Enhancing access to cancer education for rural healthcare providers via telehealth

Supporting best practice in the management of chronic diseases in primary health care settings: a scoping review of training programs for Indigenous Health Workers and Practitioners

Background To improve diabetes management in primary health care for the Aboriginal and Torres Strait Islander peoples population, training programs that are culturally and contextually relevant to the local context are required. Using a scoping review methodology, the aim of this review was to describe the characteristics of chronic disease management training programs for Aboriginal Health Workers and Practitioners, their effectiveness on knowledge and skills, and client-related outcomes, and the enablers, barriers to delivery and participation. Methods Following protocol parameters, a systematic search was conducted in relevant databases and grey literature. Two independent reviewers screened the title and abstract of each paper to determine if the study met the inclusion criteria. Results Of the 23 included studies, most were developed with stakeholders, profession facilitated and delivered by cultural facilitators. All training programs included content knowledge, two included a professional support network, four provided on-the-job support and six had follow-up support post-training. Modes of delivery ranged from didactic, storytelling and hands-on learning. Two studies reported significant improvement in participants' knowledge and confidence; one reported improvement in knowledge (12.7% increase pre-post training), and an increase in confidence in both clinical and non-clinical skills. Enablers (relevance, modes of learning, power of networking, improved knowledge, confidence and clinical practice) and barriers (adult learning capabilities, competing work-family commitments) were reported. Few studies reported on knowledge transfer into clinical practice and client-related outcomes. Conclusions Multifaceted training programs for Aboriginal health workers are well received and may improve workforce capability.

Policy strategies for capacity building and scale up of the workforce for comprehensive cancer care: a systematic review

BACKGROUND

Patients with cancer in low- and middle-income countries experience worse outcomes as a result of the limited capacity of health systems to deliver comprehensive cancer care. The health workforce is a key component of health systems; however, deep gaps exist in the availability and accessibility of cancer care providers.

MATERIALS AND METHODS

We carried out a systematic review of the literature evaluating the strategies for capacity building of the cancer workforce. We studied how the policy strategies addressed the availability, accessibility, acceptability, and quality (AAAQ) of the workforce. We used a strategic planning framework (SWOT: strengths, weaknesses, opportunities, threats) to identify actionable areas of capacity building. We contextualized our findings based on the WHO 2030 Global Strategy on Human Resources for Health, evaluating how they can ultimately be framed in a labour market approach and inform strategies to improve the capacity of the workforce (PROSPERO: CRD42020109377).

RESULTS

The systematic review of the literature yielded 9617 records, and we selected 45 eligible papers for data extraction. The workforce interventions identified were delivered mostly in the African and American Regions, and in two-thirds of cases, in high-income countries. Many strategies have been shown to increase the number of competent oncology providers. Optimization of the existing workforce through role delegation and digital health interventions was reported as a short- to mid-term solution to optimize cancer care, through quality-oriented, efficiency-improving, and acceptability-enforcing workforce strategies. The increased workload alone was potentially detrimental. The literature on retaining the workforce and reducing brain drain or attrition in underserved areas was commonly limited.

CONCLUSIONS

Workforce capacity building is not only a quantitative problem but can also be addressed through quality-oriented, organizational, and managerial solutions of human resources. The delivery of comprehensive, acceptable, and impact-oriented cancer care requires an available, accessible, and competent workforce for comprehensive cancer care. Efficiency-improving strategies may be instrumental for capacity building in resource-constrained settings.

Factors Influencing the Effectiveness of E-Learning in Healthcare: A Fuzzy ANP Study

E-learning has transformed the healthcare education system by providing healthcare professionals with training and development opportunities, regardless of their location. However, healthcare professionals in remote or rural areas face challenges such as limited access to educational resources, lack of reliable internet connectivity, geographical isolation, and limited availability of specialized training programs and instructors. These challenges hinder their access to e-learning opportunities and impede their professional development. To address this issue, a study was conducted to identify the factors that influence the effectiveness of e-learning in healthcare. A literature review was conducted, and two questionnaires were distributed to e-learning experts to assess primary variables and identify the most significant factor. The Fuzzy Analytic Network Process (Fuzzy ANP) was used to identify the importance of selected factors. The study found that success, satisfaction, availability, effectiveness, readability, and engagement are the main components ranked in order of importance. Success was identified as the most significant factor. The study results highlight the benefits of e-learning in healthcare, including increased accessibility, interactivity, flexibility, knowledge management, and cost efficiency. E-learning offers a solution to the challenges of professional development faced by healthcare professionals in remote or rural areas. The study provides insights into the factors that influence the effectiveness of e-learning in healthcare and can guide the development of future e-learning programs.

Project ECHO: Enhancing palliative care for primary care occupational therapists and physiotherapists in Ireland

Project ECHO (Extension for Community Healthcare Outcomes) uses videoconferencing technology to support and train healthcare professionals (HCPs) remotely. A 4-month fortnightly ECHO programme was developed and implemented to enhance palliative care provision by primary care therapists. Teaching and case-based discussions were facilitated by palliative care specialists. A mixed-methods cohort study was used to evaluate the project. ECHO participants completed pre- and post-programme questionnaires regarding their knowledge and skills across key palliative care domains. Focus groups were held before programme commencement to explore participants' attitudes and experiences of palliative care and after programme conclusion to explore their experiences of ECHO. Twenty-six primary care HCPs commenced the ECHO programme. Mean scores in self-rated confidence in knowledge and skill improved significantly (p < .002) following the programme. Twenty-one primary care HCPs completed the post-ECHO surveys and scores of self-rated confidence in knowledge and skills were significantly higher than pre-ECHO scores. Ninety-five percent of participants (n = 19) reported ECHO met their learning needs and was an effective format to enhance clinical knowledge. Eighty-five percent of participants (n = 17) would recommend ECHO to their colleagues. Project ECHO improved palliative care knowledge and skills of primary care HCPs in Ireland, with potential to address the growing need for integrated palliative care services.

Information Sources Used by Oncologists to Understand Multi-marker Tumor Panel Tests for Cancer Patients

Precision medicine using multi-marker tumor panel (MMTP) testing can help inform cancer treatment decisions. Oncologists' knowledge of these tests and their ability to find up-to-date information about their application in clinical care is essential. This study aimed to (1) describe information sources used by oncologists to learn about new genomic tests and (2) examine characteristics associated with the use of each information source. The National Cancer Institute's National Survey of Precision Medicine in Cancer Treatment surveyed a nationally representative sample of oncologists about MMTP testing. We examined the use of 11 information sources among oncologists that reported using MMTP tests (n = 1222). Bivariate analyses were used to examine whether information sources differed by oncologist- and practice-level characteristics and type of MMTP test. Most oncologists reported using peer-reviewed medical literature (88.8%), scientific conferences (87.9%), and medical professional societies (83.8%) to learn about MMTPs. In contrast, government websites, FDA inserts, and foundation resources were each used by < 36% of oncologists. The use of information sources differed by oncologist and practice characteristics. For example, a greater percentage of oncologists with an academic affiliation used peer-reviewed medical literature and scientific conferences, as compared to those without an academic affiliation (p = 0.006). As the number and type of MMTP tests increase, providing oncologists with current information about their appropriate application is essential. Further understanding of how oncologists use specific information sources may improve the dissemination and effective implementation of new MMTPs and help tailor educational interventions based on provider characteristics.

The role of digital health technology in rural cancer care delivery: A systematic review

PURPOSE

Rural residents face higher cancer incidence rates and mortality rates, disparities that could be mitigated with health technology interventions, yet a digital divide is also apparent. This paper systematically and critically examines existing literature to understand how digital technologies have been used to support rural oncology care.

METHODS

PubMed, CINAHL Complete, PsycINFO, and Embase were searched using Medical Subject Headings terms and keywords. Studies were eligible if they presented empirical data investigating the use of technology in rural oncology and were published in English in a peer-reviewed journal within the last decade. The Mixed Methods Appraisal Tool was used to assess methodological quality.

FINDINGS

Digital health has been less extensively utilized in rural oncology compared with the general cancer population and other chronic diseases. We identified 54 studies that used technology in rural cancer care delivery, a comparatively small number, representing a significant gap in the literature. Studies were classified into 4 categories: Telemedicine (n = 32), phone calls (n = 11), Internet (n = 9), and mobile phone (n = 2). Of the 54 articles, 12 were RCTs, 17 were quasi-experimental, 3 were descriptive, 12 were mixed methods, and 10 were qualitative. Most of the studies involved patients only (n = 31) and were not specific to a cancer type (n = 41).

CONCLUSIONS

Further implementation and expansion of telemedicine and phone-based strategies in rural cancer care delivery are warranted. Rural cancer survivors value digital approaches to their care. However, social and behavioral determinants of health and access to technology must be considered.

eHealth Education: Methods to Enhance Oncology Nurse, Patient, and Caregiver Teaching

BACKGROUND

eHealth can enhance the delivery of clinical cancer care by offering unique education opportunities for oncology nurses, patients, and family caregivers throughout the cancer trajectory.

OBJECTIVES

This article reviews eHealth technology that can be applied to oncology education, such as mobile health applications, text messaging, web-based education, and audio- and videoconferencing.

METHODS

Case studies provide exemplars of eHealth technologies used for delivering oncology education to nurses, patients, and caregivers.

FINDINGS

By using eHealth technologies to obtain and provide education, oncology nurses are well positioned to improve the lives of patients and caregivers.

Homestead together: Pediatric palliative care telehealth support for rural children with cancer during home-based end-of-life care

BACKGROUND

Children with terminal cancer and their families describe a preference for home-based end-of-life care. Inadequate support outside of the hospital is a limiting factor in home location feasibility, particularly in rural regions lacking pediatric-trained hospice providers.

METHODS

The purpose of this longitudinal palliative telehealth support pilot study was to explore physical and emotional symptom burden and family impact assessments for children with terminal cancer receiving home based-hospice care. Each child received standard of care home-based hospice care from an adult-trained rural hospice team with the inclusion of telehealth pediatric palliative care visits at a scheduled minimum of every 14 days.

RESULTS

Eleven children (mean age 11.9 years) received pediatric palliative telehealth visits a minimum of every 14 days, with an average of 4.8 additional telehealth visits initiated by the family. Average time from enrollment to death was 21.6 days (range 4-95). Children self-reported higher physical symptom prevalence than parents or hospice nurses perceived the child was experiencing at time of hospice enrollment with underrecognition of the child's emotional burden. At the time of hospice enrollment, family impact was reported by family caregivers as 46.4/100 (SD 18.7), with noted trend of improved family function while receiving home hospice care with telehealth support. All children remained at home for end-of-life care.

CONCLUSION

Pediatric palliative care telehealth combined with adult-trained rural hospice providers may be utilized to support pediatric oncology patients and their family caregivers as part of longitudinal home-based hospice care.

Real-Time Learning Through Telemedicine Enhances Professional Training in Rural Emergency Departments

Background: The low volume and the intermittent nature of serious emergencies presenting to rural emergency departments (EDs) make it difficult to plan and deliver pertinent professional training. Telemedicine provides multiple avenues for training rural ED clinicians. This study examines how telemedicine contributes to professional training in rural EDs through both structured and unstructured approaches. Methods: This qualitative study examined training experiences in 18 hospitals located in 6 Midwest states in the United States, which participated in a single hub-and-spoke telemedicine network. Twenty-eight interviews were conducted with 7 physicians, 10 advanced practice providers, and 11 nurses. Standard, inductive qualitative analysis was used to identify key themes related to experiences with telemedicine-based training and its impact on rural ED practice. Results: For structured formal training, rural ED clinicians used asynchronous sessions more often than live sessions. It was reported that the formal training program may not have been fully utilized due to time and workload constraints. Rural clinicians strongly valued unstructured real-time training during telemedicine consultations. It was perceived consistently across professional groups that real-time training occurred frequently and its spontaneous nature was beneficial. Hub providers offering suggestions respectfully and explaining the rationale behind recommendations facilitated real-time learning. Rural providers and nurses perceived several effects of real-time training, including keeping rural practice up to date, instilling confidence, and improving performance. Discussion: Our research shows that telemedicine provided rural ED providers and nurses both formal training and real-time training opportunities. Real-time training occurred frequently, complemented formal training, and was perceived to have many advantages.

Factors Determining Patients' Choice Between Mobile Health and Telemedicine: Predictive Analytics Assessment

BACKGROUND

The solution to the growing problem of rural residents lacking health care access may be found in the use of telemedicine and mobile health (mHealth). Using mHealth or telemedicine allows patients from rural or remote areas to have better access to health care.

OBJECTIVE

The objective of this study was to understand factors influencing the choice of communication medium for receiving care, through the analysis of mHealth versus telemedicine encounters with a virtual urgent clinic.

METHODS

We conducted a postdeployment evaluation of a new virtual health care service, Virtual Urgent Clinic, which uses mHealth and telemedicine modalities to provide patient care. We used a multinomial logistic model to test the significance and predictive power of a set of features in determining patients' preferred method of telecare encounters-a nominal outcome variable of two levels (mHealth and telemedicine).

RESULTS

Postdeployment, 1403 encounters were recorded, of which 1228 (87.53%) were completed with mHealth and 175 (12.47%) were telemedicine encounters. Patients' sex (P=.004) and setting (P<.001) were the most predictive determinants of their preferred method of telecare delivery, with significantly small P values of less than .01. Pearson chi-square test returned a strong indication of dependency between chief concern and encounter mediums, with an extremely small P<.001. Of the 169 mHealth patients who responded to the survey, 154 (91.1%) were satisfied by their encounter, compared with 31 of 35 (89%) telemedicine patients.

CONCLUSIONS

We studied factors influencing patients' choice of communication medium, either mHealth or telemedicine, for a virtual care clinic. Sex and geographic location, as well as their chief concern, were strong predictors of patients' choice of communication medium for their urgent care needs. This study suggests providing the option of mHealth or telemedicine to patients, and suggesting which medium would be a better fit for the patient based on their characteristics.

Palliative Oncologic Care Curricula for Providers in Resource-Limited and Underserved Communities: a Systematic Review

Familiarity with principles of palliative care, supportive care, and palliative oncological treatment is essential for providers caring for cancer patients, though this may be challenging in global communities where resources are limited. Herein, we describe the scope of literature on palliative oncological care curricula for providers in resource-limited settings. A systematic literature review was conducted using PubMed, Embase, Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Med Ed Portal databases, and gray literature. All available prospective cohort studies, case reports, and narratives published up to July 2017 were eligible for review. Fourteen articles were identified and referenced palliative care education programs in Argentina, Uganda, Kenya, Australia, Germany, the USA, or multiple countries. The most common teaching strategy was lecture-based, followed by mentorship and experiential learning involving role play and simulation. Education topics included core principles of palliative care, pain and symptom management, and communication skills. Two programs included additional topics specific to the underserved or American Indian/Alaskan Native community. Only one program discussed supportive cancer care, and no program reported educational content on resource-stratified decision-making for palliative oncological treatment. Five programs reported positive participant satisfaction, and three programs described objective metrics of increased educational or research activity. There is scant literature on effective curricula for providers treating cancer patients in resource-limited settings. Emphasizing supportive cancer care and palliative oncologic treatments may help address gaps in education; increased outcome reporting may help define the impact of palliative care curriculum within resource-limited communities.

Evaluating Online Continuing Professional Development Regarding Weight Management for Pregnancy Using the New World Kirkpatrick Model

INTRODUCTION

Clinical practice guidelines advocate the importance of continuing professional development (CPD) that supports health professionals (HPs) to discuss the sensitive topic of maternal weight management with women. However, there is a lack of accredited CPD related to this important area of preconception and antenatal care. Therefore, aims were to evaluate HPs' reactions to accredited online CPD regarding weight management for pregnancy and their knowledge, attitudes, confidence, and commitment to provide women with advice after completing the course.

METHODS

A mixed-methods evaluation was based on the New World Kirkpatrick Model (NWKM). Accredited online CPD was developed by experts in maternal nutrition and weight management. Participants completed a questionnaire before (n = 136) and after (n = 65) the weight management components of the course. McNemar and Wilcoxon signed-rank tests were used to evaluate paired data (n = 36) (p < .05). Deductive content analyses explored free-text responses (n = 65).

RESULTS

Participants' reactions to the online CPD were encouraging, facilitating increases in perceptions of the importance of weight management for pregnancy and confidence to provide advice. Quantitative measures assessed no change in participants' knowledge; however, qualitative analyses revealed an increase in participants' knowledge of communication strategies that they intend to apply in practice.

DISCUSSION

The NWKM facilitated an evaluation of HPs' encouraging reactions to online CPD and the affective constructs of education including attitudes, confidence, and commitment to provide advice. Online CPD should be developed with collaboration between universities/professional associations and health care providers, so that evaluation of organizational change and clinical outcomes is possible.

The effectiveness of internet-based e-learning on clinician behavior and patient outcomes: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this systematic review is to identify, appraise and synthesize the best available evidence for the effectiveness of internet-based e-learning programs on health care professional behavior and patient outcomes.

BACKGROUND

Technological innovation has not only impacted social change in recent years but has been the prime driver of educational transformation.The newest consumers of post-secondary education, the so-called 'digital natives', have come to expect education to be delivered in a way that offers increased usability and convenience. Health care professionals (HCPs) in the clinical setting, particularly those in rural and remote communities, are no different. Today's health workforce has a professional responsibility to maintain competency in practice through achieving a minimum number of hours of continuing professional development. Consequently, HCPs seeking professional development opportunities are reliant on sourcing these independently according to individual learning needs. However, difficulties exist in some health professionals' access to ongoing professional development opportunities, particularly those with limited access face-to-face educationdue to geographical isolation or for those not enrolled in a formal program of study.These issues challenge traditional methods of teaching delivery; electronic learning (e-learning) is at the nexus of overcoming these challenges.The term e-learning originated in the mid-1990s as the internet began to gather momentum.Electronic learning can be broadly defined as any type of educational media that is delivered in an electronic form.Terms such as computer-assisted learning, online learning, web-based learning and e-learning are often used synonymously but all reflect knowledge transfer via an electronic device. This broad definition allows for a gamut of multimedia to be used for the purpose of constructing and assessing knowledge. Multimedia typically used in e-learning range from the now archaic Compact Disc Read-Only Memory (CD-ROMs), to the simple Microsoft PowerPoint, or the more advanced and complex virtual worlds such a second life. Electronic learning can be delivered in asynchronous or synchronous formats, with the latter (for example interactive online lectures via platforms such as BlackboardCollaborate or WebEx) more commonly used in formal educational settings according to set timetables of study.Person-to-person interactivity is an important enabler of knowledge generation and while functionalities such as web 1.0 (discussion board and email) and more recently web 2.0 (Wikis and blogs) allow for this to occur both synchronously and asynchronously, it is usually utilized in formal educational contexts only. However, the economy of formal education does not allow for free access to courses which proves challenging for HCPs seeking quality educational opportunities who choose not to undergo a formal program of study or are just looking to meet a specific learning need. Alternatively, asynchronous e-learning is a more learner-centred approach that affords the opportunity to engage in learning at a time and location that is convenient and enables the learner to balance professional development with personal and work commitments.These learning opportunities are self-directed and do not require a human to facilitate learning, rather, technology officiates/facilitates the learning process and, in the asynchronous e-learning context, the learner negotiates meaning independently.Health-related e-learning research has focused on several domains including media comparative designs, self-efficacy, user satisfaction, instructional design, knowledge outcomes, clinical skills development, and facilitators/barriers to its use.The benefits of e-learning are well documented in terms of increased accessibility to education, efficacy, cost effectiveness, learner flexibility and interactivity.However, some fundamental methodological and philosophical flaws exist in e-learning research, not least the use of comparative design studies. Comparison between e-learning and traditional teaching methods are illogical and methodologically flawed because comparison groups are heterogeneous, lack uniformity and have multiple confounders that cannot be adjusted for.As early as 1994, researchersin computer-assisted learning were citing these limitations and called for a fresh research agenda in this area. Cookrepeated this call in 2005 and again in 2009 and noted a paucity of research related to patient or clinical practice outcomes. Electronic learning is not an educational panacea and research needs to progress from pre- and post-interventional and comparative designs that evaluate knowledge increases and user satisfaction. It is time to move towards determining whether improved self-efficacy or knowledge gained through e-learning improves patient outcomes or influences clinical behavior change and whether these changes are sustained. In order to develop the empirical evidence base in e-learning, research needs to be guided by established theoretical frameworks and use validated instruments to move from assessing knowledge generation towards improving our understanding of whether e-learning improves HCP behavior and more importantly, patient outcomes.One suitable framework that is congruent with e-learning research is Kirkpatrick'sfour levels of evaluation. Kirkpatrick's model is hierarchically based with level one relating to student reaction and how well the learner is satisfied with the education program. Level two pertains to learning and the evaluation of knowledge, level three expands on this and considers whether the education has influenced behavior. In the context of this review, behavior change is any practice that is intrinsically linked with the outcomes of the e-learning program undertaken. Finally, level four evaluates the impact on outcomes such as cost benefit or quality improvements.The majority of e-learning research has focused on participant experience and knowledge acquisition, outcomes that correspond with the first two levels of Kirkpatrick's model.To date, few studies have examined the effectiveness of internet-based e-learning programs on HCP behavior, which aligns with Level 3 of Kirkpatrick's model.Studies exist that use self-reported measures of intention to change behavior, however self-reported intention to change does not necessarily translate into actual behavior change. Studies that have not used self-reported measures of behavior change have used objectively measured evaluation criteria including objective structured assessment of technical skills (OSATS) using various methods including simulation task trainers and clinical simulations using standardized patients scored by a panel of experts using standardized assessment tools. Carney et al. used a national reporting and data system to measure the impact of a single one hour e-learning program undertaken by radiologists (n=31) aimed at reducing unnecessary recall during mammography screening. Carney et al. reported a null effect and attributed this to the complexities of behavior change, suggesting that longer term reinforcement of principles relating to mammography recall was required to effect behavior change. These findings also suggest that a multi-modal intervention may be required in order to reduce excessive recall rates in this area, rather than a single intervention. Contrary to Carney et al., Pape-Koehler et al. and Smeekins et al. reported positive findings using randomized controlled designs to test the efficacy of e-learning interventions on individual's surgical performance and the detection of child abuse, respectively. Pape-Koehler et al. used a 2x2 factorial design to demonstrate that an e-learning intervention significantly improved novice surgeon (n=70) surgical performance of a laparoscopic cholecystectomy (change between pre-post test OSATS p 0.001) when used in isolation or in combination with a practical training session compared to practical training alone. Smeekins et al. demonstrated that a 2 hour e-learning program improved nurses' (n=25) ability to detect child abuse in an emergency department. The nurses in the intervention (n=13) group demonstrated significantly better (p=0.022) questioning techniques and consequently, higher quality history taking, to determine children at risk of child abuse when compared with the control group who received no training at all.These three exemplar studies demonstrate the broad range of applications e-learning has in HCP education, as each study used different designs, had different subject areas and target health care professionals. This reflects the conceptual and practical challenges of the area of research that addresses levels three of Kirkpatrick's model. For this reason, the e-learning research agenda in health should focus on whether knowledge generated through e-learning is able to be re-contextualized into clinical practice, and influence sustained clinical behavior change and patient outcomes.A preliminary search of PubMed, CINAHL, The Cochrane Library, The JBI Database of Systematic Reviews and Implementation Reports, ERIC and PROSPERO was conducted to determine if a systematic review on the topic of interest already existed. This search identified four systematic reviews that specifically reviewed outcome measures of knowledge and skill improvement in the domain of e-learning. Two examined research conducted in nursing, with the other two in orthodontics. Lahti et al. systematic review examined the impact of e-learning on nurses' and nursing students' knowledge, skills and satisfaction. Lahti et al. were unable to demonstrate a statistical difference between cohorts undertaking e-learning compared to conventional teaching methods, findings that were not replicated by Du et al. This may be due to the decision by Lahti et al. (ABSTRACT TRUNCATED)

Telehealth to Expand Community Health Nurse Education in Rural Guatemala: A Pilot Feasibility and Acceptability Evaluation

Telehealth education has the potential to serve as an important, low-cost method of expanding healthcare worker education and support, especially in rural settings of low- and middle-income countries. We describe an innovative educational strategy to strengthen a long-term health professional capacity building partnership between Guatemalan and US-based partners. In this pilot evaluation, community health nurses in rural Guatemala received customized, interactive education via telehealth from faculty at the supporting US-based institution. Program evaluation of this 10 lecture series demonstrated high levels of satisfaction among learners and instructors as well as knowledge gain by learners. An average of 5.5 learners and 2 instructors attended the 10 lectures and completed surveys using a Likert scale to rate statements regarding lecture content, technology, and personal connection. Positive statements about lecture content and the applicability to daily work had 98% or greater agreement as did statements regarding ease of technology and convenience. The learners agreed with feeling connected to the instructors 100% of the time, while instructors had 86.4% agreement with connection related statements. Instructors, joining at their respective work locations, rated convenience statements at 100% agreement. This evaluation also demonstrated effectiveness with an average 10.7% increase in pre- to posttest knowledge scores by learners. As the global health community considers efficiency in time, money, and our environment, telehealth education is a critical method to consider and develop for health worker education. Our pilot program evaluation shows that telehealth may be an effective method of delivering education to frontline health workers in rural Guatemala. While larger studies are needed to quantify the duration and benefits of specific knowledge gains and to perform a cost-effectiveness analysis of the program, our initial pilot results are encouraging and show that a telehealth program between a US-based university and a rural community health program in a low- and middle-income country is both feasible and acceptable.

Telemedicine Use in Rural Native American Communities in the Era of the ACA: a Systematic Literature Review

Native American communities face serious health disparities and, living in rural areas, often lack regular access to healthcare services as compared to other Americans. Since the early 1970’s, telecommunication technology has been explored as a means to address the cost and quality of, as well as access to, healthcare on rural reservations. This systematic review seeks to explore the use of telemedicine in rural Native American communities using the framework of cost, quality, and access as promulgated by the Affordable Care Act of 2010 and urge additional legislation to increase its use in this vulnerable population. As a systematic literature review, this study analyzes 15 peer-reviewed articles from four databases using the themes of cost, quality, and access. The theme of access was referenced most frequently in the reviewed literature, indicating that access to healthcare may be the biggest obstacle facing widespread adoption of telemedicine programs on rural Native American reservations. The use of telemedicine mitigates the costs of healthcare, which impede access to high-quality care delivery and, in some cases, deters prospective patients from accessing healthcare at all. Telemedicine offers rural Native American communities a means of accessing healthcare without incurring high costs. With attention to reimbursement policies, educational services, technological infrastructure, and culturally competent care, telemedicine has the potential to decrease costs, increase quality, and increase access to healthcare for rural Native American patients. While challenges facing the implementation of telemedicine programs exist, there is great potential for it to improve healthcare delivery in rural Native American communities. Public policy that increases funding for programs that help to expand access to healthcare for Native Americans will improve outcomes because of the increase in access.

The effectiveness of Internet-based e-learning on clinician behaviour and patient outcomes: A systematic review

BACKGROUND

The contemporary health workforce has a professional responsibility to maintain competency in practice. However, some difficulties exist with access to ongoing professional development opportunities, particularly for staff in rural and remote areas and those not enrolled in a formal programme of study. E-learning is at the nexus of overcoming these challenges. The benefits of e-learning have been reported in terms of increased accessibility to education, improved self-efficacy, knowledge generation, cost effectiveness, learner flexibility and interactivity. What is less clear, is whether improved self-efficacy or knowledge gained through e-learning influences healthcare professional behaviour or skill development, whether these changes are sustained, and whether these changes improve patient outcomes.

OBJECTIVE

To identify, appraise and synthesise the best available evidence for the effectiveness of e-learning programmes on health care professional behaviour and patient outcomes.

DESIGN

A systematic review of randomised controlled trials was conducted to assess the effectiveness of e-learning programmes on clinician behaviour and patient outcomes. Electronic databases including CINAHL, Embase, ERIC, MEDLINE, Mosby's Index, Scopus and Cochrane - CENTRAL were searched in July 2014 and again in July 2015.

QUALITY ASSESSMENT AND DATA EXTRACTION

Studies were reviewed and data extracted by two independent reviewers using the Joanna Briggs Institute standardised critical appraisal and data extraction instruments.

DATA SYNTHESIS

Seven trials met the inclusion criteria for the analysis. Due to substantial instructional design, subject matter, study population, and methodological variation between the identified studies, statistical pooling was not possible and a meta-analysis could not be performed. Consequently, the findings of this systematic review are presented as a narrative review.

RESULTS

The results suggest that e-learning was at least as effective as traditional learning approaches, and superior to no instruction at all in improving health care professional behaviour. There was variation in behavioural outcomes depending on the skill being taught, and the learning approach utilised. No papers were identified that reported the effectiveness of an e-learning programme on patient outcomes.

CONCLUSION

This review found insufficient evidence regarding the effectiveness of e-learning on healthcare professional behaviour or patient outcomes, consequently further research in this area is warranted. Future randomised controlled trials should adhere to the CONSORT reporting guidelines in order to improve the quality of reporting, to allow evaluation of the effectiveness of e-learning programmes on healthcare professional behaviour and patient outcomes.

Using Telehealth to Train Providers of a Cancer Support Intervention

BACKGROUND

Group interventions are effective for addressing the transition from cancer treatment to survivorship but are not widely available outside of urban areas. In addition, minimal training is available for group facilitators outside of the mental healthcare discipline. Telehealth as a medium can facilitate conversation and interactive learning and make learning accessible to individuals in areas that lack resources for traditional classroom teaching. Little is known, however, regarding the feasibility and acceptability of a telehealth training program for group leaders. This project aimed to investigate the utility of a telehealth training program for the delivery of a copyrighted, manualized psychosocial group intervention, Cancer Transitions: Moving Beyond Treatment.

MATERIALS AND METHODS

Nine group leaders attended one in-person orientation, four telehealth training classes, and four telehealth supervision sessions, completing self-report measures of content knowledge, quality satisfaction, and self-confidence. Following the completion of their last Cancer Transitions facilitation, group leaders participated in a focus group to provide qualitative feedback regarding their experiences in training for and leading the respective groups in eight urban and rural North Carolina communities.

RESULTS

Group leaders rated the training program highly across the domains of content knowledge, quality satisfaction, and self-confidence. Satisfaction with the technology itself was equivocal.

CONCLUSIONS

Telehealth represents a feasible avenue for training and supporting leaders of psychosocial interventions. In addition, telehealth is particularly well suited to the need for training group leaders in areas outside urban centers or academic communities.

Best Practices for Effective Clinical Partnerships with Indigenous Populations of North America (American Indian, Alaska Native, First Nations, Métis, and Inuit)

This article presents a review of the literature to identify best practices for clinical partnerships with indigenous populations of North America, specifically American Indian/Alaska Native, First Nations, Métis, and Inuit of Canada. The authors have identified best practices and lessons learned from collaborating with indigenous populations, presented in 2 categories: conceptual guidelines and health care delivery guidelines. Major themes include the importance of trust and communication, the delivery of culturally congruent health care, and the necessity of working in partnership with tribal entities for successful delivery of health care. Best practices in health care delivery with indigenous populations are presented.

Formative Evaluation to Assess Communication Technology Access and Health Communication Preferences of Alaska Native People

OBJECTIVE

Information technology can improve the quality, safety, and efficiency of healthcare delivery by improving provider and patient access to health information. We conducted a nonrandomized, cross-sectional, self-report survey to determine whether Alaska Native and American Indian (AN/AI) people have access to the health communication technologies available through a patient-centered medical home.

METHODS

In 2011, we administered a self-report survey in an urban, tribally owned and operated primary care center serving AN/AI adults. Patients in the center's waiting rooms completed the survey on paper; center staff completed it electronically.

RESULTS

Approximately 98% (n = 654) of respondents reported computer access, 97% (n = 650) email access, and 94% (n = 631) mobile phone use. Among mobile phone users, 60% had Internet access through their phones. Rates of computer access (p = .011) and email use (p = .005) were higher among women than men, but we found no significant gender difference in mobile phone access to the Internet or text messaging. Respondents in the oldest age category (65-80 years of age) were significantly less likely to anticipate using the Internet to schedule appointments, refill medications, or communicate with their health care providers (all p < .001).

CONCLUSION

Information on use of health communication technologies enables administrators to deploy these technologies more efficiently to address health concerns in AN/AI communities. Our results will drive future research on health communication for chronic disease screening and health management.

Palliative care professional education via video conference builds confidence to deliver palliative care in rural and remote locations

BACKGROUND

People living in rural and remote locations are disadvantaged in accessing palliative care. This can be attributed to several factors including the role diversity and the low numbers of patients with specific conditions, as well as the difficulties rural health practitioners have in accessing opportunities for professional education. A program of multidisciplinary palliative care video conferences was presented to health practitioners across part of northern Australia in an effort to address this problem.

METHOD

The educational content of the video conferences was developed from participant responses to an educational needs assessment. Following cycles of four consecutive video conferences, 101 participants completed evaluative on-line surveys. The quantitative data were analysed using frequencies and analysis of variance tests with post-hoc analyses where appropriate, and an accessibility and remoteness index was used to classify their practice location.

RESULTS

All participants found the content useful regardless of their remoteness from the tertiary centre, their years of experience caring for palliative care patients or the number of patients cared for each year. However, change in confidence to provide palliative care as a result of attending the video conferences was significant across all disciplines, regardless of location. Doctors, medical students and allied health professionals indicated the greatest change in confidence.

CONCLUSIONS

The provision of professional education about palliative care issues via multidisciplinary video conferencing increased confidence among rural health practitioners, by meeting their identified need for topic and context specific education. This technology also enhanced the networking opportunities between practitioners, providing an avenue of ongoing professional support necessary for maintaining the health workforce in rural and remote areas. However, more attention should be directed to the diverse educational needs of allied health professionals.

Supervision, support and mentoring interventions for health practitioners in rural and remote contexts: an integrative review and thematic synthesis of the literature to identify mechanisms for successful outcomes

OBJECTIVE

To identify mechanisms for the successful implementation of support strategies for health-care practitioners in rural and remote contexts.

DESIGN

This is an integrative review and thematic synthesis of the empirical literature that examines support interventions for health-care practitioners in rural and remote contexts.

RESULTS

This review includes 43 papers that evaluated support strategies for the rural and remote health workforce. Interventions were predominantly training and education programmes with limited evaluations of supervision and mentoring interventions. The mechanisms associated with successful outcomes included: access to appropriate and adequate training, skills and knowledge for the support intervention; accessible and adequate resources; active involvement of stakeholders in programme design, implementation and evaluation; a needs analysis prior to the intervention; external support, organisation, facilitation and/or coordination of the programme; marketing of the programme; organisational commitment; appropriate mode of delivery; leadership; and regular feedback and evaluation of the programme.

CONCLUSION

Through a synthesis of the literature, this research has identified a number of mechanisms that are associated with successful support interventions for health-care practitioners in rural and remote contexts. This research utilised a methodology developed for studying complex interventions in response to the perceived limitations of traditional systematic reviews. This synthesis of the evidence will provide decision-makers at all levels with a collection of mechanisms that can assist the development and implementation of support strategies for staff in rural and remote contexts.

Mixed Methods in Nursing Research : An Overview and Practical Examples

Mixed methods research methodologies are increasingly applied in nursing research to strengthen the depth and breadth of understanding of nursing phenomena. This article describes the background and benefits of using mixed methods research methodologies, and provides two examples of nursing research that used mixed methods. Mixed methods research produces several benefits. The examples provided demonstrate specific benefits in the creation of a culturally congruent picture of chronic pain management for American Indians, and the determination of a way to assess cost for providing chronic pain care.

The national sports safety in secondary schools benchmark (N4SB) study: defining athletic training practice characteristics

CONTEXT

Increased rates of sport participation and sport-related injury have led to greater emphasis on and attention to medical care of student-athletes in the secondary school setting. Access to athletic training services is seen as a critical factor for delivering adequate injury prevention and medical care to student-athletes. However, few data are available regarding practice characteristics of athletic trainers (ATs) in this setting.

OBJECTIVE

To characterize the practices of secondary school athletic trainers (ATs).

DESIGN

Descriptive study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 17 558 ATs with current National Athletic Trainers' Association membership were identified for survey distribution. Of these, 4232 ATs indicated that they practiced in the secondary school setting, and 4045 completed some part of the survey.

MAIN OUTCOME MEASURE(S)

A Web-based survey was used to obtain demographic information about ATs and their secondary schools and characteristics of athletic training practice. Descriptive data regarding the athletic trainer's personal characteristics, secondary school characteristics, and practice patterns are reported as percentages and frequencies.

RESULTS

Most respondents were in the early stages of their careers and relatively new to the secondary school practice setting. Nearly two-thirds (62.4%; n = 2522) of respondents had 10 or fewer years of experience as secondary school ATs, 52% (n = 2132) had been certified for 10 or fewer years, and 53.4% (n = 2164) had 10 or fewer years of experience in any practice setting. The majority of respondents (85%) worked in public schools with enrollment of 1000 to 1999 (35.5%) and with football (95.5%). More than half of respondents were employed directly by their school. Most respondents (50.6%) reported an athletic training budget of less than $4000. The majority of ATs performed evaluations (87.5%) on-site all of the time, with a smaller percentage providing treatments (73.3%) or rehabilitation (47.4%) services all of the time.

CONCLUSIONS

This is the first study to describe secondary school athletic training that reflects national practice trends. To improve the quality of athletic training care and to support and improve current working conditions, the profession must examine how its members practice on a day-to-day basis.

Bridging the distance: a prospective tele-oncology study in Northern Norway

PURPOSE

The University Hospital of North Norway (UNN) is a tertiary-level hospital and has the main responsibility of providing specialized cancer health care in the remote area of Northern Norway. Weekly videoconferences (VCs) have been established to enable clinicians at a local hospital and primary cancer health care providers in five different communities to discuss cases with specialist cancer care services at UNN. In this study, we aimed to evaluate the feasibility of these VCs.

METHODS

This is a prospective registration study. Descriptive data were collected at UNN, and for each patient discussed at the VC, a survey was completed by the local health care provider responsible for the patient.

RESULTS

During an 18-month period, 167 cases were discussed (101 patients). A median of 7 health care providers participated in each VC. According to the local physicians and nurses, the VCs contributed in 96% of cases to give "quite a bit" or "very much" confidence in adequate patient care. They reported that patient care in 85% of cases would be improved "quite a bit" or "very much" due to the VC. The mean number of days waiting for VC were 2.0 days (range, 0-7; SD, 2.0) and was significantly shorter (P < 0.001) than the estimated time waiting if alternative consultations were to be used (mean, 10.2 days (range, 0-30; SD, 5.8)).

CONCLUSION

VC may be a useful supplemental tool to support primary health care providers at local hospitals and remote communities in their effort to offer efficient and high-quality cancer care.