Responding to rural skills shortages : innovations using vocational education and training

Aims & Rationale/Objectives
To locate, analyse and make accessible innovative models of health training and service delivery that have been developed in response to a shortage of skills.

Methods
Drawing on a synthesis of Australian and international literature on innovative and effective models for addressing health skill shortages, 50 models were selected for further study. Models were also identified from nominations by key health sector stakeholders. Selected models represent diversity in terms of the nature of skill shortage addressed, barriers overcome in developing the model, health care specialisations, and customer groups.

Principal Findings
Rural and remote areas have become home to a set of innovative service delivery models. Models identified encompass local, regional and state/national responses. Local responses are usually single health service-training provider partnerships. Regional responses, the most numerous, tend to have a specific focus, such as training young people. A small number of holistic state or national responses, eg the skills ecosystem approach, address multiple barriers to health service provision. Typical barriers include unwillingness to risk-take, stakeholder differences, and entrenched workplace cultures. Enhancers include stakeholder commitment, community acceptance, and cultural fit.

Discussion
Of particular interest is increasing numbers of therapy assistants to help address shortages of allied health professionals, and work to formalise their training, and develop standards of practice and policy. Other models likely to help address skill shortage amongst VET health workers focus on recruiting, supporting and training employees from a range of disadvantaged target groups, and on providing career paths with opportunities for staff to expand their skills. Such models are underpinned by nationally recognised qualifications, but each solution is targeted to a particular context in terms of the potential workforce and local need.

Using project evaluation to build capacity for integrated health care at local levels

Capacity-building evaluation featuring multidisciplinary cross-agency workshops fostered continuous quality improvement, while focusing on skills required and systemic barriers to health care integration between GPs and a regional hospital.

Having a baby in the new land : a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia

Introduction: Australia is a land of cultural diversity. Cultural differences in maternity care may result in conflict between migrants and healthcare providers, especially when migrants have minimal English language knowledge. The aim of the study was to investigate Asian migrant women’s child-birth experiences in a rural Australian context.

Method: The study consisted of semi-structured interviews conducted with 10 Asian migrant women living in rural Tasmania to explore their childbirth experiences and the barriers they faced in accessing maternal care in the new land. The data were analysed using grounded theory and three main categories were identified: ‘migrants with traditional practices in the new land’, ‘support and postnatal experiences’ and ‘barriers to accessing maternal care’.

Results: The findings revealed that Asian migrants in Tasmania faced language and cultural barriers when dealing with the new healthcare system. Because some Asian migrants retain traditional views and practices for maternity care, confusion and conflicting expectations may occur. Family and community play an important role in supporting migrant women through their maternity care.

Conclusions: Providing interpreting services, social support for migrant women and improving the cross-cultural training for healthcare providers were recommended to improve available maternal care services.

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.

Small rural emergency departments are not simply cut-down large urban emergency departments

 It is important to understand how small rural emergency departments work. They are a significant fraction of a state’s medical system. Although they each see only a few thousand patients a year, as a group they are likely to treat more emergency patients than the largest city hospital. It is a myth that they only deal with minor ailments. 

Comparison of the work of psychologists in rural and urban settings : implications for professional training

To compare the work practices and training needs of rural and urban psychologists, 774 surveys were sent to psychologists throughout Australia. The psychologists were selected from the Australian Psychological Society (APS) Directory of Psychologists, 1992- 1993. A total of 86 rural psychologists and 282 urban psychologists responded to the survey. The survey comprised of four sections with questions asking respondents their demographic and employment background, past and current training activities, work experience, and relations with community. Results showed that the decision to practice and remain in a rural area was influenced by psychologists’ childhood experience and professional training in a rural setting, A substantial proportion of rural psychologists (28%) had been working in rural practice for five years or less. These rural psychologists were identified as a group that had a demographic and training profile more similar to urban psychologists than their rural colleagues. The employment conditions and training background of rural and urban psychologists were similar, though rural psychologists were more likely to be working in private practice and have undertaken their studies in a rural setting. Rural and urban psychologists rated their undergraduate and postgraduate training in psychology as only somewhat adequate. Training in rural health and community issues received the lowest ratings from both groups of psychologists. The work practices of rural and urban psychologists were also similar. There were some differences in the demographic profile of the client groups seen by the two groups. Rural psychologists reported the type of relations with their communities that are conducive to rural practice. The main evidence of this was that rural psychologists were collaborating with the natural helpers of their communities, and expressed willingness to formally train natural helpers to assist in the provision of psychological services. There were several conclusions drawn from this study. The first conclusion was that rural psychologists with urban demographic and training backgrounds are a group that is likely to migrate from rural practice to urban practice, Secondly, training needs to be specialised for rural practice if there is to be an improvement in the number of psychologists practicing in rural settings. Thirdly, rural psychologists were conducting the type of relations with their communities that are important to the requirements of rural practice.

Train the trainer model : implications for health professionals and farm family health in Australia

Australia is a large country with 60% of land used for agricultural production. Its interior is sparsely populated, with higher morbidity and mortality recorded in rural areas, particularly farmers, farm families, and agricultural workers. Rural health professionals in addressing health education gaps of farming groups have reported using behavioralist approaches. These approaches in isolation have been criticized as disempowering for participants who are identified as passive learners or 'empty vessels.' A major challenge in rural health practice is to develop more inclusive and innovative models in building improved health outcomes. The Sustainable Farm Families Train the Trainer (SFFTTT) model is a 5-day program developed by Western District Health Service designed to enhance practice among health professionals working with farm families in Australia. This innovative model of addressing farmer health asks health professionals to understand the context of the farm family and encourages them to value the experience and existing knowledge of the farmer, the family and the farm business. The SFFTTT program has engaged with health agencies, community, government, and industry groups across Australia and over 120 rural nurses have been trained since 2005. These trainers have successfully delivered programs to 1000 farm families, with high participant completion, positive evaluation, and improved health indicators. Rural professionals report changes in how they approach health education, clinical practice, and promotion with farm families and agricultural industries. This paper highlights the success of SFFTTT as an effective tool in enhancing primary health practice in rural and remote settings. The program is benefiting not only drought ravaged farmers but assisting rural nurses, health agencies, and health boards to engage with farm families at a level not identified previously. Furthermore, nurses and health professionals are now embracing a more 'farmer-centered model of care.'

The Sustainable Farm Families Project : changing attittudes to health

Introduction: Farm health and safety has historically focussed on strategies such as injury prevention, safety audits and fulfilling legislative responsibilities. However, farmer injuries mask deeper health issues including higher rates of cancer, suicides, cardiovascular disease and stress. The relationship between occupational health and safety and farm family health has not been fully investigated. The Sustainable Farm Families (SFF) project attempts to make this connection in order to address premature death, morbidity and injury on Australian farms. The SFF project illustrates how increasing health literacy through education and physical assessment can lead to improved health and knowledge outcomes for farm families.

Methods: The SFF project focuses on the human resource in the triple bottom line and is working with farmers, families, industry and universities to collaboratively assess and promote improvement in the health and wellbeing of farm families. Based on a model of extension that engages farm families as active learners where they commit to healthy living and safe working practices, the SFF project is proving to be an effective model for engaging communities in learning and change. Health education and information is delivered to farm men and women aged 18 to 75 years using a workshop format. Pre- and post-knowledge surveys, annual physical assessments and focus group discussions form the methodological context for the research over a three-year intervention.

Results: This article discusses the progress of the research outlining the design of the SFF project, the delivery and extension processes used to engage 321 farm families from within a broadacre and dairy-farming family sample. The article presents key learnings on intersectoral collaboration, engaging farmers and families in health, and the future for this project extending into agricultural industries across the nation. Key results reveal that health issues do exist in farming families and are often underreported by family members. Health indicators were at a level where referral and intervention was required in over 60% of men and 70% of women in both broad acre and dairy industries. Farm men and women verbalised health concerns relating to access, support and control mechanisms of the health system. Participants also revealed how they put into practice their new knowledge and how this has influenced their health.

Conclusions: The key learning is that farm men and women who are at high risk of premature morbidity and mortality will participate in health education and assessment programs based on industry collaboration with high levels of individual participation. This program provides evidence that farmers will engage with health professionals if programs are presented to them in personally engaging and relevant ways. The SFF program is a definite tool for interventional health promotion that supports attitudinal change to health and farming practices.

Rural smokers : a prevention opportunity

Background: Smoking is the largest single cause of preventable death and disease in Australia. This study describes smoking prevalence and the characteristics of rural smokers to guide general practitioners in targeting particular groups.

Methods: Cross sectional surveys in the Greater Green Triangle region of southeast Australia using a random population sample (n=1563, participation rate 48.7%) aged 25–74 years. Smoking information was assessed by a self administered questionnaire.

Results: Complete smoking data were available for 1494 participants. Overall age adjusted current smoking prevalence was 14.9% (95% CI: 13.1–16.7). In both genders, current smoking prevalence decreased with age. Those aged 25–44 years were more likely to want to stop smoking and to have attempted cessation, but less likely to have received cessation advice than older smokers.

Discussion: This study provides baseline smoking data for rural health monitoring and identifies intervention opportunities. General practice is suited to implement interventions for smoking prevention and cessation at every patient encounter, particularly in younger individuals.

Diabetes risk reduction behaviours of rural postpartum women with a recent history of gestational diabetes

Introduction: For most women, gestational diabetes is temporary; however, an episode of gestational diabetes mellitus (GDM) confers an approximately seven-fold increased risk of developing type 2 diabetes mellitus. Objective: To examine readiness to adopt diabetes risk reduction behaviours and the prevalence of these behaviours among rural women with GDM during their last pregnancy.
Methods: The study design was a self-administered mailed questionnaire seeking information about demographics, stage of change, physical activity level and dietary fat intake. Setting: Regional outpatient context. Participants: Women with a single episode of GDM between 1 July 2001 and 31 December 2005 (n = 210). Main outcome measures: Stage of change for physical activity, weight loss and reducing dietary fat behaviour; meeting activity targets, body mass index (BMI) and dietary fat score.
Results: Eighty-four women returned completed questionnaires (40% response rate). Of the 77 women eligible (mean age 35 ± 3.8 years), 58% met recommended activity targets. Sixty-three percent of women were overweight or obese: mean BMI 29.6 kg/m2 (± 7.30). Women reported a high level of preparedness to engage in physical activity, weight loss and reduction of fat intake. Thirty-nine percent of women had not had any postpartum follow-up glucose screening. Women who remembered receiving diabetes prevention information were significantly more likely to meet physical activity targets (p<0.05).
Conclusions: Readiness to engage in behaviour change was high among this group of rural women for all three diabetes risk reduction behaviours measured. However, despite a high proportion of women meeting activity targets and reducing fat intake, the majority of women remained overweight or obese. Postpartum follow-up glucose testing needs to be improved and the impact of diabetes prevention information provided during pregnancy warrants further study.

Rural adolescent alcohol, tobacco, and illicit drug use: a comparison of students in Victoria, Australia, and Washington State, United States

Purpose: There are inconsistent research findings regarding the impact of rurality on adolescent alcohol, tobacco, and illicit substance use. Therefore, the current study reports on the effect of rurality on alcohol, tobacco, and illicit
drug use among adolescents in 2 state representative samples in 2 countries, Washington State (WA) in the United States and Victoria (VIC) in Australia.
Participants: The International Youth Development Study (IYDS) recruited representative samples of students from Grade 7 (aged 12 to 13 years) and Grade 9 (aged 14 to 15) in both states. A total of 3,729 students responded to questions about alcohol, tobacco, cannabis, and other illicit substance use (n_VIC = 1,852; n_WA = 1,877). In each state, males and females were equally represented and ages ranged from 12 to 15 years.
Methods: Data were analyzed to compare lifetime and current (past 30 days) substance use for students located in census areas classified as urban, large or small town, and rural. Findings were adjusted for school clustering and
weighted to compare prevalence at median age 14 years.
Findings: Rates of lifetime and current alcohol, tobacco, and cannabis use were significantly higher in rural compared to urban students in both states (odds ratio for current substance use = 1.31).
Conclusions: In both Washington State and Victoria, early adolescent rural students use substances more frequently than their urban counterparts. Future studies should examine factors that place rural adolescents at risk for alcohol, tobacco, and illicit drug use.