Remote Clinical Placement Research Articles

A virtual reality environment for supporting mental wellbeing of students on remote clinical placement: A multi-methods evaluation

BackgroundNursing and Allied Health Profession (NAHP) students undertake clinical placements as part of their pre-registration training. The remote nature of some placement sites, shiftwork and the emotionally challenging nature of the workload has led to mental wellbeing issues in many students. AimThis project aimed to evaluate a novel 3D immersive virtual reality environment that supports mental wellbeing for NAHP students on clinical placement. It comprises a calming 3D tropical beach environment where students and tutors can meet for reflection and mutual support. DesignA multi-methods design gathered quantitative impact data with validated measurement tools and qualitative output related to the lived experience of students. Settings and participantsAll 600 pre-registration NAHP students within the institution undertaking clinical placements were invited to participate, irrespective of mental wellbeing status. Students were randomly assigned to either a VR or Conventional cohort; all participants received the control support mechanism in a subsequent placement. MethodsAll participants completed an initial demographic and Readiness for Therapy survey followed by weekly Beck Anxiety and Depression Inventories during placement. All participants were invited to a semi-structured interview. ResultsOverall, 32 participants engaged with the application; although the VR cohort demonstrated improved scores on both Beck inventories, these were not statistically significant. This is probably due to the low response rate for the control cohort. A total of 15 interviews were conducted and several themes emerged from the data in relation.to both experiential outcomes (escapism, anonymity and sense of community) and instrumental outcomes (calming, mindfulness and combatting loneliness). ConclusionsUser feedback indicates that a VR environment can provide a calming escape from the pressures and anxiety arising from clinical placement for healthcare students. The relaxing beach environment facilitated mindfulness meditation and the additional opportunities for pseudo-anonymous interactions with peers and tutors were wellreceived by students.

A comparative evaluation of quality and depth of learning by trainee doctors in regional, rural, and remote locations

BackgroundAn equitable supply and distribution of medical practitioners for all the population is an important issue, especially in Australia where 28% of the population live in rural and remote areas. Research identified that training in rural/remote locations is a predictor for the uptake of rural practice, but training must provide comparable learning and clinical experiences, irrespective of location. Evidence shows GPs in rural and remote areas are more likely to be engaged in complex care. However, the quality of GP registrar education has not been systematically evaluated. This timely study evaluates GP registrar learning and clinical training experiences in regional, rural, and remote locations in Australia using assessment items and independent evaluation.MethodsThe research team retrospectively analysed GP trainee formative clinical assessment reports compiled by experienced medical educators during real-time patient consultations. Written reports were assessed using Bloom’s taxonomy classified into low and high cognitive level thinking. Regional, rural, and remotely located trainees were compared using Pearson chi-squared test and Fisher’s exact test (for 2 × 2 comparisons) to calculate associations between categorical proportions of learning setting and ‘complexity’.Results1650 reports (57% regional, 15% rural and 29% remote) were analysed, revealing a statistically significant association between learner setting and complexity of clinical reasoning. Remote trainees were required to use a high level of clinical reasoning in managing a higher proportion of their patient visits. Remotely trained GPs managed significantly more cases with high clinical complexity and saw a higher proportion of chronic and complex cases and fewer simple cases.ConclusionsThis retrospective study showed GP trainees in all locations experienced comparable learning experiences and depth of training. However, learning in rural and remote locations had equal or more opportunities for seeing higher complexity patients and the necessity to apply greater levels of clinical reasoning to manage each case. This evidence supports learning in rural and remote locations is of a similar standard of learning as for regional trainees and in several areas required a superior level of thinking. Training needs to seriously consider utilising rural and remote clinical placements as exceptional locations for developing and honing medical expertise.

Satisfaction with nursing clinical placements in the Northern Territory and work intentions post-graduation

Objective: The aims of this study are to assess nursing student satisfaction with their Northern Territory clinical placement; describe the characteristics of these students; and examine the relationship between student placements and future rural/remote work intentions. Background: Positive clinical placement experiences in a rural or remote setting can encourage student nurses to consider working in rural and remote locations after graduation. Study design and methods: The study is a cross-sectional survey of nursing students, and a review of placement data. Participants were studying a pre-registration Bachelor of Nursing course from a variety of Australian universities who undertook a clinical placement of usually four or more weeks in the Northern Territory from 2017-2019. The main outcome measures are overall satisfaction with their placement, and consideration of living and working in a rural or remote location after graduating. Logistic regression analyses examined the relationship between student placements and future rural or remote work intentions. Results: One hundred and sixty three undergraduate nursing students responded to the online survey. The majority (70%) of placements were undertaken in remote or very remote (18%) locations. Satisfaction with the placement was very high (94%), and 88% agreed/strongly agreed that the placement had encouraged them to consider working in a rural or remote setting. Satisfaction with educational resources and prior interest in working remotely were associated with overall placement satisfaction (p<0.10). Overall satisfaction with the placement and prior consideration of working regionally, rurally, or remotely were significantly associated with feeling encouraged to consider working rurally or remotely (p<0.05). Conclusion: This study supported the logical pathway of providing a satisfying clinical nursing placement in the Northern Territory to contribute to a higher likelihood of the student considering working in a remote or rural setting after graduation. Providing satisfying remote clinical placements is a strategy for growing a nursing workforce for remote and rural settings. Implications for research, policy and practice: Ongoing investment in remote clinical nursing placements is needed to ensure nursing students are satisfied with their placement. In particular, the educational resources and support during the placement need to be of high quality. Actively recruiting students who had a prior interest in working in a regional, rural or remote setting will likely lead to high satisfaction with the placement and contribute to an interest in working in a rural or remote setting post-graduation. What is already known about this topic? Recruitment of student nurses and preparation for working in the rural and remote sector are important for improving population healthcare outcomes for populations who live there. Previous studies of nursing, allied health and medical students indicate that exposure to positive placement experiences in regional, rural or remote locations increases the likelihood of students returning to those locations after completing their study. What this paper adds Data from this study come predominately from remote clinical placements. Satisfaction with clinical placements in remote locations in the Northern Territory of Australia, and prior interest in working remotely, are associated with considering working in a regional, rural or remote location. Satisfaction with educational resources is associated with overall placement satisfaction.

Cultural respect in midwifery service provision for Aboriginal women: longitudinal follow-up reveals the enduring legacy of targeted program initiatives

BackgroundCulturally competent maternity care provision to Aboriginal and Torres Strait Islander women was identified as a priority area by Australia’s National Maternity Services Plan in 2011. While midwifery programs responded by including core Indigenous content and community placements in curricula, little is known about whether knowledge learned, and insights gained in response to these initiatives have endured and been applied in clinical practice. This follow-up study explores the impact of a compulsory Indigenous unit and a remote clinical placement on two cohorts of non-Indigenous midwives who were participants in an earlier 2012–14 study.MethodsFourteen non-Indigenous participants who were either students or recent graduates in 2012–14 were located and re-interviewed in 2019–20. In-depth interviews based on a semi-structured interview guide were conducted by telephone or face-to face; recordings were transcribed and thematically analysed using standard qualitative procedures.ResultsExposure to Indigenous content and settings during training had an enduring impact on participants’ midwifery practice; most felt better prepared to provide culturally safe care, build respectful relationships and advocate for improved services for Aboriginal women. Despite this positive legacy, they also expressed apprehension about causing offence and recognised their own knowledge deficits with regard to Aboriginal cultural practices. Organisational constraints, including restrictions on the number of family members accompanying a birthing mother were identified as barriers to optimal care; some positive organisational initiatives were also described.ConclusionsThis follow-up study provides encouraging evidence that well-designed and delivered Indigenous content and community placement opportunities in midwifery programs can have a lasting impact on service provision to Aboriginal women, contribute to a more informed, empathetic and culturally competent maternity workforce and help catalyse health service changes towards more culturally safe care.

What works, why and how? A scoping review and logic model of rural clinical placements for allied health students

BackgroundAllied health services are core to the improvement in health outcomes for remote and rural residents. Substantial infrastructure has been put into place to facilitate rural work-ready allied health practitioners, yet it is difficult to understand or measure how successful this is and how it is facilitated.MethodsA scoping review and thematic synthesis of the literature using program logic was undertaken to identify and describe the contexts, mechanisms and outcomes of successful models of rural clinical placements for allied health students. This involved all empirical literature examining models of regional, rural and remote clinical placements for allied health students between 1995 and 2019.ResultsA total of 292 articles were identified; however, after removal of duplicates and article screening, 18 were included in the final synthesis. Australian papers dominated the evidence base (n = 11). Drivers for rural allied health clinical placements include: attracting allied health students to the rural workforce; increasing the number of allied health clinical placements available; exposing students to and providing skills in rural and interprofessional practice; and improving access to allied health services in rural areas. Depending on the placement model, a number of key mechanisms were identified that facilitated realisation of these drivers and therefore the success of the model. These included: support for students; engagement, consultation and partnership with key stakeholders and organisations; and regional coordination, infrastructure and support. Placement success was measured in terms of student, rural, community and/or program outcomes. Although the strength and quality of the evidence was found to be low, there is a trend for placements to be more successful when the driver for the placement is specifically reflected in the structure of the placement model and outcomes measured. This was seen most effectively in placement models that were driven by the need to meet rural community needs and upskill students in interprofessional rural practice.ConclusionThis study identifies the factors that can be manipulated to ensure more successful models of allied health rural clinical placements and provides an evidence based framework for improved planning and evaluation.

Applying a Midwifery Lens to Indigenous Health Care Delivery: The Contribution of Campus Learning and Rural Placements to Effecting Systemic Change.

Increasing cultural safety in health settings is essential to address stark health disparities between Indigenous and non-Indigenous Australians. Respect for cultural knowledge, better communication, and recognition of racism as a determinant of health are required for improved service delivery. How this knowledge is acquired in health professional training and translated to clinical settings is poorly understood. Impacts of an innovative Indigenous health unit and remote clinical placements on knowledge acquisition and attitude change were explored among midwifery students to inform cultural competency initiatives in health professional training. A multiphased, mixed methods research design used surveys, observations, and interviews. Qualitative analysis was strengthened through triangulation with quantitative data. A unit conceived with substantial Indigenous Australian input and which privileged these voices enhanced knowledge and shifted attitudes in a positive direction; however, immediate gains diminished over time. Remote placements had a profound effect on student learning. Exposure to Indigenous Australians in classrooms and communities, and the self-reflection generated, helped dispel stereotypes and challenge assumptions based on limited cultural knowledge and contact. Optimization of receptivity to Indigenous Australian content and opportunities for remote placements contributed to students' developing cultural capabilities with implications for all health professional training. Whether this heightened awareness is enough to address institutional racism identified in health service delivery remains unanswered. The focus must include those established health practitioners and administrators who influence organizational culture if real systemic change is to occur. Given appropriate on-going support, graduates can play a vital role in expediting this process.

Academic performance of third-year medical students learning in rural settings.

Investigate the academic performance of medical students in rural and remote discipline rotations by rurality of placement. A retrospective cohort study. Rural and remote clinical placement locations in Queensland, Australia. University of Queensland third-year medical students. In this study, student results for a range of assessments are the main outcome measures with rural area of student placement locations as categorised by the Australian Standard Geographical Classification - Remoteness Areas system the independent variable of interest. There was a significant effect of Australian Standard Geographical Classification - Remoteness Areas of placement on the health project, clinical case presentation, clinical participation assessment and overall grade, after controlling for the potential confounding impact of sex, age, students who attended the rural clinical school, cohort year, rotation during the year and type of health service where students were placed. No significant effect of rural placement level was identified for the written examination, poster or journal of achievement assessments. Medical students' academic achievement is associated with many factors, but this study shows that being placed in remote areas is one factor that either does not impede or can positively influence the learning and academic performance of medical students.

Challenges to student transition in allied health undergraduate education in the Australian rural and remote context: a synthesis of barriers and enablers

The optimum supply of an allied health workforce in rural and remote communities is a persistent challenge. Despite previous indicative research and government investment, the primary focus for rural and remote recruitment has been on the medical profession. The consequent shortage of allied health professionals leaves these communities less able to receive appropriate health care. This comprehensive review incorporates a literature analysis while articulating policy and further research implications. The objective was to identify drivers to recruitment and retention of an allied health workforce in rural and remote communities. This issue was observed in two parts: identification of barriers and enablers for students accessing allied health undergraduate tertiary education, and barriers and enablers to clinical placement experience in rural and remote communities. A search of empirical literature was conducted together with review of theoretical publications, including public health strategies and policy documents. Database searches of CINAHL, Medline, ERIC, PsychInfo and Scopus were performed. Selection criteria included Australian research in English, full text online, keywords in title or abstract, year of publication 1990 to 2012 and research inclusive of rural and remote context by application of the Australian Standard Geographical Classication (ASGC) Remoteness Structure. Theoretical publications, or grey literature, were identified by broad Google searches utilising a variety of search terms relevant to the review objective. Allied health professions were defined as including audiology, dietetics, occupational therapy, optometry, orthoptics, orthotics and prosthetics, pharmacy, physiotherapy, podiatry, psychology, radiography, social work, speech pathology and Aboriginal and Torres Strait Islander Health Workers. A total of 28 empirical publications met the selection criteria with a further 22 grey literature texts identified with relevance to the research objective. Patterns of barriers and enablers for rural and remote student transition in the allied health professions were identified in the literature. Recruitment pathways to allied health tertiary studies in rural and remote communities are vague and often interrupted, and the return of graduates is haphazard. Students from rural and remote communities face an assembly of barriers. They often experience secondary education disadvantage with inadequate subject choices, pathways and opportunities. Programs designed to facilitate transition to tertiary study are often limited in their capacity to address cumulative concerns. Students also face financial imposts and are confronted by daunting social isolation, and separation from families and support systems. In regard to clinical placement, the disincentives weigh heavily. The financial burdens of a rural placement offer little inducement. Social isolation associated with a placement far from home is more acutely felt by students when there is inadequate administrative support and consequent disillusionment. Students also lack a frame of reference to pursue a rural placement option, and are often discouraged by the cumulative commitments involved. Clear and accessible pathways to allied health training for students from rural and remote communities are pivotal to a stronger representation of this cohort among graduates. Similarly, greater representation of rural and remote clinical placements for allied health undergraduate students is an important facilitator. Despite regional coordination and strategies designed to promote a broader range of placement opportunities, the problems remain. This review has consequences for policy and program development for growth of the rural allied health workforce in Australia, as well as identifying knowledge deficits to guide future research endeavours.

TelePresence in Rural Medical Education: A Mixed Methods Evaluation

In response to rural health workforce shortages, universities and training providers offer rural and remote clinical placements. This has led to development of educational methods to counter the barriers of distance. In this emerging field, recent improvements in technology have provided solutions including the use of sophisticated videoconferencing systems such as the Cisco TelePresence model CTS-500. This paper evaluates the use of TelePresence in diverse medical education activities using a mixed methods design—questionnaires n=60, individual interviews n=33, and observed practice of activities n=22. TelePresence was found to be beneficial to learning and teaching and superior to other systems participants had used. In particular, the audiovisual quality, resulting intimacy, convenience, and ease of use facilitated teaching and learning, while the fixed camera and poorly arranged physical environment were found to be limitations. The system is best suited for small group activities. Clinical skills-based activities are viable. It is recommended that technical support be available during setup and use and a picture-in-picture mode be included and improved integration of office suite software to provide a joint workspace for display of presentations, images, editing or annotation of documents, and file sharing.

"Listening to the silence quietly": investigating the value of cultural immersion and remote experiential learning in preparing midwifery students for clinical practice.

BackgroundCultural immersion programs are increasingly offered to medical and health science students in an effort to provide experiential learning opportunities that focus on ‘the self’ as well as ‘the other’. Immersion programs encourage self-reflection on attitudes towards cultural differences, provide opportunities to build relationships and work with community members, and allow students to apply knowledge and skills learned in training programs in a supervised practice setting. The aim of this paper is to describe midwifery students’ reflections on a remote Aboriginal clinical placement that has been offered at a Western Australian university since 2010.MethodsInterviews were conducted over a period of 15 months with the first seven participants who completed the program. At the time of interview, four participants were in the final year of their undergraduate degree and three were practicing midwives. In addition, access was given to a detailed journal kept by one participant during the placement. Interviews also were conducted with midwifery staff at the university and practice setting, although the focus of this paper is upon the student experience.ResultsStudent selection, preparation and learning experiences as well as implications of the placement for midwifery practice are described. The remote clinical placement was highly valued by all students and recommended to others as a profound learning experience. Highlights centred on connections made with community members and cultural knowledge learned experientially, while challenges included geographic and professional isolation and the complexities of health care delivery in remote settings, especially to pregnant and birthing Aboriginal women. All students recognised the transferability of the knowledge and skills acquired to urban settings, and some had already incorporated these learnings into clinical practice.ConclusionsCultural immersion programs have the potential to provide students with rich learning experiences that cannot be acquired in classroom settings. In Aboriginal communities on the Ngaanyatjarra Lands students gained valuable insights into the impact of isolation on health service delivery, the extent and strength of cultural traditions in the region, and a heightened awareness of the difficulties encountered by pregnant and birthing Aboriginal women in remote locations.Electronic supplementary materialThe online version of this article (doi:10.1186/1756-0500-7-685) contains supplementary material, which is available to authorized users.

Multi‐site videoconference tutorials for medical students in Australia

About two-thirds of medical students are distributed among the major metropolitan tertiary teaching hospitals in Queensland, while the remainder are sent to regional hospitals up to 500 km away. The aim of this study was to investigate the feasibility and effectiveness of conducting surgical tutorials via videoconferencing (VC) for medical students undertaking at remote hospitals. Surgical tutorials were offered to final-year medical students at the Royal Children's Hospital (RCH) in Brisbane and shared by VC to students undertaking clinical placement at nine remotely located hospitals in Queensland. We have conducted a retrospective review of service activity, student satisfaction and subject scores from 2008 to 2010. The main outcome measures were VC activity, medical students' satisfaction and student exam results pre- and post-introduction of the surgical tutorial programme. Between March 2009 and November 2010, a total of 57 VC tutorials were conducted during nine rotations for a total of 669 students. Approximately, 35% of students (236) attended tutorials face-to-face at the RCH while the remainder (including those at the Mater Children's Hospital in Brisbane and eight regional sites) participated via VC. A snapshot survey to measure satisfaction of both groups of students showed that overall satisfaction was very high. A total of 299 students completed the paediatrics and child health multiple-station assessment task exam in 2008, 326 in 2009 and 382 in 2010. The pre-intervention (tutorials not delivered by VC) median scores (interquartile range) of surgical and non-surgical questions were 5 (4-6) and 23 (21-25). Post-intervention, surgical scores increased significantly to 6 (5-7) (P < 0.001), while non-surgical scores remained similar at 23 (21-25) (P = 0.64). Our study demonstrates that VC is a feasible and effective method of engaging medical students regardless of their location. VC provides equitable access to medical teaching for medical students undertaking remote clinical placements.

Living and working with the people of ‘the bush’: A foundation for rural and remote clinical placements in undergraduate medical education

Background: The Australian Government's policies and programmes to redress the medical workforce shortage in rural and remote areas focus on recruitment of rural students and provision of rural clinical placements. The University of Notre Dame's Rural and Remote Health Placement Programme (RRHPP) uses an additional approach to address this issue.Aim: This article describes the RRHPP undertaken by all medical students in the first 2-years of their course and examines the educational worth of this approach.Method: Data were obtained from curricular documents, publications about the RRHPP and evaluation questionnaires administered to students and supervisors.Results: The RRHPP provides students with opportunities to develop a patient- and community-centred perspective on the health issues of rural and remote populations by having them live and work with people in these areas prior to clinical placements. It is based on sound educational principles and underpinned by participation of rural/remote communities as experts and equal teaching partners. The RRHPP is valued and perceived by a majority of students and placement hosts as a useful strategy to develop medical students’ understanding of the rural/remote community context and its impact on health.Conclusion: This community participatory approach benefits medical students and rural/remote communities.

Supporting rural/remote primary health care placement experiences increases undergraduate nurse confidence

This paper reports on the analysis of data from undergraduate nursing students who participated in the Primary Health Care Intensive Programme (PHCIP) in far west New South Wales between 2006 and 2008. This analysis looks specifically at pre/post confidence levels of participants in relation to their grasp of underlying principles associated with primary health care practice and Indigenous health care delivery. Bachelor of nursing curricula remains heavily weighted towards acute care in large metropolitan facilities however; universities actively seek clinical fieldwork experiences in rural/remote and Indigenous communities for their students. The PHCIP was developed and delivered through the Broken Hill University Department of Rural Health, University of Sydney, and sought to address the disparity in student preparedness for practice in these settings through the provision of a structured and educational rural and remote clinical placement experience. Pre/post questionnaires, focus groups and three month post-placement phone interviews provided data on levels of participant confidence in the areas of primary health care delivery and culturally knowledgeable practice. This study indicates that structured preparation for practice, underpinned by authentic learning experiences and aligned with comprehensive education programmes can have a positive impact in the areas of skills, knowledge and attitudes and enhance the confidence of undergraduate nurses undertaking clinical placements in these settings. These findings are relevant to contemporary nursing education and evolving models of health care delivery for rural and remote communities.

UNDERGRADUATE NURSING STUDENTS‘ CLINICAL EXPERIENCES IN RURAL AND REMOTE AREAS: RECRUITMENT IMPLICATIONS

ABSTRACT: Providing rural and remote clinical experiences for undergraduate nursing students could help address future recruitment in these areas, but adequate financial support for students during clinical placements is also necessary. Strategies to address nursing shortages to date have emphasised funding for rural re‐entry programs, or supporting students from rural backgrounds to attend university courses. Assisting current undergraduate nursing students, especially those from urban backgrounds, to experience living and working in rural areas has been overlooked as a potential recruitment strategy. Ongoing qualitative evaluation of a clinical placement program shows students respond positively and with increased interest in returning to rural nursing after graduation. Unfortunately, many are disadvantaged financially by the added expense of their rural clinical rotation. Finding ways to support students from both urban and non‐urban backgrounds to undertake rural and remote clinical placements should be an important strategic and funding priority.

Undergraduate nursing students' clinical experiences in rural and remote areas: recruitment implications.

Providing rural and remote clinical experiences for undergraduate nursing students could help address future recruitment in these areas, but adequate financial support for students during clinical placements is also necessary. Strategies to address nursing shortages to date have emphasised funding for rural re-entry programs, or supporting students from rural backgrounds to attend university courses. Assisting current undergraduate nursing students, especially those from urban backgrounds, to experience living and working in rural areas has been overlooked as a potential recruitment strategy. Ongoing qualitative evaluation of a clinical placement program shows students respond positively and with increased interest in returning to rural nursing after graduation. Unfortunately, many are disadvantaged financially by the added expense of their rural clinical rotation. Finding ways to support students from both urban and non-urban backgrounds to undertake rural and remote clinical placements should be an important strategic and funding priority.