Direct patient contacts of dietetic students during their final clinical placement

Direct student-patient contacts, during the professional clinical placement of a Master of Nutrition and Dietetics course, were collected and analysed for the first time using a computerised method. In the final eight-week hospital placement, 26 dietetic students submitted data on direct patient contacts which included: dietetic activities (e.g. assessing, counselling and reviewing); the primary nutritional condition of the patient (e.g. type 2 diabetes and liver disease); and the time spent in contact with patients. The most common dietetic activities were reviews, followed by collection of dietary information and counselling. The most common nutritional condition encountered by students was an inadequate nutrient intake, followed by patients receiving enteral nutrition. Contact time with patients increased over the placement, with proportionately more time spent by students seeing patients independently than when being observed by supervising dietitians. The data collected provided valuable informa tion on the amount of time spent by students in direct patient contacts, the range of dietetic activities undertaken and the amount of time student activities were directly observed. This information will be useful in the development of benchmarks for clinical skill development, hospital and university staff planning and the assessment of the impact of any changes to the format of student placement experience in the clinical setting.

Engaging rural communities in health care through a paramedic expanded scope of practice

Introduction: This article explores how community engagement by paramedics in an expanded scope role contributes to both primary health care and to an overall improved emergency response capacity in rural communities. Understanding how expanded scope paramedics (ESP) can strengthen community healthcare collaborations is an important need in rural areas where low workforce numbers necessitate innovation.

Methods: Four examples of Australian rural ESP roles were studied in Tasmania, New South Wales, South Australia and Victoria to gather information on consistent elements that could inform a paramedic expanded scope model. Qualitative data were collected from semi-structured interviews with key stakeholders and organisational documents. Thematic analysis within and across cases found community engagement was a key element in the varied roles. This article relies heavily on data from the Victorian and Tasmanian case studies because community engagement was a particularly strong aspect of these cases.

Results: The ESP in the case studies increased interactions between ambulance services and rural communities with an overall benefit to health care through: increasing community response capacity; linking communities more closely to ambulance services; and increasing health promotion and illness prevention work at the community level. Leadership, management and communication skills are important for paramedics to successfully undertake expanded scope roles.

Conclusion: ESP in rural locations can improve health care beyond direct clinical skill by active community engagement that expands the capacity of other community members and strengthens links between services and communities. As health services look to gain maximum efficiency from the health workforce, understanding the intensification of effort that can be gained from practitioner and community coalitions provides important future directions.

Exploring nurses' reactions to a novel technology to support acute health care delivery

AIMS AND OBJECTIVES: To explore nurses' reactions to new novel technology for acute health care. BACKGROUND: Past failures of technology developers to deliver products that meet nurses' needs have led to resistance and reluctance in the technology adoption process. Thus, involving nurses in a collaborative process from early conceptualisation serves to inform design reflective upon current clinical practice, facilitating the cementing of 'vision' and expectations of the technology. DESIGN: An exploratory descriptive design to capture nurses' immediate impressions. METHODS: Four focus groups (52 nurses from medical and surgical wards at two hospitals in Australia; one private and one public). RESULTS: Nursing reactions towards the new technology illustrated a variance in barrier and enabler comments across multiple domains of the Theoretical Domains Framework. Most challenging for nurses were the perceived threat to their clinical skill, and the potential capability of the novel technology to capture their clinical workflow. Enabling reactions included visions that this could help integrate care between departments; help management and support of nursing processes; and coordinating their patients care between clinicians. Nurses' reactions differed across hospital sites, influenced by their experiences of using technology. For example, Site 1 nurses reported wide variability in their distribution of barrier and enabling comments and nurses at Site 2, where technology was prevalent, reported mostly positive responses. CONCLUSION: This early involvement offered nursing input and facilitated understanding of the potential capabilities of novel technology to support nursing work, particularly the characteristics seen as potentially beneficial (enabling technology) and those conflicting (barrier technology) with the delivery of both safe and effective patient care. RELEVANCE TO CLINICAL PRACTICE: Collaborative involvement of nurses from the early conceptualisation of technology development brings benefits that increase the likelihood of successful use of a tool intended to support the delivery of safe and efficient patient care.

Effects of low- versus high-fidelity simulations on the cognitive burden and performance of entry-level paramedicine students: a mixed-methods comparison trial using eye-tracking, continuous heart rate, difficulty rating scales, video observation and inte

INTRODUCTION: High-fidelity simulation-based training is often avoided for early-stage students because of the assumption that while practicing newly learned skills, they are ill suited to processing multiple demands, which can lead to "cognitive overload" and poorer learning outcomes. We tested this assumption using a mixed-methods experimental design manipulating psychological immersion. METHODS: Thirty-nine randomly assigned first-year paramedicine students completed low- or high-environmental fidelity simulations [low-environmental fidelity simulations (LFenS) vs. high-environmental fidelity simulation (HFenS)] involving a manikin with obstructed airway (SimMan3G). Psychological immersion and cognitive burden were determined via continuous heart rate, eye tracking, self-report questionnaire (National Aeronautics and Space Administration Task Load Index), independent observation, and postsimulation interviews. Performance was assessed by successful location of obstruction and time-to-termination. RESULTS: Eye tracking confirmed that students attended to multiple, concurrent stimuli in HFenS and interviews consistently suggested that they experienced greater psychological immersion and cognitive burden than their LFenS counterparts. This was confirmed by significantly higher mean heart rate (P < 0.001) and National Aeronautics and Space Administration Task Load Index mental demand (P < 0.05). Although group allocation did not influence the proportion of students who ultimately revived the patient (58% vs. 30%, P < 0.10), the HFenS students did so significantly more quickly (P < 0.01). The LFenS students had low immersion resulting in greater assessment anxiety. CONCLUSIONS: High-environmental fidelity simulation engendered immersion and a sense of urgency in students, whereas LFenS created assessment anxiety and slower performance. We conclude that once early-stage students have learned the basics of a clinical skill, throwing them in the "deep end" of high-fidelity simulation creates significant additional cognitive burden but this has considerable educational merit.

Innovative model for clinical education in dietetics

Aim: Professional practice placement programs in dietetics face a number of challenges in respect of quantity, quality and sustainability. The aim of the present study is to report on the development of an innovative placement model based on a variety of training and supervision approaches to address these aforementioned challenges.

Methods: The model was developed following an investigation of existing practice and the literature with approaches that were identified as important to the requirements and constraints of dietetics clinical training incorporated into the model.

Results: Although one-on-one supervision is the predominant approach in Australian dietetic education, the educational literature and the authors' experience showed that a variety of approaches are represented in some form. The model developed involves the pairing of two students with one supervisor with students changing peer partners and supervisors every three weeks during the nine-week placement to diversify exposure to working and learning styles. The model integrates four customised approaches: incremental exposure to tasks; use of a clinical reasoning framework to help structure student understanding of the methods and judgements involved in patient care; structured enquiry in group discussions; and peer observation and feedback.

Conclusions: The model has potential to achieve efficiencies in supervisors' involvement by coordinating the skill development activities of students as a group and promoting peer-assisted learning.

Skill shortages in health : innovative solutions using vocational education and training

Introduction: This article reports findings of a project funded by the Australian National Council for Vocational Education Research. The project explores solutions to current and projected skills shortages within the health and community services sector, from a vocational education and training perspective. Its purpose is to locate, analyse and disseminate information about innovative models of health training and service delivery that have been developed in response to skill shortages.

Methods: The article begins with a brief overview of Australian statistics and literature on the structure of the national health workforce and perceived skill shortages. The impact of location (state and rurality), demographics of the workforce, and other relevant factors, on health skill shortages is examined. Drawing on a synthesis of the Australian and international literature on innovative and effective models for addressing health skill shortages and nominations by key stakeholders within the health sector, over 70 models were identified. The models represent a mixture of innovative service delivery models and training solutions from Australia, as well as international examples that could be transposed to the Australian context. They include the skill ecosystem approach facilitated by the Australian National Training Authority Skill Ecosystem Project. Models were selected to represent diversity in terms of the nature of skill shortage addressed, barriers overcome in development of the model, healthcare specialisations, and different customer groups.

Results: Key barriers to the development of innovative solutions to skills shortages identified were: policy that is not sufficiently flexible to accommodate changing workplace needs; unwillingness to risk take in order to develop new models; delays in gaining endorsement/accreditation; current vocational education and training (VET) monitoring and reporting systems; issues related to working in partnership, including different cultures, ways of operating, priorities and timelines; workplace culture that is resistant to change; and organisational boundaries. For training-only models, additional barriers were: technology; low educational levels of trainees; lack of health professionals to provide training and/or supervision; and cost of training. Key enhancers for the development of models were identified as: commitment by all partners and co-location of partners; or effective communication channels. Key enhancers for model effectiveness were: first considering work tasks, competencies and job (re)design; high profile of the model within the community; community-based models; cultural fit; and evidence of direct link between skills development and employment, for example VET trained aged care workers upskilling for other health jobs. For training only models, additional enhancers were flexibility of partners in accommodating needs of trainees; low training costs; experienced clinical supervisors; and the provision of professional development to trainers.

Conclusions: There needs to be a balance between short-term solutions to current skill shortages (training only), and medium to longer term solutions (job redesign, holistic approaches) that also address projected skills shortages. Models that focus on addressing skills shortages in aged care can provide a broad pathway to careers in health. Characteristics of models likely to be effective in addressing skill shortages are: responsibility for addressing skills shortage is shared between the health sector, education and training organisations and government, with employers taking a proactive role; the training component is complemented by a focus on retention of workers; models are either targeted at existing employees or identify a target group(s) who may not otherwise have considered a career in health.

Clinical research and leadership training program as a knowledge translation initiative across an Australian health care service

 Health professionals need to be integrated more effectively in clinical research initiatives to ensure that research addresses key clinical needs and provides practical, implementable solutions at the coal face of care. Here we describe the informative phase of a broader program to enable and support health professionals at Monash Health who do not have a research background, to engage in and lead research to improve healthcare outcomes. The findings will be used to develop a dedicated clinical research and leadership training program. The training program will support Monash Health staff to up-skill or enhance skills to conduct rigorous research; engage and lead multidisciplinary, collaborative teams; and to use research to guide practice, as well as identify and address gaps in clinical research.  

Nursing educator perspectives of overseas qualified nurses' intercultural clinical communication: barriers, enablers and engagement strategies

AIMS AND OBJECTIVES: To understand the intercultural communication experiences and associated communication training needs of overseas qualified nurses in the Australian healthcare system from the unique perspectives of nurse educators teaching in accredited bridging programmes. BACKGROUND: Overseas qualified nurses are an integral part of the nursing workforce in migration destination countries. Communication training needs are more complex when there are cultural, ethnic and language differences between nurses, other health professionals and patients. DESIGN: A qualitative, exploratory research design using semi-structured interviews. METHODS: All (nine) organisations involved in conducting the Australian Health Practitioner Regulation Agency approved preregistration bridging programmes for overseas qualified nurses within the state of Victoria, Australia, were involved in the study. Participants were 12 nurse educators employed in these organisations. Thematic analysis was undertaken. RESULTS: Three macro themes emerged about the overseas qualified nurses' intercultural communication: (1) pre-existing barriers and enablers to intercultural communication, for example, nurses' reluctance to engage in communicative strategies that build rapport with patients, (2) transitional behaviours and impact on communication, including maintenance of perceived cultural hierarchies between health professionals and (3) development of communicative competence, including expanding one's repertoire of conversational gambits. CONCLUSIONS: The findings point to the domains and causes of communication challenges facing overseas qualified nurses in new healthcare settings as well as strategies that the nurse educators and nurses can adopt. Communication cannot be merely regarded as a skill that can be taught in a didactic programme. Comprehensive understanding is needed about the sociocultural dimensions of these nurses' orientation, which can impact on how they communicate in their new healthcare settings. RELEVANCE TO CLINICAL PRACTICE: The findings can act as triggers for discussion with overseas qualified nurses and other health professionals to raise awareness about the aspects of intercultural communication and to debate alternative viewpoints and explanations. They can also inform changes in the structure and content of the bridging programmes.

Core components of communication of clinical reasoning: a qualitative study with experienced Australian physiotherapists

Communication is an important area in health professional education curricula, however it has been dealt with as discrete skills that can be learned and taught separate to the underlying thinking. Communication of clinical reasoning is a phenomenon that has largely been ignored in the literature. This research sought to examine how experienced physiotherapists communicate their clinical reasoning and to identify the core processes of this communication. A hermeneutic phenomenological research study was conducted using multiple methods of text construction including repeated semi-structured interviews, observation and written exercises. Hermeneutic analysis of texts involved iterative reading and interpretation of texts with the development of themes and sub-themes. Communication of clinical reasoning was perceived to be complex, dynamic and largely automatic. A key finding was that articulating reasoning (particularly during research) does not completely represent actual reasoning processes but represents a (re)construction of the more complex, rapid and multi-layered processes that operate in practice. These communications are constructed in ways that are perceived as being most relevant to the audience, context and purpose of the communication. Five core components of communicating clinical reasoning were identified: active listening, framing and presenting the message, matching the co-communicator, metacognitive aspects of communication and clinical reasoning abilities. We propose that communication of clinical reasoning is both an inherent part of reasoning as well as an essential and complementary skill based on the contextual demands of the task and situation. In this way clinical reasoning and its communication are intertwined, providing evidence for the argument that they should be learned (and explicitly taught) in synergy and in context.

Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers' perspectives and experiences

BACKGROUND: Hypertension and diabetes, key risk factors for cardiovascular disease, are significant health problems globally. As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000, clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011. This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting.

METHODS: A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the usability and practicality of the guidelines. Ten family health centres were randomly chosen from a list of all the family health centres (n = 136) located in Ulaanbaatar City. In each centre, a focus group discussion with nurses (n = 20) and individual interviews with practice doctors (n = 10) and practice managers (n = 10) were conducted. Data was analysed using a thematic approach utilising the Theoretical Domains Framework.

RESULTS: The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice. They also reported having attended guideline training sessions which were focused on practice skill development. The majority of participants expressed satisfaction with the wide range of resources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines. The resources, supplied from 2011 onwards, included screening devices, equipment for blood tests, medications and educational materials. Other enablers were the participants' commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines. Primary care providers reported a number of challenges in implementing the guidelines, including frustration caused by increased workload and long waiting times, time constraints, difficulties with conflicting tasks and low patient health literacy.

CONCLUSIONS: This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low resource primary care settings. It also offers some key lessons that might be carefully considered when other evidence-based clinical guidelines are to be put into effect in low resource settings and elsewhere.