Generalist Health Research Articles

Community colleges and public health: an integral part of the continuum of education for public health.

Undergraduate education for public health has grown rapidly in the last decade since the Institute of Medicine recommended that “…all undergraduates should have access to education in public health.” Despite the growth of undergraduate education for public health in 4-year institutions, public health education in community colleges is at an early stage of development. In a comprehensive 2011–12 web-based catalog search of community colleges, only seven associate degree programs in public health or related fields could be identified (1, 2). Public health organizations are encouraging growth of education for public health in community colleges as well as 4-year colleges. The American Public Health Association has endorsed undergraduate public health education at both community colleges and 4-year colleges (3). Healthy People 2020 includes objectives to substantially increase the number of community colleges as well as 4-year institutions offering undergraduate public health education (4). As part of the Framing the Future Task Force, convened by the Association of Schools and Programs of Public Health, the Community Colleges and Public Health (CC&PH) project, has been developed and co-sponsored by the League for Innovation in the Community College (the League), which represents over 800 of the 1100 community colleges. The CC&PH is co-chaired by the two authors of this article. The mission of the CC&PH project is to fully include community colleges in the continuum of public health education. The Community Colleges and Public Health Report (5) is expected to be a component of the final report of the Framing the Future Task Force (6). The CC&PH project has included two phases, a first phase consisting of an Expert Panel, which developed a series of Foundation and Consensus Statements that reflected what public health and community college educational organizations could do together (5). The second phase, recommended by the Expert Panel, focused on development of “prototype curricular models” designed for associate degrees and academic certificate programs in community colleges. Two basic models, (1) Public Health: Generalist and Specialization and (2) Health Navigator,1 were chosen after consultations with community colleges, project and Task Force leadership, and public health practice organizations (ASTHO and NACCHO), as well as academic associations in disciplines, which offer related bachelor’s degree programs (SOPHE, AUPHA, and AEHAP2). The CC&PH report recommends that Public Health associate degrees should be built on fundamental skills including writing, oral communications, and quantitative skills consistent with the Association of American Colleges and Universities (AAC&U) LEAP initiative (7) and VALUE Rubrics (8). Associate degrees and academic certificate programs are also encouraged to incorporate ASPPH Undergraduate Public Health Learning Outcomes. (9). The Community Colleges and Public Health Project report recommends academic programs in Public Health: Generalist and Specializations designed for transfer to bachelor’s degree programs in general public health, health education, health administration, or environmental health. It also recommends Health Navigator academic certificate and associate degree programs. The CC&PH report also recommends specific courses and provides recommended content outlines: http://www.league.org/league/projects/ccph/. The remainder of this article summarizes the two prototype curricular models and discusses next steps in implementation.

Relational coordination amongst health professionals involved in insulin initiation for people with type 2 diabetes in general practice: an exploratory survey.

BackgroundThe majority of people with type 2 diabetes (T2D) receive their care in general practice and will eventually require initiation of insulin as part of their management. However, this is often delayed and frequently involves referral to specialists. If insulin initiation is to become more frequent and routine within general practice, coordination of care with specialist services may be required. Relational coordination (RC) provides a framework to explore this. The aim of this study was to explore RC between specialist physicians, specialist diabetes nurses (DNEs), generalist physicians in primary care (GPs) and generalist nurses (practice nurses (PNs)) and to explore the association between RC and the initiation of insulin in general practice, and the belief that it is appropriate for this task to be carried out in general practice.MethodsA survey was distributed to a convenience sample of specialist physicians, DNEs, GPs and practice nurses. We collected data on demographics, models of care and RC in relation to insulin initiation. We expected that RC would be higher between specialists than between specialists and generalists. We expected higher RC between specialists and generalists to be associated with insulin initiation in general practice and with the belief that it is appropriate for insulin initiation to be carried out in general practice. We used descriptive statistics and non-parametric tests to explore these hypotheses.Results179 health professionals returned completed surveys. Specialists reported higher RC with each other and lower RC with PNs. All groups except PNs reported their highest RC with DNEs, suggesting the potential for DNEs to serve as boundary spanners. Lower RC with specialists was reported by those working within a general practice model of care. Health professionals who felt that a general practice model was appropriate reported lower communication with specialist physicians and higher shared knowledge with GPs.ConclusionGiven the need for coordination between specialist and generalist care for the task of insulin initiation, this study’s results suggest the need to build relationships and communication between specialist and generalist health professional groups and the potential for DNE’s to play a boundary spanner role in this process.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-014-0515-3) contains supplementary material, which is available to authorized users.

Teleological care and the last years of life.

The final years of life present challenges for care. In middle-/high-income countries, the percentage of people of advanced age in the population is growing, and the dying process continues to become more complex and protracted. We propose that a new understanding of care, 'teleological care', be considered as an important response to the contemporary challenges of the final years of life. Teleological care is a philosophy of care built around the root idea of a telos (i.e. end) in three senses: (1) the end of life as a temporal limit; (2) the ends of life as the individual's purpose and meaning; (3) the end of life as the meaning of life as a whole. In its practice, teleological care adheres to principles of (1) fidelity of practitioner to patient; (2) generalism of practitioners; and (3) coordination of care within existing services. With this philosophy and practice, care is administered by generalist health care professionals arranging for flow between care that attempts to reverse, stop or slow the disease process when appropriate, with care to address symptoms, and with care that responds to the difficulties of dying. Teleological care involves already existing programmes in roughly their present forms, serving as an overarching layer of organization added to the existing systems. Teleological care refocuses the concept of care to the patient's perspective with emotional, spiritual and practical support for facing the end of life, and a space for narrative and reflection within a wider circle of care.

Exploring the acceptability of online sexually transmissible infection testing for rural young people in Victoria

To examine the availability of and previous engagement with health services among rural young people and compare barriers and facilitators to using face-to-face and online sexual health testing and treatment. Participants were recruited for focus groups and were asked to discuss their access to local sexual health services (what services they used, when, why and how) and then shown a website and asked to provide feedback about online STI testing. Community sporting clubs in two small country towns in Victoria. Seven focus groups with fifty participants, grouped by gender and age, were conducted. Participants views of accessible and acceptable services for STI testing. Three main themes emerged from the analysis: (i) readiness to seek sexual health services; (ii) barriers and facilitators to using the local general practitioner; and (iii) barriers and facilitators to online testing, including 'using the mail during online STI testing' and 'cost of the online service'. In general, the participants described some concerns about accessing sexual health services locally. This was less discussion about availability of services and more about privacy, trust, reliability and using generalist health care providers for sexual health needs. Free online testing services address issues of access for rural young people. While barriers external to rural sexual health services may remain, free online STI testing services are acceptable to these rural young people.

Harmful Alcohol Use Among Aboriginal People in Southern Taiwan

This cross-sectional study aims to examine the prevalence and correlates of harmful alcohol use among aboriginal people in southern Taiwan and to examine the associations between harmful alcohol use and adverse drinking effects. Four hundred forty-nine aboriginal adults were recruited from two townships in southern Taiwan to complete the questionnaires. Among the aborigines, 59.7% scored an 8 or above on the Alcohol Use Disorders Identification Test, including 26.7% who were found to be hazardous drinkers (AUDIT level II), 18.5% who were harmful drinkers (level III), and 14.5% who were with likely dependence (level IV). Male aborigines who participated less in religious activities, had stressful life events, were cigarette smokers, or were betel quid chewers were more likely to have harmful alcohol use. Harmful alcohol use was also associated with an inability to work and with arguments with other people. Our study suggests that aboriginal people in southern Taiwan experience alcohol-related risks at rates as high as other worldwide populations for which AUDIT results are available. Individuals with AUDIT scores at levels II and III are generally candidates for brief interventions delivered in generalist health settings. Individuals with AUDIT scores at level IV should be referred for an addiction specialty evaluation and possible treatment as well as lower-risk individuals (those with AUDIT levels II-III) if they have concurrent physical or psychiatric disorders.

A review of generalist and specialist community health workers for delivering adolescent health services in sub-Saharan Africa

BackgroundThe health of adolescents is increasingly seen as an important international priority because the world’s one point eight billion young people (aged 10 to 24 years) accounts for 15.5% of the global burden of disease and are disproportionately located in low- and middle-income countries (LMICs). Furthermore, an estimated 70% of premature adult deaths are attributable to unhealthy behaviors often initiated in adolescence (such as smoking, obesity, and physical inactivity). In order for health services to reach adolescents in LMICs, innovative service delivery models need to be explored and tested. This paper reviews the literature on generalist and specialist community health workers (CHWs) to assess their potential for strengthening the delivery of adolescent health services.MethodsWe reviewed the literature on CHWs using Medline (PubMed), EBSCO Global Health, and Global Health Archive. Search terms (n = 19) were sourced from various review articles and combined with subject heading ‘sub-Saharan Africa’ to identify English language abstracts of original research articles on generalist and specialist CHWs.ResultsA total of 106 articles, from 1985 to 2012, and representing 24 African countries, matched our search criteria. A single study in sub-Saharan Africa used CHWs to deliver adolescent health services with promising results. Though few comprehensive evaluations of large-scale CHW programs exist, we found mixed evidence to support the use of either generalist or specialist CHW models for delivering adolescent health services.ConclusionsThis review found that innovative service delivery approaches, such as those potentially offered by CHWs, for adolescents in sub-Saharan Africa are lacking, CHW programs have proliferated despite the absence of high quality evaluations, rigorous studies to establish the comparative effectiveness of generalist versus specialist CHW programs are needed, and further investigation of the role of CHWs in providing adolescent health services in sub-Saharan Africa is warranted.

P2.161 Exploring the Acceptability of Online STI Testing For Rural Young People in Victoria

BackgroundRural young people living in Australia experience disadvantage in service access for STI testing and treatment. As such, innovative programmes using telemedicine have been developed but results show relatively low...

Young people describe their prediagnosis cancer experience

Young people often report a protracted journey to diagnosis and frequently report perceived delays. This study was undertaken to increase understanding of the self-reported prediagnosis experiences in young people with a non-haematological cancer, as close as possible to the time of diagnosis. Narrative interviews were conducted with 24 young people aged 16-24, 2-4 months from the diagnosis of a solid tumour. Data were analysed to identify whether prediagnosis narratives could be classified according to shared characteristics (typologies) to identify broader contextual issues concerning cancer, and cancer risk perceptions, in this age group. Case notes were also accessed to contextualize and confirm accounts. The main themes, which included a group narrative concerning perspectives of delay, included the impact on an individual's everyday life by symptoms; the role that significant others in young peoples' lives played in the interpretation of symptom significance; the negotiation of entry into, and experiences of, generalist health care; entry into specialist care; and the threshold points that exemplified when events shifted and a diagnosis was eventually obtained. The narratives reveal complex, and multidimensional explanations for delay with individual and contextual factors contributing. Insights were gained into preventable diagnostic delay; including investigations having been instigated, but not followed up. Each narrative also offered significant insights into how cancer symptoms should be considered within the context of young peoples' lives. This would help prevent signs and symptoms in this age group failing to trigger suspicion and not being treated seriously.

Chronic Oedema: Impact and Management

Chronic oedema of all causes is thought to be more prevalent than studies have shown. The impact of this chronic condition encompasses many physical, psychological and social domains, many of which are not acknowledged nor addressed. Successful management relies on three factors. The first is early detection and commencement of treatment to prevent complications occurring. The second is an holistic multidimensional approach to address all the associated physical, psychological and social sequellae. Finally, collaboration between specialist and generalist health professionals is essential to ensure the best treatment is delivered in the best healthcare location. To achieve these there needs to be a network of suitably qualified practitioners who are upskilled by robust awareness and education systems, all of which should be supported by stable financial and human resources.

Priorities for Rural Health

On the last day of the 12th National Rural Health Conference, delegates broadly endorsed a set of priority recommendations that had emerged over the previous three days. They fall into four themes: infrastructure, clinical services, workforce and improving the health of Australia's first peoples. High-speed broadband should be available to all families, businesses and communities in rural and remote areas, ensuring equity of access no matter where people live and work. Political parties were also called on to commit to the principles of the Royalties for Regions program of Western Australia in order to strengthen rural and remote communities, their health, infrastructure and services. There was strong support for place-based models of services – empowering local communities – in areas such as health, education, housing and arts and culture. In the health sector, it will be interesting to see what the Federal Election campaign brings in relation to Medicare locals and local hospital networks or boards. Another of the priority recommendations called for food security in rural and remote areas to be ensured. Under the ‘clinical services’ theme, there were recommendations on improving eye health for Aboriginal people, aged care, oral health, maternity care, early childhood health services and the link between services based in metropolitan areas and patients in rural and remote areas. The last makes the point that specialist health services in rural areas should not be dependent on tenuous links with metropolitan services and the goodwill of visiting specialists. Instead, there should be service agreements and clinical governance structures that ensure continuity and networking of services in rural areas. The ‘workforce’ theme includes an expression of the hope that integration in rural areas of the disability, aged and health care sectors might improve the availability of sustainable allied health services. This would both increase access to allied health services and enable existing professionals to take leave and professional development entitlements. Development of Disability Care (the NDIS) has successfully highlighted the key role played by allied health professionals in disability and rehabilitation services. There is also a plea for a national campaign to promote the importance and rewards of generalist health practice as a specialty in its own right – one that is essential to leading and providing health care in rural and remote Australia. The Conference recommendation concerning the health of Australia's first peoples focuses on the potential benefits of greater numbers of culturally respectful health promotion campaigns addressing hypertension, heart disease and diabetes. These would be informed and managed by local community leadership and would help address the social determinants of health experienced by Aboriginal and Torres Strait Islander people. The priority recommendations are on the National Rural Health Alliance Conference website at http://www.ruralhealth.org.au.

‘eSimulation’ Part 1: Development of an interactive multimedia mental health education program for generalist nurses

Generalist health care professionals are increasingly challenged to provide mental health care within their own clinical specialties. Educators are challenged with providing innovative, engaging and accessible education programs to increase the mental health knowledge and skills of generalist health care professionals. Simulation is increasingly being used within learning curricula to optimise learning and the use of information and communication technology has emerged as a novel way of providing simulated learning. This paper describes the development process of an interactive, multimedia 'eSimulation' mental health education program for generalist health care professionals. The resulting eSimulation education program incorporated the following five key attributes of simulation: (1) Creating a hypothetical opportunity; (2) Authentic representation; (3) Active participation; (4) Integration; and (5) Repetition, evaluation and reflection. This process can be used to guide nursing educators in the development of tailored eSimulation education programs. An evaluation of the eSimulation will be reported elsewhere, in Part 2 of this paper.

Making a difference through QELCA: a time to engage community nurses

We have recently witnessed increased requests from patients and a huge ‘push’ from government for more people to die in their own homes across England. Most of the patients wishing to die at home tend to be experiencing life-threatening and limiting illnesses, and their care demands knowledge and skills in dealing with their palliative care needs. As a result, there is an inevitable added pressure on community nurses to care for all these people. The result is that patients presenting with complex end-of-life care needs may end up being cared for predominantly by generalist health professionals. Some community nurses may feel inadequately trained and prepared to care for the needs of patients at the end of life, and as a result, be left with a sense of having failed their patients. The End of Life Care Strategy (Department of Health, 2008) makes it clear that workforce development is a priority if patients are to receive high-quality and appropriate care at the end of life. However, current austerity measures inhibit the training of health professionals to care for dying patients in the community. If we have fewer skilled carers in the community, the risk is that dying patients will not receive adequate and appropriate care, which respects their wishes and dignity. In addition, the impact of poorly delivered care on the bereaved relatives and friends will inevitably manifest in bereavement complication, like traumatic distress, anxiety and even depression. For caring health professionals working at the generalist level of palliative care, more training and education is needed if we are to benefit all dying patients, regardless of where they are being cared for. In recognition of these needs, a specially designed education programme: ‘Quality End of Life Care for All’ (QELCA), has been developed by St Christopher’s Hospice in Sydenham, London to empower generalist nurses to deliver confident, competent end-of-life care. One of the key aims of QELCA, in addition to empowering nurses with knowledge about palliative and end-oflife care, is to develop and equip nurses to remain engaged in meaningful emotional contact with patients and their relatives. At the same time, it aims to ensure that nurses can preserve their professional and personal integrity without becoming emotionally exhausted and experiencing burnout. This is an important and brave goal, as it will require adept skills from the facilitators in order to instil the balance and ability in nurses to separate personal feelings from professional care and respect for the feelings of the dying patient. It is well documented in literature on burnout that when this delicate balance is not achieved properly, nurses experience emotional exhaustion that can lead to burnout, and patients may feel unsupported and without a sense of being treated as a unique individual (Maslach, 2003). QELCA consists of a 5-day training programme with follow-up sessions using action learning sets, and offers a platform for sharing ideas and experiences while learning new skills to improve on patient care. Of course, in today’s financial climate, there are challenges of funding, time and staff shortages, but it has been shown that QELCA training can help nurses make the best use of their limited time while learning vital skills that they can use to care for all patients at the end of life (Bryan et al, 2011). It is hoped that long-term benefits will include a more confident generalist practitioner, reduced incidents of absenteeism, and continuity of care for dying patients. The evaluation to date shows that, on the whole, QELCA is making a difference among generalist and community nurses in particular, who at first thought palliative care was not their remit or role. Senior managers need to support all community nurses to attend and help improve the care of all dying patients, regardless of setting. It is an aim of QELCA to train trainers in order to spread the benefits across the country, and quickly. In addition, such knowledge and skill will help ameliorate emotional exhaustion and eventually, burnout. Although QELCA may be aimed at generalist nurses, it could be equally helpful to other professional groups, ensuring that patients receive the best care possible from all health professionals. BJCN

Mental health education programmes for generalist health professionals: An integrative review

Mainstreaming of mental health services has led to an increase in the presentation and care of mental health patients in generalist health settings. The lack of adequate mental health educational preparation of general health professionals (GHP) has been identified as a major barrier to meeting the health-care needs of mental health patients. This study aimed to review and synthesize research evidence on mental health education programmes (MHEP) that have been designed to develop the knowledge, skills, and attitudes of GHP. An integrative literature review was conducted following a search of key electronic databases and hand searching of references of relevant papers, and 25 papers met the study inclusion criteria. Knowledge, skill, and attitudinal improvements in GHP post MHEP were shown in most studies. MHEP that included supervised clinical experience, role play, and case scenarios were reported as being more effective. Issues such as patient participation in education, interprofessional education models, and the willingness, interest and, motivation for GHP to be involved in MHEP warrant further research.

Implementation and evaluation of an education program to guide palliative care for people with motor neurone disease

Background: Despite a recognized need for a palliative approach to caring for people with motor neurone disease (MND), access to palliative care is often limited. Aim: This project aimed to improve the knowledge of health professionals about a palliative approach to MND care. Design: A three-phase study was undertaken to develop, implement and evaluate an education program for health professionals that promoted a palliative approach to MND care. This paper discusses the second and third phases: the implementation and evaluation of the project. Education workshops were held for health professionals. Their knowledge of palliative care was measured before and after the workshops and one month later. Attitudes to providing MND care were also measured. Setting: Workshops were held in South Australia and Western Australia. Participants were health professionals working in the areas of MND care or palliative care. Some aged care and generalist health professionals were included if they had a role in providing care to people with MND. Results: The participants demonstrated an improvement in MND knowledge (χ2 = 64.13(2), p = 0.000) and palliative care knowledge (χ2 = 17.24(2), p = 0.000); both were sustained at one month. Attitudes to providing MND care also improved (χ2 = 11.85(2), p = 0.003) and were maintained at the six-month follow-up. Participants indicated that the knowledge gained positively influenced their clinical practice. Conclusions: A targeted education program for health professionals improved understanding about end-of-life care for people with MND. Health care providers also reported having made improvements in the care provided to patients and carers, particularly communication, psychosocial care and symptom management.

‘That’s part of everybody’s job’: the perspectives of health care staff in England and New Zealand on the meaning and remit of palliative care

Background: the right for patients of all diagnoses to be in receipt of palliative care from an early point in the diagnosis of a life-limiting condition is now enshrined in policy in a number of countries and increased emphasis is placed upon the role of generalist palliative care. However, little is known as to how this policy is enacted on the ground. Aim: to explore understandings of, and perceived roles in relation to, palliative care provision amongst generalist and specialist health care providers in England and New Zealand. Design: qualitative data were collected via individual interviews and focus groups. Setting/participants: participants comprised generalist and specialist palliative care providers working in a variety of settings in England (n = 58) and New Zealand (n = 80). Results: the following issues with significant implications for this new phase of development for palliative care were identified: (1) difficulties with terminology and perceived roles/responsibilities; (2) problems of integrating palliative care into a generalist workload; (3) challenges in generalist/specialist partnership working; and (4) the potential negative consequences of specialization. Conclusions: these data indicate that, within England and New Zealand, the policy rhetoric of universal palliative care provision is not being straightforwardly translated into service delivery and individual clinical practice. Further research is required to explore and evaluate different models of organization and service provision that empower ‘generalists’ to provide palliative care, without resulting in deskilling. Finally, definitional clarity at an academic/policy level is also needed.

Effectiveness of service linkages in primary mental health care: a narrative review part 1.

BackgroundWith the move to community care and increased involvement of generalist health care providers in mental health, the need for health service partnerships has been emphasised in mental health policy. Within existing health system structures the active strategies that facilitate effective partnership linkages are not clear. The objective of this study was to examine the evidence from peer reviewed literature regarding the effectiveness of service linkages in primary mental health care.MethodsA narrative and thematic review of English language papers published between 1998 and 2009. Studies of analytic, descriptive and qualitative designs from Australia, New Zealand, UK, Europe, USA and Canada were included. Data were extracted to examine what service linkages have been used in studies of collaboration in primary mental health care. Findings from the randomised trials were tabulated to show the proportion that demonstrated clinical, service delivery and economic benefits.ResultsA review of 119 studies found ten linkage types. Most studies used a combination of linkage types and so the 42 RCTs were grouped into four broad linkage categories for meaningful descriptive analysis of outcomes. Studies that used multiple linkage strategies from the suite of "direct collaborative activities" plus "agreed guidelines" plus "communication systems" showed positive clinical (81%), service (78%) and economic (75%) outcomes. Most evidence of effectiveness came from studies of depression. Long term benefits were attributed to medication concordance and the use of case managers with a professional background who received expert supervision. There were fewer randomised trials related to collaborative care of people with psychosis and there were almost none related to collaboration with the wider human service sectors. Because of the variability of study types we did not exclude on quality or attempt to weight findings according to power or effect size.ConclusionThere is strong evidence to support collaborative primary mental health care for people with depression when linkages involve "direct collaborative activity", plus "agreed guidelines" and "communication systems".

Co-ordination of generalist care for patients towards the end of life: a literature review

Introduction and aimIncreased coordination and collaboration have been highlighted as improving the provision of health and social care for people at the end of life. We aimed to review the...

A residential aged care end-of-life care pathway (RAC EoLCP) for Australian aged care facilities

The objective of this study was to develop, implement and evaluate an end-of-life (terminal) care pathway and associated infrastructure suitable for Australian residential aged care facilities that improves resident and health system outcomes. The residential aged care end-of-life care pathway was developed by a multidisciplinary collaboration of government and non-government professionals and incorporated best clinical management for dying residents to guide care and increase palliative care capacity of generalist staff. Implementation included identifying and up-skilling Link Nurses to champion the pathway, networking facilities with specialist palliative care services, delivering education to generalists and commencing a Palliative Care Medication Imprest System in each facility. The primary outcome measure for evaluation was transfer to hospital; secondary measures included staff perceived changes in quality of palliative care provided and family satisfaction with care. Results indicated that the pathway, delivered within a care framework that guides provision of palliative care, resulted in improved resident outcomes and decreased inappropriate transfers to acute care settings.

(Re)Organising and ‘liberating’ primary care

(Re)Organising and ‘liberating’ primary care

Sustaining and growing the rural nursing and midwifery workforce: Understanding the issues and isolating directions for the future

Nurses and midwives represent the largest group of health professionals in the Australian health care system. In rural environments nurses and midwives make up a greater proportion of the health workforce than in urban settings, which makes their role in service provision even more significant. The role and scope of these nurses and midwives' practice is by necessity more generalist than specialist, which results in disciplinary strengths and weaknesses. As generalist health professionals they work in diverse settings such as public hospitals, multi-purpose services, community health, aged care and in non-government and private for profit and no-profit organisations including general practices. Their scope of practice covers prevention, intervention and rehabilitation and is lifespan inclusive. Rural nurses and midwives are older than their metropolitan based counterparts, work part-time and traditionally have limited access to professional development often due to ineffective locum relief programs. Workplace inflexibility, access to acceptable housing and partner employment are factors cited as inhibitors to growing this workforces. The future of the rural nursing and midwifery workforce will only be secured if Government invests to a greater degree in both education and training and the development of a nationally agreed remuneration scale that allows for part-time work.