Reflections on an evaluation of the 'Remote Health Experience' - an interprofessional learning, cultural immersion program.

INTRODUCTION: Cultural immersion can be an effective method of health professional student cultural learning, and part of interprofessional learning. This evaluation aimed to report the views of staff and Aboriginal and Torres Strait Islander contributors about a cultural immersion program, as well as the student perspective. METHODS: Semi-structured interviews with staff (11 non-Aboriginal, 3 Aboriginal) and Aboriginal contributors (n=3) were conducted after the 2020 immersion program. Data were collected from 138 student participants following the 2018 (n=45), 2019 (n=33) and 2020 (n=60) remote health experience immersion weekends in Katherine, in the Northern Territory of Australia. Seven staff of the 2020 weekend provided written feedback about their experiences. Qualitative data were analysed thematically, and quantitative results scored from ratings on a five-point scale were presented as means, standard deviations and percentage of respondents agreeing or strongly agreeing with evaluative statements. RESULTS: Results are presented under the four themes that were identified: (1) understanding remote practice, (2) Aboriginal culture, (3) working together and learning from each other, and (4) ongoing opportunities. Feedback from students and staff was overwhelmingly positive, with learning occurring in each of the intended areas. Relationship building and embedding Aboriginal and Torres Strait Islander culture and knowledge throughout the weekend were seen as invaluable components. CONCLUSION: The Katherine Remote Health Experience is a valuable, immersive introduction to remote health practice for students from multiple disciplines. As a standalone event it has developed positive relationships, improved knowledge, and encouraged students to consider practising outside of metropolitan areas. There is scope to further develop pathways into remote practice for interested students.

Perceptions of Australian remote area nurses about why they stay or leave: A qualitative study.

AIM: The aim of this study was to examine the perspectives of experienced Australian remote area nurses about remote nursing staff retention strategies. BACKGROUND: There is low retention of remote area nurses in remote Australia. Retention of remote area nurses can be improved by a supportive environment including good management, professional development and supervision. METHOD: This is a qualitative study using in-depth interviews with seven registered nurses with a minimum of 3 years remote area nursing experience. Participants were interviewed by phone, with the interviews audio-recorded then transcribed and analysed thematically. RESULTS: Participants had on average 12 years of experience as a remote area nurse. They valued teamwork, effective and flexible management practices and the ability to maintain their own cultural and social connectedness. A flexible service model with regular short breaks, filled by returning agency nurses to enable continuity of care and cultural connections, was seen as a viable approach. CONCLUSION: Flexible management practices that encourage short breaks for remote area nurses may increase retention. This would need to occur within a supportive management framework. IMPLICATIONS FOR NURSING MANAGEMENT: Management strategies that reduce isolation from personal and social networks can increase the retention of skilled remote area nurses.

Workplace locations of allied health and nursing graduates who undertook a placement in the Northern Territory of Australia from 2016 to 2019: An observational cohort study.

OBJECTIVE: The aim of the study is to determine the current work locations of allied health professionals and nurses who undertook a student placement in the Northern Territory of Australia from 2016-2019. DESIGN: An observational cohort study was conducted in October 2020, with students emailed a link to an on-line survey, plus two reminders. SETTING: Primary health care in the Northern Territory of Australia. PARTICIPANTS: All allied health and nursing students who undertook a student learning placement in the Northern Territory from 2016-2019 (n = 1936). MAIN OUTCOME MEASURES: Practicing nurses and allied health professionals were asked about their work history and locations (coded using the Modified Monash Model of remoteness and population size). RESULTS: The response rate was 14.2% (275/1936 students). Most respondents reported that their placement positively influenced them to consider working: in a rural or remote location (76%), in the Northern Territory (81%), and with marginalised or under-served populations (74%). Of the respondents, 224 had graduated and 203 were currently working in their health profession. A total of 31.4% of respondents reported that they had worked in a remote or rural location after graduation. CONCLUSIONS: The student placement had a positive effect on the likelihood of students working in a rural or remote location. A focus on recruiting students with a remote upbringing/background and offering longer placements would likely be successful in helping build the health professional workforce in remote locations.

Characteristics of nursing and allied health student placements in the Northern Territory over time (2017-2019) and placement satisfaction.

OBJECTIVE: Assess nursing and allied health student satisfaction with their remote Northern Territory integrated learning placement and consideration of future rural/remote work Describe the characteristics of these students Examine changes in student characteristics over time. DESIGN: A cross-sectional survey of students and a review of student placement data. SETTING: Northern Territory, Australia. PARTICIPANTS: Former students having a work integrated learning placement of more than 1 week in the Northern Territory from 2017 to 2019. MAIN OUTCOME MEASURE(S): Agreement with the statements 'This placement has encouraged me to consider living and working in a rural or remote location after I graduate' and 'Overall, I was satisfied with my placement.' The administrative record review examined student numbers, and placement length over time. RESULTS: A total of 341 students responded to the online survey. Overall satisfaction with the placement was very high (93%), and 84% agreed/strongly agreed that the placement had encouraged them to consider working in a rural or remote setting. High-quality clinical supervision and educational resources were associated with overall placement satisfaction. Overall placement satisfaction, prior interest in working remotely and satisfaction with educational resources were associated with consideration of working remotely. The number of students having a placement increased by 29% in 2017 to 2019. The number of placement weeks also increased (35%). CONCLUSIONS: The number/placement time of nursing and allied health students has increased in the NT. Satisfaction with remote work integrated learning placements is an the important pathway to growing a local health professional workforce in remote and rural settings.

Health Professional Student Placements and Workforce Location Outcomes: Protocol of an Observational Cohort Study.

BACKGROUND: The successful recruitment and retention of health professionals to rural and remote areas of Australia is a health policy priority. Nursing or allied health professional students' learning placements in the Northern Territory (NT) of Australia, most of which is considered remote, may influence rural or remote work location decisions. OBJECTIVE: The aim of this study is to determine where allied health professionals and nurses who have had a student placement in the NT of Australia end up practicing. METHODS: This research is an observational cohort study, with data collection occurring at baseline and then repeated annually over 10 years (ie, 2017-2018 to 2029). The baseline data collection includes a demographic profile of allied health and nursing students and their evaluations of their NT placements using a nationally consistent questionnaire (ie, the Student Satisfaction Survey). The Work Location Survey, which will be administered annually, will track work location and the influences on work location decisions. RESULTS: This study will generate unique data on the remote and rural work locations of nursing and allied health professional students who had a placement in the NT of Australia. It will be able to determine what are the most important characteristics of those who take up remote and rural employment, even if outside of the NT, and to identify barriers to remote employment. CONCLUSIONS: This study will add knowledge to the literature regarding rates of allied health and nursing professionals working in remote or rural settings following remote or rural learning placements. The results will be of interest to government and remote health workforce planners. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000797976; https://www.anzctr.org.au/ACTRN12620000797976.aspx. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/21832.

The value of best-practice guidelines for OSCEs in a postgraduate program in an Australian remote area setting.

INTRODUCTION: Nurses in remote areas of Australia are the primary healthcare professionals, who need to be able to deliver comprehensive and culturally sensitive care to clients, many of whom are Indigenous Australians. Adequate and specific preparation for practice is crucial to the quality of care delivered by remote area nurses (RANs). Objective structured clinical examinations (OSCE) provide an excellent opportunity for student practice in a simulated environment that is safe, authentic, fair and valid when well constructed. Seven integrated best practice guidelines (BPGs), previously developed by project team members to inform OSCEs within educational programs, provided guidance in restructuring the OSCE. This paper provides a detailed analysis of the value of BPGs used in the development, teaching and learning, and evaluation of OSCEs in a rural and remote postgraduate course for RANs. METHOD: A pre-site visit to the Centre for Remote Health, Alice Springs, Northern Territory, was conducted with modification of the course and previous OSCE according to BPGs. Following delivery of the course and OSCE, evaluations occurred via a mixed method approach. Student surveys (n=15) and focus groups (n=13) and staff interviews (n=5) provided an in-depth analysis of their perceptions of the revised OSCE. Descriptive statistics were used to describe the student sample. The narrative data were transcribed verbatim and analysed using content analysis. Triangulation was achieved with the convergence of the separate data sources focusing on themes and patterns within and between students and tutors. RESULTS: All 15 students and five tutors provided feedback. The majority of student participants had limited experience in working in remote area nursing prior to participation and therefore the opportunities that availed themselves were critical in adequately equipping them with the requisite knowledge, skills and abilities. Three themes emerged from the data: (1) value of common and significant events in OSCE; (2) power of deliberate actions; and (3) learning cultural sensitivity. DISCUSSION: OSCEs in this setting proved to be a good way for students to learn the skills required by RANs. Overwhelmingly, the modifications using the BPGs were highly valued by students and staff. Three themes emerged and were clearly linked to specific BPGs, indicating the positive impact the BPGs had on the OSCEs and student learning. The authentic content for the scenarios was seen as relevant and motivational for student learning. The practice element of the OSCEs enhanced the learning experience and feedback supported learning. CONCLUSIONS: OSCEs developed, taught and assessed using BPGs were highly valued. The BPGs provided an integrated approach with real-life scenarios with a strong cultural perspective - all important features to the RANs' future success in providing individualised care to clients in remote areas of Australia. Further use of BPGs is recommended.

Cost of best-practice primary care management of chronic disease in a remote Aboriginal community.

OBJECTIVE: To estimate the cost of completing all chronic care tasks recommended by the Central Australian Rural Practitioners Association Standard Treatment Manual (CARPA STM) for patients with type 2 diabetes and chronic kidney disease (CKD). DESIGN AND SETTING: The study was conducted at a health service in a remote Central Australian Aboriginal community between July 2010 and May 2011. The chronic care tasks required were ascertained from the CARPA STM. The clinic database was reviewed for data on disease prevalence and adherence to CARPA STM guidelines. Recommended tasks were observed in a time-and-motion study of clinicians' work. Clinicians were interviewed about systematic management and its barriers. Expenditure records were analysed for salary and administrative costs. MAIN OUTCOME MEASURES: Diabetes and CKD prevalence; time spent on chronic disease care tasks; completion of tasks recommended by the CARPA STM; barriers to systematic care identified by clinicians; and estimated costs of optimal primary care management of all residents with diabetes or CKD. RESULTS: Projected annual costs of best-practice care for diabetes and CKD for this community of 542 people were $900 792, of which $645 313 would be met directly by the local primary care service. Estimated actual expenditure for these conditions in 2009-10 was $446 585, giving a projected funding gap of $198 728 per annum, or $1733 per patient. High staff turnover, acute care workload and low health literacy also hindered optimal chronic disease care. CONCLUSION: Barriers to optimal care included inadequate funding and workforce issues. Reduction of avoidable hospital admissions and overall costs necessitates adequate funding of primary care of chronic disease in remote communities.

Occupational stress in remote area nursing: development of the Remote Area Nursing Stress Scale (RANSS).

BACKGROUND AND PURPOSE: The purpose of this study was to develop a measure that would adequately and sensitively measure the occupational stress experience of nurses working in very remote health care facilities. Because no existing nursing stress tool is suitable to assess the unique stressors of remote nursing practice, the aim was to address this gap in psychometric measurement capacity and develop the Remote Area Nursing Stress Scale (RANSS). METHOD: A focus group (n = 19) of remote area nurses identified potential questionnaire items through open discussion and by later listing the stressors they experienced individually in their day-to-day functioning. Subsequently, the Delphi method was employed to further refine the questionnaire (n = 12 experts). The RANSS was successfully pilot tested and was afterward administered to nurses working in very remote Australia in 2008 (n = 349) and in 2010 (n = 433). RESULTS: Principal components analysis and confirmatory factor analysis were performed for both waves of survey administration, demonstrating a robust 7-factor structure consistent across samples and accounting for significant variance in dependent measures. CONCLUSION: The development and validation of the RANSS is a significant advancement in remote area nursing research. The RANSS should be administered on an ongoing basis to monitor occupational stress among nurses working in very remote Australia. The RANSS should also be administered internationally in countries that also accommodate remote health care facilities. This would determine whether the RANSS is a psychometrically valid stress measure beyond the context of very remote Australia.

Reducing the risk of violence towards remote area nurses: a violence management toolbox.

OBJECTIVE: To explore the knowledge of a panel of experts to develop possible ways of minimising the risk of occupational violence towards remote area nurses. DESIGN: The Delphi method using open-ended questionnaires and an online survey to measure support for suggested control measures. SETTING: Remote area nursing posts across Australia. PARTICIPANTS: A panel of expert remote area nurses (n = 10) from geographically diverse regions. MAIN OUTCOME MEASURE: Identified and described measures with the potential to reduce the risk of violence. RESULTS: A 'toolbox' of strategies was suggested in recognition of the complex nature of occupational violence within the remote health context. Job-specific education included de-escalation techniques, risk assessment and cultural safety training. Professional support included access to counselling and debriefing services. Organisational responsibilities included: adequate staffing to provide backup, policies and procedures and action from management when hazards are identified. Community collaboration with the health service in developing orientation programs, safety plans and addressing violence within the community was also recommended. CONCLUSION: A variety of strategies were identified that could be used to reduce the risk of occupational violence towards remote health care staff. Further development and assessment of this 'toolbox' of strategies is recommended to address the high incidence of violence towards remote health professionals in Australia and overseas.

Organisational intervention to reduce occupational stress and turnover in hospital nurses in the Northern Territory, Australia.

OBJECTIVE: To evaluate the impact of an organisational intervention aimed to reduce occupational stress and turnover rates of 55% in hospital nurses. DESIGN: The evaluation used a pre- and post-intervention design, triangulating data from surveys and archival information. SETTING: Two public hospitals (H1 and H2) in the Northern Territory (NT) Australia participated in the intervention. SUBJECTS: 484 nurses from the two NT hospitals (H1, Wave 1, N = 103, Wave 2, N = 173; H2, Wave 1, N = 75, Wave 2, N = 133) responded to questionnaires administered in 2008 and in 2010. MEASURES: The intervention included strategies such as the development and implementation of a nursing workload tool to assess nurse workloads, roster audits, increased numbers of nursing personnel to address shortfall, increased access to clinical supervision and support for graduates, increased access to professional development including postgraduate and short courses, and a recruitment campaign for new graduates and continuing employees. We used an extended Job Demand-Resources framework to evaluate the intervention and 17 evaluation indicators canvassing psychological distress, emotional exhaustion, work engagement, job satisfaction, job demands, job resources, and system factors such as psychosocial safety climate. Turnover rates were obtained from archival data. RESULTS: Results demonstrated a significant reduction in psychological distress and emotional exhaustion and a significant improvement in job satisfaction, across both hospitals, and a reduction in turnover in H2 from 2008 and 2010. Evidence suggests that the intervention led to significant improvements in system capacity (adaptability, communication) in combination with a reduction in job demands in both hospitals, and an increase in resources (supervisor and coworker support, and job control) particularly in H1. CONCLUSIONS: The research addresses a gap in the theoretical and intervention literature regarding system/organisation level approaches to occupational stress. The approach was very successful on a range of health, work outcome, and job design indicators with results providing compelling evidence for the success of the system/organisational level intervention. The quasi-experimental design enabled us to conclude that improvements for the nurses and midwives could be attributed to the organisational intervention by the NT Department of Health (DoH). Further research should be undertaken to explore longer-term impacts, and particularly the influence on turnover. Levels of stress in hospital nurses remain high and present important implications for the psychological well-being of staff.

Nursing workforce in very remote Australia, characteristics and key issues.

OBJECTIVE: To describe the nursing workforce in very remote Australia, characteristics and key issues. METHODS: Data were collected from four main sources: the refined CRANAplus database of remote health facilities; the 2006 census which provided population and percentage of Indigenous people in communities in very remote Australia; a national survey on occupational stress among nurses and an earlier study into violence and remote area nurses conducted in 1995. A descriptive analysis of the data was conducted. SETTING: Health facilities in very remote Australia. RESULTS: The registered nursing workforce in very remote Australia is mostly female (89%) and ageing, with 40.2% 50 years or over, compared to 33% nationally. Many (43%) are in remote Indigenous communities. Over the last decade, there has been a significant decrease in registered nurses with midwifery qualifications (55%) and in child health nurses (39%) in very remote Australia. Only 5% have postgraduate qualifications in remote health practice. CONCLUSION: The nursing workforce in very remote areas of Australia is in trouble. The workforce is ageing, the numbers of nurses per population has fallen and the numbers of midwives and child health nurses have dropped significantly over the last 15 years. As many of these nurses work in Indigenous communities, if these trends continue it is likely to have a negative effect on 'closing the gap' in Indigenous health outcomes.

Levels of occupational stress in the remote area nursing workforce.

OBJECTIVE: To identify key workplace demands and resources for nurses working in very remote Australia and measure levels of occupational stress in this population. METHODS: The study used a cross-sectional design, utilising a structured questionnaire. SETTING: Health centres in very remote Australia. RESULTS: Nurses working in very remote Australia experience significantly higher levels of psychological distress and emotional exhaustion, compared with other professional populations. Paradoxically, results also highlight higher than average levels of work engagement. Nurses working in very remote regions in Australia further report moderate levels of job satisfaction. Most significant job demands identified were emotional demands, staffing issues, workload, responsibilities and expectations, and social issues. Key job resources included supervision, opportunities for professional development, and skill development and application. CONCLUSION: In a context of high stress, high levels of work engagement and moderate levels of job satisfaction do not obviate high workforce turnover for this population. There is a need to reduce job demands and increase job resources in order to foster long-term work engagement and reduced emotional exhaustion. This might subsequently decrease remote area nursing workforce turnover.

What stresses remote area nurses? Current knowledge and future action.

OBJECTIVE: Review and synthesise the literature identifying the stresses experienced by remote area nurses (RANs). Identify interventions implemented to address identified stresses. Explore the use of the job demands-resources (JD-R) model. METHODS: A comprehensive literature review was conducted using the meta-databases Ovid and Informit. SETTING: Remote Australian primary health care centres. RESULTS: The reported demands experienced by RANs can be grouped into four themes: (i) the remote context; (ii) workload and extended scope of practice; (iii) poor management; and (iv) violence in the workplace and community. In this high-demand, low-resource context, the JD-R model of occupational stress is particularly pertinent to examining occupational stress among RANs. The demands on RANs, such as the isolated geographical context, are immutable. However, there are key areas where resources can be enhanced to better meet the high level of need. These are: (i) adequate and appropriate education, training and orientation; (ii) appropriate funding of remote health services; and (iii) improved management practices and systems. CONCLUSION: There is a lack of empirical evidence relating to stresses experienced by RANs. The literature identifies some of the stresses experienced by RANs as unique to the remote context, while some are related to high demands coupled with a deficit of appropriate resources. Use of models, such as the JD-R model of occupational stress, might assist in identifying key areas where resources can be enhanced to better meet the high level of need and reduce RANs' levels of stress.

The frontline and the ivory tower: a case study of service and professional-driven curriculum.

OBJECTIVE: To describe the development of a postgraduate, multidisciplinary program designed to meet the needs of remote health professionals, present formative evaluation findings and to offer an analysis of the difficulties and lessons learnt. DESIGN: Case study. SETTING: University Department of Rural Health in a remote region. PARTICIPANTS: University staff, students and stakeholders involved in the development of the remote health practice program. RESULTS: Formative evaluation suggests that a curriculum driven by service and professional groups, such as the Flinders University Remote Health Practice program, is able to better prepare remote health practitioners and improve their effectiveness. Difficulties in development included a lack of recognition by some university academics of the value of practitioner knowledge and a reluctance to accept a clinical component in a masters program. Lessons learnt included the importance of: (i) respect for practitioner knowledge; (ii) explicit and appropriate values; (iii) high-quality academics with strong service links; (iv) appropriate length of lead time; (v) institutional links between university and both relevant professional organisations and health services; (vi) a receptive university; (vii) location; and (viii) ongoing engagement with services and professional responsive development. CONCLUSION: The success of the program was due in large part to the relationship with professional bodies and close links with remote health services. We have described a number of lessons learnt from this experience that can be useful to other educational groups developing or revising their educational programs.