Matthew McGrail

To synthesise key Australian empirical rural retention evidence and outline implications and potential applications for policymaking. A comprehensive search of Medline, PsychINFO, CINAHL plus, Scopus and EMBASE revealed eight peer-reviewed empirical studies published since 2000 quantifying factors associated with actual retention. Rural and remote Australian primary health care workers. Hazard ratios (hazard of leaving rural), mean length of stay in current rural position and odds ratios (odds of leaving rural). A broad range of geographical, professional, financial, educational, regulatory and personal factors are strongly and significantly associated with the rural retention of Australian primary health care workers. Important factors included geographical remoteness and population size, profession, providing hospital services, practising procedural skills, taking annual leave, employment grade, employment and payment structures, restricted access to provider numbers, country of t...

Cultural desire is considered to be a prerequisite for developing cultural competence. This study explored cultural desire among student nurses towards Aboriginal peoples and its association with participation in a one-semester unit on Aboriginal health through a cross-sectional survey. Our main outcome, cultural desire, was measured using two items level of agreement with Aboriginal health being an integral component of the nursing curriculum and an expressed interest in Aboriginal health. 220 (74.58%) student nurses completed the survey. Completing the Aboriginal Health and wellbeing unit did not influence students' opinions on inclusion of the unit as part of the nursing curriculum (odds ratio OR 0.73, 95% CI 0.43-1.29) or their overall cultural desire (mean difference = -0.69, 95% CI -1.29 to -0.08, p = 0.026). Students who completed the unit reported a higher understanding of Aboriginal health (OR = 2.35, 95% CI = 1.35-4.08) but lower interest levels in the subject (OR = 0.45, 95% CI: 0.24-0.84). Further research is necessary to explore how and when cultural desire might develop in nurses who are trained in cultural competence particularly in the contexts of post-colonial disparities and political conflict.

To assess the effect that the presence of an emergency physician in the ED has on the access indicators of the Australian Council on Healthcare Standards. A retrospective study was carried out in a 265 bed regional referral hospital in Victoria. The performance of the ED over a 6 month period, during which time there was incomplete emergency physician coverage, was monitored using The Australian Council on Healthcare Standards (ACHS) access indicators as the benchmark. These indicators are waiting time by triage category, and access block. A total of 11 999 patient presentations were eligible for inclusion in the study. Emergency physicians were present for 76.5% of these presentations. All the indicators show a trend towards improvement when an emergency physician was present. However, the only indicator that shows a significant improvement is waiting time by triage category, and this is due mainly to an improvement within triage category 4. There is some evidence that the presence of an emergency physician improves performance within this group of access based indicators within a rural ED, however, the effect seen here is small. More studies are needed on this topic and also on the development of quality indicators for rural ED.

This paper reports on the design and testing of a new questionnaire, "Perspectives on the Use in Communities of CAM" (the PUC-CAM-Q [questionnaire]). The questionnaire consisted of scales and questions for 27 concepts considered to affect complementary and alternative medicine (CAM) usage. Scales encompassed 13 beliefs about nature, scientific medicine, and the environment, as well as personal characteristics, such as stoicism and resilience. A matrix provided space for respondents to indicate their use, or likelihood of use, of 23 of the most commonly available CAM modalities. Also included were questions about the reasons for CAM use and sources of health information. The questionnaire was mailed to a randomly selected sample of people in a pilot study of two metropolitan and five rural localities in Victoria, Australia. The response rate was 40% (n = 459). The majority of the questionnaires were completed consistently, and the reliability and validity and questions were satisfactory. Seven (7) of the 13 scales that explored the beliefs and concerns about CAM use and the characteristics of the respondents had Cronbach alphas of above 0.7. Refinement of the other six scales resulted in alphas of between 0.6 and 0.7, with good corrected item-total correlations for included questions. Responses to the matrix question on the use, or likelihood of use, of individual CAM modalities were also good. However, some adjustments to the layout would provide more comprehensive information for future use of the PUC-CAM-Q. This questionnaire provided good data that were appropriate for the exploratory nature of this PUC-CAM study. After more attention to the scales, as well as some refinement of some nonscale questions, the PUC-CAM-Q would be a practical instrument for further studies on CAM use.

To explore the characteristics of specialists who provide ongoing rural outreach services and whether the nature of their service patterns contributes to ongoing outreach. Specialist doctors providing rural outreach in a large longitudinal survey of Australian doctors in 2008, together with new entrants to the survey in 2009, were followed up to 2011. Providing outreach services to the same rural town for at least 3 years. Of 953 specialists who initially provided rural outreach services, follow-up data were available for 848. Overall, 440 specialists (51.9%) provided ongoing outreach services. Multivariate analysis found that participation was associated with being male (odds ratio [OR], 1.82; 95% CI, 1.28-2.60), in mid-career (45-64 years old; OR, 1.44; 95% CI, 1.04-1.99), and working in mixed, mainly private practice (OR, 1.73; 95% CI, 1.18-2.53). Specialists working only privately were less likely to provide ongoing outreach (OR 0.51; 95% CI, 0.32-0.82), whereas metropolitan and...

Objective This paper describes the service distribution and models of rural outreach by specialist doctors living in metropolitan or rural locations.Methods The present study was a national cross-sectional study of 902 specialist doctors providing 1401 rural outreach services in the Medicine in Australia: Balancing Employment and Life study, 2008. Five mutually exclusive models of rural outreach were studied.Results Nearly half of the outreach services (585/1401; 42%) were provided to outer regional or remote locations, most (58%) by metropolitan specialists. The most common model of outreach was drive-in, drive-out (379/902; 42%). In comparison, metropolitan-based specialists were less likely to provide hub-and-spoke models of service (odd ratio (OR) 0.31; 95% confidence interval (CI) 0.21-0.46) and more likely to provide fly-in, fly-out models of service (OR 4.15; 95% CI 2.32-7.42). The distance travelled by metropolitan specialists was not affected by working in the public or pri...

Over 70% of all hospital admissions have a peripheral intravenous device (PIV) inserted; however, the failure rate of PIVs is unacceptably high, with up to 69% of these devices failing before treatment is complete. Failure can be due to dislodgement, phlebitis, occlusion/infiltration and/or infection. This results in interrupted medical therapy; painful phlebitis and reinsertions; increased hospital length of stay, morbidity and mortality from infections; and wasted medical/nursing time. Appropriate PIV dressing and securement may prevent many cases of PIV failure, but little comparative data exist regarding the efficacy of various PIV dressing and securement methods. This trial will investigate the clinical and cost-effectiveness of 4 methods of PIV dressing and securement in preventing PIV failure. A multicentre, parallel group, superiority randomised controlled trial with 4 arms, 3 experimental groups (tissue adhesive, bordered polyurethane dressing, sutureless securement device)...

Poor access to doctors at times of need remains a significant impediment to achieving good health for many rural residents. The two-step floating catchment area (2SFCA) method has emerged as a key tool for measuring healthcare access in rural areas. However, the choice of catchment size, a key component of the 2SFCA method, is problematic because little is known about the distance tolerance of rural residents for health-related travel. Our study sought new evidence to test the hypothesis that residents of sparsely settled rural areas are prepared to travel further than residents of closely settled rural areas when accessing primary health care at times of need. A questionnaire survey of residents in five small rural communities of Victoria and New South Wales in Australia was used. The two outcome measures were current travel time to visit their usual doctor and maximum time prepared to travel to visit a doctor, both for non-emergency care. Kaplan-Meier charts were used to compare t...

Rurality and rural population issues require consideration when conducting and reporting on rural health research. A first article focused on the planning stage of the research. The objective of this article is to explore conducting and reporting issues that require attention when undertaking rural health research. The privacy of participants, the collection of data, the cultural traditions of Indigenous communities, the dissemination of results, and giving something back to the community, are all aspects of conducting and reporting rural health research that require attention. Procedures such as identifying the characteristics of the population, attention to safety issues when collecting data, the use of local liaison persons and acknowledging the ownership of intellectual property, increase the quality of the research outcomes. They are issues that are relevant to both qualitative and quantitative research methods. Procedures are available to address issues of particular concern i...

Rurality and rural population issues require special consideration when planning both qualitative and quantitative health research in rural areas. The objective of this article was to explore the issues that require attention when planning the research. This is the first of two articles and focus on issues that require consideration when undertaking rural health research. The diversity of study populations, the feasibility of a research topic, the selection of a research team, and the cultural traditions of Indigenous communities, are all aspects of rural health research planning that require attention. Procedures such as identifying the characteristics of the population, the selection of measures of rurality appropriate for the research topic, the use of local liaison persons, decisions on the use of 'insider' or 'outsider' researchers, and the identification of skills resources available, increase the quality of the research outcomes. These issues are relevant to b...

Access to rural health research information together with the type and availability of educational resources in rural areas, are important to rural health care providers, community members, researchers, students, planners and policy makers. The Rural Health Research Register (RHRR) focuses on current and recent research activity being undertaken in Australia in the field of rural health, while the Health Education Rural Remote Resources Database (HERRD) focuses on education courses and resources relevant to the practice and professional development of rural and remote health professionals throughout Australia. Early versions of these databases were established between 1992 and 1997, and in the period 1998-2001 both information resources were systematically updated through targeted promotion, registrations and the creation of web-accessible search facilities. They continue to be maintained and updated. Detailed information is available by searching the RHRR and HERRD databases via th...

The number of health-sciences students who spend time training in rural areas is increasing. Students undertaking rural placements have identified the need to be fully informed about the rural areas in which they are to be placed. To address this need, Echidna, a Web-based database containing rural-community information has been developed. The website brings fragmented information together in one easily navigable location for quick and accurate searching. Information provided in the website includes demographic data, health and community services information and relevant links. This paper examines the history of Echidna's development, data inclusion and data maintenance issues and discusses how students from medicine, nursing and other health disciplines, as well as other health professionals and organisations benefit from the resource.

We assessed whether a modified fascia iliaca compartment block in unilateral total hip arthroplasty provides a morphine-sparing effect in the first 24 hours. This involved a randomised, double blind study of 44 patients. Both groups received a modified fascia iliaca block with the trial group receiving 30 ml 0.5% bupivacaine with 1:200,000 adrenaline, 150 microg clonidine and 9 ml 0.9% saline and the control group receiving 40 ml 0.9% saline. Otherwise both groups received identical care with a subarachnoid block for operative anaesthesia. Patient-controlled morphine analgesia was commenced postoperatively and data were collected at three, six, 12 and 24 hours post commencement of surgery. We found that the trial group used less morphine at 12 and 24 hours (P < 0.001). The median morphine usage at 24 hours was 37.5 mg in the control patients and 22 mg in the trial patients. Pain scores were similar between groups. We conclude that a modified fascia iliaca compartment block has a significant morphine-sparing effect in unilateral total hip arthroplasty.

This study investigated whether increased numbers of primary healthcare clinical consultations in Indigenous communities in some remote areas of Australia are associated with the reduced need for urgent medical evacuations and remote telephone consultations. A retrospective comparison study of routinely collected data utilising correlation analysis was conducted. Statistical associations have been measured using Pearson product-moment correlation coefficients. The setting was 20 primary healthcare centres in the Northern Territory servicing ≥5900 residents between July 2008 and June 2010; data were collected from Central Australia Remote Health and the Royal Flying Doctor Service-Central Operations, Alice Springs base. Main outcome measures included number of acute medical evacuations and number of remote telephone consultations relative to number of face-to-face consultations with Aboriginal health workers, remote area nurses and general practitioners. Statistically significant pos...

Objective Access to primary healthcare (PHC) services is key to improving health outcomes in rural areas. Unfortunately, little is known about which aspect of access is most important. The objective of this study was to determine the relative importance of different dimensions of access in the decisions of rural Australians to utilise PHC provided by general practitioners (GP). Methods Data were collected from residents of five communities located in 'closely' settled and 'sparsely' settled rural regions. A paired-comparison methodology was used to quantify the relative importance of availability, distance, affordability (cost) and acceptability (preference) in relation to respondents' decisions to utilise a GP service for non-emergency care. Results Consumers reported that preference for a GP and GP availability are far more important than distance to and cost of the service when deciding to visit a GP for non-emergency care. Important differences in rankings emerged by geographic context, gender and age. Conclusions Understanding how different dimensions of access influence the utilisation of PHC services is critical in planning the provision of PHC services. This study reports how consumers 'trade-off' the different dimensions of access when accessing GP care in rural Australia. The results show that ensuring 'good' access requires that policymakers and planners should consider other dimensions of access to services besides geography. What is known about the topic? Research indicates that poorer 'access' to GPs, an impediment to seeking primary care at times of need, is the most important factor distinguishing rural from urban health service utilisation behaviour, which undoubtedly contributes to the poorer health outcomes characterising rural and remote populations. Much of the policy on access to date has focussed on increasing the number of GP located in rural and remote areas that are characterised by acute medical workforce shortages. What does this paper add? This study provides empirical data to show how different dimensions of access influence rural Australians' decisions to utilise a GP service. Overall, rural Australians rank preference for a GP as the most important factor in their decision to visit a doctor for a non-emergency consultation. Important differences in rankings emerged by geographic context, gender and age. Distance to a GP service ranks consistently as the third most important access factor and cost is rated the least important aspect of access. What are the implications for practitioners? Although current rural health policies and incentives should continue to target the need to increase the availability of GP in non-metropolitan areas, this alone may not be sufficient to improve GP service utilisation. Other dimensions of access, particularly consumer preference, which are amenable to interventions both nationally and locally, are equally important.

The objectives of this study were to measure the relative strength, significance and contribution of factors associated with rural and remote medical workforce retention. Length of stay data from two Australian GP workforce datasets, the 2008 National Minimum Data Set (4223 GPs) and a subset of the 2008 Medicine in Australia: Balancing Employment and Life dataset (1189 GPs), were separately analysed using multiple linear regression models and the results compared. Length of employment in their current practice location was the outcome measure. Consistent results were obtained across both datasets. The most important factors associated with the retention of rural and remote GPs, after adjusting for GP age, were primary income source, registrar status, hospital work and restrictions on practice location (which are linked to geographic location). Practice ownership was associated with -70% higher retention than average, whilst undertaking hospital work in addition to routine general practice was associated with at least 18% higher retention compared with if no hospital work was undertaken. Less important factors included geographic location, procedural skills, annual leave, workload and practice size. Our findings quantify a range of financial and economic, professional and organisational, and geographic factors contributing to the retention of rural GPs. These findings have important implications for future medical workforce policy, providing an empirical evidence base to support the targeting and 'bundling' of retention initiatives in order to optimise the retention of rural GPs.

Vascular access devices (VADs), such as peripheral or central venous catheters, are vital across all medical and surgical specialties. To allow therapy or haemodynamic monitoring, VADs frequently require administration sets (AS) composed of infusion tubing, fluid containers, pressure-monitoring transducers and/or burettes. While VADs are replaced only when necessary, AS are routinely replaced every 3-4 days in the belief that this reduces infectious complications. Strong evidence supports AS use up to 4 days, but there is less evidence for AS use beyond 4 days. AS replacement twice weekly increases hospital costs and workload. This is a pragmatic, multicentre, randomised controlled trial (RCT) of equivalence design comparing AS replacement at 4 (control) versus 7 (experimental) days. Randomisation is stratified by site and device, centrally allocated and concealed until enrolment. 6554 adult/paediatric patients with a central venous catheter, peripherally inserted central catheter o...

This paper reports on the design and testing of a new questionnaire, "Perspectives on the Use in Communities of CAM" (the PUC-CAM-Q [questionnaire]). The questionnaire consisted of scales and questions for 27 concepts considered to affect complementary and alternative medicine (CAM) usage. Scales encompassed 13 beliefs about nature, scientific medicine, and the environment, as well as personal characteristics, such as stoicism and resilience. A matrix provided space for respondents to indicate their use, or likelihood of use, of 23 of the most commonly available CAM modalities. Also included were questions about the reasons for CAM use and sources of health information. The questionnaire was mailed to a randomly selected sample of people in a pilot study of two metropolitan and five rural localities in Victoria, Australia. The response rate was 40% (n = 459). The majority of the questionnaires were completed consistently, and the reliability and validity and questions were satisfactory. Seven (7) of the 13 scales that explored the beliefs and concerns about CAM use and the characteristics of the respondents had Cronbach alphas of above 0.7. Refinement of the other six scales resulted in alphas of between 0.6 and 0.7, with good corrected item-total correlations for included questions. Responses to the matrix question on the use, or likelihood of use, of individual CAM modalities were also good. However, some adjustments to the layout would provide more comprehensive information for future use of the PUC-CAM-Q. This questionnaire provided good data that were appropriate for the exploratory nature of this PUC-CAM study. After more attention to the scales, as well as some refinement of some nonscale questions, the PUC-CAM-Q would be a practical instrument for further studies on CAM use.