihood of delivery on transfer. Additionally, this study aims to determine the outcomes of transfers in terms of location of delivery, timing of delivery and to explore the association between delivery after transfer and clinical reasons for transfer. METHOD: All women from the Riverland region of South Australia who were transferred antenatally at >20 weeks gestational age for an acute admission to a TPC over a 5-year period were included in a retrospective review. Participants were determined from hospital coding data, and medical case notes were retrieved for all participants. The demographic and clinical data, including details of the emergency presentation and outcomes of women transferred to a tertiary hospital, were analysed with descriptive statistics (mean, standard deviation). A logistic regression was performed for predictive factors associated with delivery on transfer. RESULTS: A total of 160 patients were transferred antenatally. A minority of participants delivered on admission (35%). Of the women who were discharged undelivered, 43% eventually delivered at their rural hospital and the remainder delivered later in a tertiary hospital as part of a planned admission. The most common diagnoses for transfer were preterm labour, premature preterm rupture of membranes, antepartum haemorrhage and placental disorders. Delivery on transfer was associated with preterm premature rupture of membranes and pre-eclampsia. Likelihood of delivery on transfer was not increased with preterm gestation, cervical dilation or other presenting diagnosis. There was not an association of increased number of indications for transfer and likelihood of delivering after transfer. CONCLUSION: This study suggests that the rural doctor workforce in the Riverland region appears to be well skilled at identifying obstetric emergencies despite the lack of guidance around what constitutes a high risk perinatal situation. Furthermore, this study quantifies the number of women who would potentially require support services associated with rural perinatal transfers from this area. There was a comparatively lower rate of delivery on transfer and, as such, these women eventually delivered their babies either at their hospital of origin or returned to a metropolitan hospital as part of a planned admission for delivery. Further research is needed about the practical implications of transferring pregnant women to tertiary centres and clinical decision-making tools to improve this process.

The Australian Rural Clinical School (RCS) program supports rural medical workforce: evidence from a cross-sectional study of 12 RCSs.

INTRODUCTION: Many strategies have been implemented to address the shortage of medical practitioners in rural areas. One such strategy, the Rural Clinical School Program supporting 18 rural clinical schools (RCSs), represents a substantial financial investment by the Australian Government. This is the first collaborative RCS study summarising the rural work outcomes of multiple RCSs. The aim of this study was to combine data from all RCSs' 2011 graduating classes to determine the association between rural location of practice in 2017 and (i) extended rural clinical placement during medical school (at least 12 months training in a rural area) and (ii) having a rural background. METHODS: All medical schools funded under the RCS Program were contacted by email about participation in this study. De-identified data were supplied for domestic students about their gender, origin (rural background defined as having lived in an Australian Standard Geographic Classification-Remoteness Area (ASGC-RA) 2-5 area for at least 5 years since beginning primary school) and participation in extended rural clinical placement (attended an RCS for at least 1 year of their clinical training). The postcode of their practice location according to the publicly available Australian Health Practitioner Regulation Agency (AHPRA) register was collected (February to August 2017) and classified into rural and metropolitan areas using the ASGC 2006 and the more recent Modified Monash Model (MMM). The main outcome measure was whether graduates were working in a 'rural' area (ASGC categories RA2-5 or MMM categories 3-7) or 'metropolitan' area. Pearson's χ2 test was used to detect differences in gender, rural background and extended placement at an RCS between rural and metropolitan practice locations. Binary logistic regression was used to determine odds of rural practice and 95% confidence intervals (CIs) were calculated. RESULTS: Although data were received from 14 universities, two universities had not started collecting origin data at this point so were excluded from the analysis. The proportion of students with a rural background had a range of 12.3-76.6% and the proportion who had participated in extended RCS placement had a range of 13.7-74.6%. Almost 17% (16.6%) had a principal practice postcode in a rural area (according to ASGC), range 5.8-55.6%, and 8.3% had a principal practice postcode in rural areas (according to MMM 3-7), range 4.5-29.9%. After controlling for rural background, it was found that students who attended an RCS were 1.5 times more likely to be in rural practice (95%CI 1.2-2.1, p=0.004) using ASGC criteria. Using the MMM 3-7 criteria, students who participated in extended RCS placement were 2.6 times as likely to be practising in a rural location (95%CI 1.8-3.8, p<0.001) after controlling for rural background. Regardless of geographic classification system (ASGC, MMM) used for location of practice and of student background (metropolitan or rural), those students with an extended RCS had an increased chance of working rurally. CONCLUSION: Based on the combined data from three-quarters (12/16) of the Australian medical schools who had a graduating class in 2011, this suggests that the RCS initiative as a whole is having a significant positive effect on the regional medical workforce at 5 years post-graduation.

Translating medical school social missions to student experiences.

CONTEXT: There is a growing focus on the social missions of medical schools as a way of expressing an institutional commitment to service, responsibility and accountability. However, there has been little exploration of how a social mission translates to student experiences. METHODS: This multicentre study explored how the social missions of eight medical schools (from Australia, Belgium, Canada, the Philippines, South Africa, Sudan and the USA) translated to their medical education programmes, and how their students perceived the mission. The study used a nested case study design involving interviews with final-year medical students. Constructivist grounded theory techniques were used to analyse the data. Cultural-historical activity theory concepts of externalisation and internalisation were used to structure the analyses. RESULTS: The study identified substantial variation in the form, focus and depth of expression of each school's social mission, significant variation in how and to what extent the mission was externalised in the design of each school's undergraduate medical education programme, and significant variation in how students perceived the social mission and its translation to their training experiences. The translation of a social mission to educational outcomes depended on a cascade of externalisation and internalisation processes, each of which could alter or reinterpret the mission. Translation depended to a great extent on sensitising learners to the mission's values and issues and subsequently activating this knowledge in the context of direct clinical encounters that embodied the issues the mission was seeking to address. CONCLUSION: Whether a medical school's social mission is focused on equity of access to the medical profession or on its graduates serving particular community needs, the mission principles need to be translated into practice. This translation process involves a series of externalisation and internalisation steps, each of which determines how much and what aspects of the mission are translated.

Practice intentions at entry to and exit from medical schools aspiring to social accountability: findings from the Training for Health Equity Network Graduate Outcome Study.

BACKGROUND: Understanding the impact of selection and medical education on practice intentions and eventual practice is an essential component of training a fit-for-purpose health workforce distributed according to population need. Existing evidence comes largely from high-income settings and neglects contextual factors. This paper describes the practice intentions of entry and exit cohorts of medical students across low and high income settings and the correlation of student characteristics with these intentions. METHODS: The Training for Health Equity Network (THEnet) Graduate Outcome Study (GOS) is an international prospective cohort study tracking learners throughout training and ten years into practice as part of the longitudinal impact assessment described in THEnet's Evaluation Framework. THEnet is an international community of practice of twelve medical schools with a social accountability mandate. Data presented here include cross-sectional entry and exit data obtained from different cohorts of medical students involving eight medical schools in six countries and five continents. Binary logistic regression was used to create adjusted odds ratios for associations with practice intent. RESULTS: Findings from 3346 learners from eight THEnet medical schools in 6 countries collected between 2012 and 2016 are presented. A high proportion of study respondents at these schools come from rural and disadvantaged backgrounds and these respondents are more likely than others to express an intention to work in underserved locations after graduation at both entry and exit from medical school. After adjusting for confounding factors, rural and low income background and regional location of medical school were the most important predictors of intent to practice in a rural location. For schools in the Philippines and Africa, intention to emigrate was more likely for respondents from high income and urban backgrounds. CONCLUSIONS: These findings, from a diverse range of schools with social accountability mandates in different settings, provide preliminary evidence for the selection and training of a medical workforce motivated to meet the needs of underserved populations. These respondents are being followed longitudinally to determine the degree to which these intentions translate into actual practice.

Two decades of building capacity in rural health education, training and research in Australia: University Departments of Rural Health and Rural Clinical Schools.

This review article reports on the contribution of university Departments of Rural Health and Rural Clinical Schools to the development of rural health and the rural health workforce and is set at the Australian Government's university Departments of Rural Health and Rural Clinical Training and Support Programs. The main outcome measures include educational infrastructure, clinical academic workforce, student numbers, community engagement, research outputs, rural health and workforce outcomes. As a result, university Departments of Rural Health and Rural Clinical Schools have established a substantial geographical footprint covering most of the rural and remote populations and regions across Australia. They have a large distributed rural clinical academic workforce that exceeds 1300. Medical student numbers on long-term placements have increased threefold from inception to 1200 annually. Allied health and nursing numbers doubled over 10 years to 4000 in 2013 and are projected to double again by 2018. In 2013, they published 363 peer-reviewed papers - half of which specifically addressed rural and/or remote health issues. High levels of intention to practise rurally and uptake of rural and remote practice following exposure to rural training have been reported, especially for medicine. Thus, university Departments of Rural Health and Rural Clinical Schools constitute a national network of academic units that deliver academically enriched clinical education and training for medical, nursing and allied health students and fulfil an essential academic role for the health system in rural and remote Australia. Community engagement and accountability to region are hallmarks of the program. Early evidence of the uptake of rural and remote practice following exposure to rural training has set expectations for the Rural Health Multidisciplinary Training Program.

Factors shaping how clinical educators use their educational knowledge and skills in the clinical workplace: a qualitative study.

BACKGROUND: In order to consolidate their educational knowledge and skills and develop their educational role, many clinicians undertake professional development in clinical education and supervision. It is well established that these educationally-focussed professional development activities have a positive impact. However, it is less clear what factors within the clinical workplace can shape how health professionals may use and apply their educational knowledge and skills and undertake their educational role. Looking through the lens of workplace affordances, this paper draws attention to the contextual, personal and interactional factors that impact on how clinical educators integrate their educational knowledge and skills into the practice setting, and undertake their educational role. METHODS: Data were gathered via a survey of 387 clinical educators and semi-structured interviews with 12 clinical educators and 6 workplace managers. In this paper, we focus on analysing and reporting the qualitative data gathered in this study. This qualitative data were subject to a thematic analysis and guided by theoretical constructs related to workplace affordances. RESULTS: Three key themes were identified including contextual, personal and interactional factors. Contextual elements referred to organisational structures and systems that impact on participants' educational role, how participants' clinical education role was articulated and configured within the organisation, and how the organisation shaped the educational opportunities available to clinicians. Personal factors encompassed clinicians' personal motivations and goals to teach and be involved in education, develop their own educational skills and function as a role model for students. Interactional factors referred to the professional interactions and networks through which clinicians shared their educational knowledge and skills and further consolidated their profile as educational advocates in their workplace. CONCLUSIONS: There are a number of contextual, personal and interactional factors which interrelate in complex ways and impact on how clinical educators use their educational knowledge and skills and undertake their educational role in the clinical setting. To fully realise the potential of and fulfil the requirements of their educational role, clinical educators need to be provided appropriate experiential and meaningful workplace opportunities and the guidance to use, share and reflect on their educational knowledge and skills in the clinical workplace.

A national training program for simulation educators and technicians: evaluation strategy and outcomes.

BACKGROUND: Simulation-based education (SBE) has seen a dramatic uptake in health professions education over the last decade. SBE offers learning opportunities that are difficult to access by other methods. Competent faculty is seen as key to high quality SBE. In 2011, in response to a significant national healthcare issue--the need to enhance the quality and scale of SBE--a group of Australian universities was commissioned to develop a national training program--Australian Simulation Educator and Technician Training (AusSETT) Program. This paper reports the evaluation of this large-scale initiative. METHODS: The AusSETT Program adopted a train-the-trainer model, which offered up to three days of workshops and between four and eight hours of e-learning. The Program was offered across all professions in all states and territories. Three hundred and three participants attended workshops with 230 also completing e-learning modules. Topics included: foundational learning theory; orientation to diverse simulation modalities; briefing; and debriefing. A layered objectives-oriented evaluation strategy was adopted with multiple stakeholders (participants, external experts), methods of data collection (end of module evaluations, workshop observer reports and individual interviews) and at multiple data points (immediate and two months later). Descriptive statistics were used to analyse numerical data while textual data (written comments and transcripts of interviews) underwent content or thematic analysis. RESULTS: For each module, between 45 and 254 participants completed evaluations. The content and educational methods were rated highly with items exceeding the pre-established standard. In written evaluations, participants identified strengths (e.g. high quality facilitation, breadth and depth of content) and areas for development (e.g. electronic portfolio, learning management system) of the Program. Interviews with participants suggested the Program had positively impacted their educational practices. Observers reported a high quality educational experience for participants with alignment of content and methods with perceived participant needs. CONCLUSIONS: The AusSETT Program is a significant and enduring learning resource. The development of a national training program to support a competent simulation workforce is feasible. The Program objectives were largely met. Although there are limitations with the study design (e.g. self-report), there are strengths such as exploring the impact two months later. The evaluation of the Program informs the next phase of the national strategy for simulation educators and technicians with respect to content and processes, strengths and areas for development.

Towards an understanding of medical student resilience in longitudinal integrated clerkships.

BACKGROUND: Resilience is required to succeed academically, overcome challenges during clinical training and cope positively with stress in future professional life. With medical students at high risk of mental illness, socially accountable medical schools are seeking to foster student resilience. This exploratory study proposes a conceptual framework for student resilience in longitudinal integrated clerkships (LICs). METHODS: This qualitative study sought to understand student resilience during the first year of clinical training in a rural LIC where there were consistent anecdotal reports of high student resilience. In-depth interviews were conducted with a purposive sample of 19 medical students, professional staff and clinician teachers. An interpretive approach was used to analyse the data with emerging concepts compared to define evolving theoretical constructs, and develop a conceptual framework. RESULTS: LIC students experienced adversity during the first clinical year of the medical course due to challenges encountered in the learning environment. This distress was moderated by: a secure, supportive learning environment; their profound learning journey; and utilisation of organisational structures to stay on course. CONCLUSION: This triad of inter-related themes forms a conceptual model that challenges simplistic notions that medical courses should focus solely on providing tangible and emotional supports for students. How LIC programs may contribute to student wellbeing is discussed through the lenses of agentic, reflective and transformative learning.

Outcomes of Australian rural clinical schools: a decade of success building the rural medical workforce through the education and training continuum.

INTRODUCTION: The establishment of the rural clinical schools funded through the Commonwealth Department of Health and Ageing (now Department of Health) Rural Clinical Training and Support program over a decade ago has been a significant policy initiative in Australian rural health. This article explores the impacts of this policy initiative and presents the wide range of educational innovations contextualised to each rural community they serve. METHODS: This article reviews the achievements of the Australian rural clinical and regional medical schools (RCS/RMS) through semi-structured interviews with the program directors or other key informants. The questions and responses were analysed according to the funding parameters to ascertain the numbers of students, types of student placements and range of activities undertaken by each university program. RESULTS: Sixteen university medical schools have established 18 rural programs, creating an extensive national network of RCS and RMS in every state and territory. The findings reveal extensive positive impacts on rural and regional communities, curriculum innovation in medical education programs and community engagement activities. Teaching facilities, information technology, video-conferencing and student accommodation have brought new infrastructure to small rural towns. Rural clinicians are thriving on new opportunities for education and research. Clinicians continue to deliver clinical services and some have taken on formal academic positions, reducing professional isolation, improving the quality of care and their job satisfaction. This strategy has created many new clinical academics in rural areas, which has retained and expanded the clinical workforce. A total of 1224 students are provided with high-quality learning experiences for long-term clinical placements. These placements consist of a year or more in primary care, community and hospital settings across hundreds of rural and remote areas. Many programs offer longitudinal integrated clerkships; others offer block rotations in general practice and specialist clinics. Nine universities established programs prior to 2004, and these well-established programs are finding graduates who are returning to rural practice. Universities are required to have 25% of the students from a rural background. University admission policies have changed to encourage more applications from rural students. This aspect of the policy implements the extensive research evidence that rural-origin students are more likely to become rural practitioners. Additional capacity for research in RCS has influenced the rural health agenda in fields including epidemiology, population health, Aboriginal health, aged care, mental health and suicide prevention, farming families and climate change. There are strong research partnerships with rural workforce agencies, research centres for early career researchers and PhD students. CONCLUSIONS: The RCS policy initiative has vastly increased opportunities for medical students to have long-term clinical placements in rural health services. Over a decade since the policy has been implemented, graduates are being attracted to rural practice because they have positive learning experiences, good infrastructure and support within rural areas. The study shows the RCS initiative sets the stage for a sustainable future Australian rural medical workforce now requiring the development of a seamless rural clinical training pipeline linking undergraduate and postgraduate medical education.

2014 Rural Clinical School Training and Support Program Snapshot survey.

INTRODUCTION: The Rural Clinical Training and Support (RCTS) program is an Australian Government initiative to address the shortage of medical practitioners within rural and remote Australia. There is a large amount of published information about the RCTS program and rural medical student cohorts who have undertaken short- and long-term rotations. However, very little is known about the academic and professional staff involved in the program, a knowledge gap that may impact workforce and succession planning. To address this, the Federation of Rural Australian Medical Educators (FRAME) initiated the pilot 2014 RCTS Snapshot survey to obtain data on the current RCTS workforce. METHODS: All professional, academic and clinical academic staff (fixed-term and continuing, regardless of fraction) employed through the RCTS program were invited to complete a short, web-based survey. The survey was conducted from March to June 2014. The quantitative variables in the survey included demographics (age and gender), rural background and exposure, employment history in rural/regional areas and at rural clinical schools (RCS), experience and expertise, reasons for working at RCS, and future employment intentions. The last three questions also were of a qualitative open-ended format to allow respondents to provide additional details regarding their reasons for working at RCSs and their future intentions. RESULTS: The estimated total RCTS workforce was 970. A total of 413 responses were received and 316 (40.9%) complete responses analysed. The majority of respondents were female (71%), the 40-60-year age group was predominant (28%), and professional staff constituted the majority (62%). The below 40-year age group had more professionals than academics (21% vs 12%) and more than 62% of academics were aged above 50 years. Notably, there were no academics aged less than 30 years. The percentage of professional staff with a rural background was higher (62%) than that of academics with a rural background (42%). However, more than 70% of academics had previous exposure to a rural area as an adult and 32% had an exposure as a part of university or the TAFE (technical and further education) system. More than half (62%) of RCTS academics were aged more than 50 years and thus approaching retirement age. The implementation of a FRAME-sponsored leadership and succession program was considered by most staff (84%) as one strategy that could be used to prevent a future shortage of academics. Lifestyle reasons for working at an RCS were common to both academic (54%) and professional (63%) staff. A passion for rural health and building capacity within the rural health workforce were other central themes to emerge from the qualitative data. Uncertainty around contract renewal and future funding were dominant themes to emerge from respondents regarding their future employment intentions within the RCTS program. CONCLUSIONS: This study has provided valuable insights into the professional and academic staff's views and aspirations about the RCTS program. These data on the current RCTS workforce provide a benchmark to which future surveys of the workforce can be compared to monitor trends in turnover or predict future shortages due to cohort ageing.

A patient safety focused registered nurse transition to practice program.

New graduate registered nurses (NGRN's) have an expectation of clinical support as they make the transition from novice to advanced beginner. In this 2008-2009 study of three rural transition to practice programs we found that clinical support did not eventuate. Consequently, NGRN's reported feeling underprepared for practice, overwhelmed by responsibility and often abandoned. Against this background, many were concerned that their inexperience had implications for safe patient care. Graduate nurse transition programs need to have the physical and human resources necessary to deliver the clinical support as promised in their prospectus, to ensure patient safety. This grounded theory study identified three essential core elements - leadership support, clinical supervision, and effective interprofessional relationships. Recommendation is made to address these deficits by mandating their inclusion in all transition to professional practice programs.

Adelaide stroke incidence study: declining stroke rates but many preventable cardioembolic strokes.

BACKGROUND AND PURPOSE: Stroke incidence rates are in flux worldwide because of evolving risk factor prevalence, risk factor control, and population aging. Adelaide Stroke Incidence Study was performed to determine the incidence of strokes and stroke subtypes in a relatively elderly population of 148 000 people in the Western suburbs of Adelaide. METHODS: All suspected strokes were identified and assessed in a 12-month period from 2009 to 2010. Standard definitions for stroke and stroke fatality were used. Ischemic stroke pathogenesis was classified by the Trial of ORG 10172 in Acute Stroke Treatment criteria. RESULTS: There were 318 stroke events recorded in 301 individuals; 238 (75%) were first-in-lifetime events. Crude incidence rates for first-ever strokes were 161 per 100 000 per year overall (95% confidence interval [CI], 141-183), 176 for men (95% CI, 147-201), and 146 for women (95% CI, 120-176). Adjusted to the world population rates were 76 overall (95% CI, 59-94), 91 for men (95% CI, 73-112), and 61 for women (95% CI, 47-78). The 28-day case fatality rate for first-ever stroke was 19% (95% CI, 14-24); the majority were ischemic (84% [95% CI, 78-88]). Intracerebral hemorrhage comprised 11% (8-16), subarachnoid hemorrhage 3% (1-6), and 3% (1-6) were undetermined. Of the 258 ischemic strokes, 42% (95% CI, 36-49) were of cardioembolic pathogenesis. Atrial fibrillation accounted for 36% of all ischemic strokes, of which 85% were inadequately anticoagulated. CONCLUSIONS: Stroke incidence in Adelaide has not increased compared with previous Australian studies, despite the aging population. Cardioembolic strokes are becoming a higher proportion of all ischemic strokes.