Rural family physician perspectives on communication with urban specialists: a qualitative study

Working as a Healthcare Professional at Island Primary Care: An Exploratory Qualitative Study on the Cyclades Islands, Greece

Improving the quality of and access to healthcare services in rural areas is fundamental to developing sustainable healthcare systems. This research aims to explore the motivations of healthcare professionals to work and settle in rural island areas of Greece with limited access to secondary and tertiary care. The study suggests practical ways to encourage self-motivation and attract more health workers in rural areas. An exploratory qualitative research approach was employed, involving semi-structured interviews with 16 healthcare professionals working in primary-care units that lack direct hospital or hospital-health centre access. The research was conducted specifically in the rural islands of the Cyclades. Thematic analysis was conducted to identify common themes and unique insights from the participants. The analysis revealed three thematic categories. Τhe «attraction» thematic was influenced by personal factors, random selection, origin, accommodation factors, professional factors, and obligatoriness. The «recruitment» thematic was associated with understaffing, special care issues, an unstable working environment, educational and organisational aspects, and an insular lifestyle. The thematic of «retention» highlighted personal issues, accommodation difficulties, economic and work-related issues, and unique challenges posed by an insular lifestyle. This research provides valuable insights into the motivations that drive healthcare professionals to settle, work, and remain in remote island units, as well as the challenges they encounter in making this decision. The study proposes strategies to motivate and attract more healthcare professionals to rural areas. These findings should be considered when formulating or reviewing primary healthcare empowerment policies to ensure equitable healthcare access for all individuals.

Optimizing rural healthcare through improved team function: a case study of the Rural Surgical Obstetrical Networks programme

We explored enablers and mechanisms of optimal team function within rural hospital teams, and the impact of these factors on health service sustainability in British Columbia. The data were drawn from interviews and focus groups with healthcare providers and administrators (n = 169) who participated in the Rural Surgical Obstetrical Networks (RSON) initiative to support low-volume rural surgical and obstetrical services in British Columbia, Canada. The 5-year programme (2018-2022) provided evidence-based system interventions across eight rural sites with the objective of providing sustainable, quality health services to meet population needs. To explore the impact of RSON interventions on local team function, we performed a scoping review, to assess the current literature surrounding enablers of effective rural hospital teamwork. Through inductive thematic analysis of interview data, we identified five enablers of good team function at RSON sites, including emphasis on local leadership, shared direction, commitment to sustainability, respect and solidarity among colleagues, and meaningful communication. The RSON project led to a shift in team culture in participating sites, improved team function, and contributed to improved clinical processes and patient outcomes. The findings have implications for rural health policy and practice in British Columbia and other jurisdictions with similar health service delivery models and geographic contexts.

Exploring Current Practices, Needs, and Barriers for Expanding Distributed Medical Education and Scholarship in Psychiatry: Protocol for an Environmental Scan Using a Formal Information Search Approach and Explanatory Design

BACKGROUND

Distributed medical education (DME) offers manifold benefits, such as increased training capacity, enhanced clinical learning, and enhanced rural physician recruitment. Engaged faculty are pivotal to DME's success, necessitating efforts from the academic department to promote integration into scholarly and research activities. Environmental scanning has been used to gather, analyze, and apply information for strategic planning purposes. It helps organizations identify current practices, assess needs and barriers, and respond to emerging risks and opportunities. There are process models and conceptual frameworks developed for environmental scanning in the business and educational sectors. However, the literature lacks methodological direction on how to go about designing and implementing this strategy to guide research and practice in DME, especially in the psychiatry field.

OBJECTIVE

This paper presents a protocol for an environmental scanning that aims to understand current practices and identify needs and barriers that must be addressed to facilitate the integration of psychiatrists from the Dalhousie University Faculty of Medicine's distributed education sites in Nova Scotia and New Brunswick into the Department of Psychiatry, contributing for the expansion of DME in both provinces and informing strategic planning and decision-making within the organization.

METHODS

This protocol adopts an innovative approach combining a formal information search and an explanatory design that includes quantitative and qualitative data. About 120 psychiatrists from 8 administrative health zones of both provinces will be invited to complete an anonymous web-based survey with questions about demographics, participants' experience and interest in undergraduate, postgraduate, and continuing medical education, research and scholarly activities, quality improvement, and knowledge translation. Focus group sessions will be conducted with a purposive sample of psychiatrists to collect qualitative data on their perspectives on the expansion of DME.

RESULTS

Results are expected within 6 months of data collection and will inform policy options for expanding Dalhousie University's psychiatry residency and fellowship programs using the infrastructure and human resources at distributed learning sites, leveraging opportunities regionally, especially in rural areas.

CONCLUSIONS

This paper proposes a comprehensive environmental scan procedure adapted from existing approaches. It does this by collecting important characteristics that affect psychiatrists' desire to be involved with research and scholarly activities, which is crucial for the DME expansion. Furthermore, its concordance with the literature facilitates interpretation and comparison. The protocol's new method also fills DME information gaps, allowing one to identify insights and patterns that may shape psychiatric education. This environmental scan's results will answer essential questions about how training programs could involve therapists outside the academic core and make the most of training experiences in semiurban and rural areas. This could help other psychiatry and medical units outside tertiary care establish residency and fellowship programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46835.

Managing 'sick days' in patients with chronic conditions: An exploration of patient and healthcare provider experiences

INTRODUCTION

People with chronic medical conditions often take medications that improve long-term outcomes but which can be harmful during acute illness. Guidelines recommend that healthcare providers offer instructions to temporarily stop these medications when patients are sick (i.e., sick days). We describe the experiences of patients managing sick days and of healthcare providers providing sick day guidance to their patients.

METHODS

We undertook a qualitative descriptive study. We purposively sampled patients and healthcare providers from across Canada. Adult patients were eligible if they took at least two medications for diabetes, heart disease, high blood pressure and/or kidney disease. Healthcare providers were eligible if they were practising in a community setting with at least 1 year of experience. Data were collected using virtual focus groups and individual phone interviews conducted in English. Team members analyzed transcripts using conventional content analysis.

RESULTS

We interviewed 48 participants (20 patients and 28 healthcare providers). Most patients were between 50 and 64 years of age and identified their health status as 'good'. Most healthcare providers were between 45 and 54 years of age and the majority practised as pharmacists in urban areas. We identified three overarching themes that summarize the experiences of patients and healthcare providers, largely suggesting a broad spectrum in approaches to managing sick days: Individualized Communication, Tailored Sick Day Practices, and Variation in Knowledge of Sick Day Practices and Relevant Resources.

CONCLUSION

It is important to understand the perspectives of both patients and healthcare providers with respect to the management of sick days. This understanding can be used to improve care and outcomes for people living with chronic conditions during sick days.

PATIENT OR PUBLIC CONTRIBUTION

Two patient partners were involved from proposal development to the dissemination of our findings, including manuscript development. Both patient partners took part in team meetings and contributed to team decision-making. Patient partners also participated in data analysis by reviewing codes and theme development. Furthermore, patients living with various chronic conditions and healthcare providers participated in focus groups and individual interviews.

Process improvement using telemedicine consultation to prevent unnecessary interfacility transfers for low-severity blunt head trauma

OBJECTIVE

Mild traumatic brain injuries (MTBI) associated with intracranial haemorrhage are commonly transferred to tertiary care centres. Recent studies have shown that transfers for low-severity traumatic brain injuries may be unnecessary. Trauma systems can be overwhelmed by low acuity patients justifying standardisation of MTBI transfers. We sought to evaluate the impact of telemedicine services on mitigating unnecessary transfers for those presenting with low-severity blunt head trauma after sustaining a ground level fall (GLF).

METHOD

A process improvement plan was developed by a task force of transfer centre (TC) administrators, emergency department physicians (EDP), trauma surgeons and neurosurgeons (NS) to facilitate the requesting EDP and the NS on-call to converse directly to mitigate unnecessary transfers. Consecutive retrospective chart review was performed on neurosurgical transfer requests between 1 January 2021 and 31 January 2022. A comparison of transfers preintervention and postintervention (1 January 2021 to 12 September 2021)/(13 September 2021 to 31 January 2022) was performed.

RESULTS

The TC received 1091 neurological-based transfer requests during the study period (preintervention group: 406 neurosurgical requests; postintervention group: 353 neurosurgical requests). After consultation with the NS on-call, the number of MTBI patients remaining at their respective ED's with no neurological degradation more than doubled from 15 in the preintervention group to 37 in the postintervention group.

CONCLUSION

TC-mediated telemedicine conversations between the NS and the referring EDP can prevent unnecessary transfers for stable MTBI patients sustaining a GLF if needed. Outlying EDPs should be educated on this process to increase efficacy.

Job Satisfaction of Health Practitioners Providing Outreach Health Services during COVID-19 in Rural New South Wales (NSW) and the Australian Capital Territory (ACT), Australia

Background: Outreach health practitioners play a key role in enhancing access to healthcare for remote, rural, regional, and Aboriginal and Torres Strait Islander communities in Australia. Outreach health practitioners are those providing ongoing and integrated health services in communities that would otherwise have limited access. In the context of the COVID-19 pandemic, it is important to understand the job satisfaction of health workers as it correlates with long-term retention of the workforce, as well as effectiveness in the role and clinical outcomes for patients. Method: The study analysed data from 258 outreach health practitioners who responded to two cross-sectional surveys conducted by the NSW Rural Doctors Network during the COVID-19 pandemic in 2020/21 and 2021/22 in NSW and the ACT, Australia. Both bivariate and multivariate analyses were employed to assess the associations between the outcome variable (outreach health practitioners' job satisfaction) and independent variables (sociodemographic factors, motivation, self-confidence, communication, capability). Results: Overall, the study showed that 92.2% of health practitioners were satisfied in their role providing outreach health services during the COVID-19 pandemic. In the multivariable model, factors significantly associated with higher satisfaction included good communication with other local health practitioners, using telehealth along with in-person care, and having high self-rated capability compared to those health practitioners who said they had lower job satisfaction. Conclusions: Outreach health practitioners' job satisfaction is important because poor satisfaction may lead to suboptimal healthcare delivery, poor clinical outcomes, and poor retention of staff in rural settings. These findings should be taken into consideration when developing future strategies to improve job satisfaction among rural outreach health practitioners and to enhance attraction, recruitment and retention and may be applicable to the broader health workforce.

To stay or not to stay: the role of sense of belonging in the retention of physicians in rural areas

Rural communities across the circumpolar region and worldwide perennially suffer from physician shortages despite decades of attempting targeted strategies for recruitment. Particularly in rural Canada, financial incentives have attracted but not retained a medical workforce. Although the importance of social connection or belonging is a long-established source of well-being, such information has not infiltrated the dialogue or action on physician retention in rural areas. A physician's sense of belonging, arising from that emotional need for social connectedness, is built via bilateral active efforts at community engagement, reciprocity, social integration of family and workplace collegiality. Links between rural upbringing, rural training opportunities and subsequent rural practice likely rest upon fostering this sense of belonging. Policymakers and recruiters might consider how to help physicians adapt, "fit in", and consider they have "come home" when they venture off to rural settings. Empowering the community to be involved in the recruitment and retention of rural physicians may also be effective. Perhaps this approach would better address the age-old battle to retain physicians in rural Canada and around the world.

Values and Meaning in Rural Primary Care Practices: Implications for Interventions Within Context

OBJECTIVES

It is important to understand the unique perspectives and values that motivate patients and clinicians in rural primary care settings to participate in clinical care activities. Our objective was to explore perspectives, preferences, and values related to primary care that could influence implementation of evidence-based programs.

METHODS

Qualitative study utilizing semi-structured interviews and using immersion/crystallization and thematic analysis. Participants were primary care practice members (clinicians, clinical staff, and administrators) and their patients in rural Colorado.

RESULTS

Twenty-six practice members and 23 patients across 9 practices participated. There were 4 emergent themes that were consistent across practice members and some patients. Patient perspectives are located in parenthesis. They included: (1) Focus on quality patient care, patient satisfaction, and continuity of care (patients appreciated quality and compassionate care), (2) Importance of prevention and wellness (patients appreciated help with preventing health problems), (3) Clinician willingness and ability to meet patient preferences for care (patients described comfort with local care), and (4) Passion for serving underserved, uninsured, or vulnerable populations (patients described their vulnerabilities). There were differences in how the perspectives were operationalized by practice member role, illustrating the importance of different ways of addressing these values.

CONCLUSIONS

Successful implementation requires consideration of context, and much of context is understanding what is important to those involved in the primary care experience. This study sheds light on salient values of rural primary care practice members and their patients, which may inform interventions designed with and for this setting.

Rural-Urban Differences in Non-Local Primary Care Utilization among People with Osteoarthritis: The Role of Area-Level Factors

The utilization of non-local primary care physicians (PCP) is a key primary care indicator identified by Alberta Health to support evidence-based healthcare planning. This study aims to identify area-level factors that are significantly associated with non-local PCP utilization and to examine if these associations vary between rural and urban areas. We examined rural-urban differences in the associations between non-local PCP utilization and area-level factors using multivariate linear regression and geographically weighted regression (GWR) models. Global Moran's I and Gi* hot spot analyses were applied to identify spatial autocorrelation and hot spots/cold spots of non-local PCP utilization. We observed significant rural-urban differences in the non-local PCP utilization. Both GWR and multivariate linear regression model identified two significant factors (median travel time and percentage of low-income families) with non-local PCP utilization in both rural and urban areas. Discontinuity of care was significantly associated with non-local PCP in the southwest, while the percentage of people having university degree was significant in the north of Alberta. This research will help identify gaps in the utilization of local primary care and provide evidence for health care planning by targeting policies at associated factors to reduce gaps in OA primary care provision.

Bridging the Gap in Health Personnel and Elderly Communication Training: What Can We Learn From Speech Codes Theory

Effective communication in healthcare settings allows for the expression of complex or technical terms in a manner that each patient can understand. Communication is also linked to increased trust, patient and family satisfaction, and mutual agreement between patients and healthcare personnel. As a result of aging, the elderly (age 65 and older) may develop physical, cognitive, and social changes that may lead to barriers when interacting with healthcare personnel. As a result of these age-related changes, the elderly ability to receive, retain, and convey information may be affected. Therefore, it is essential that healthcare personnel use appropriate language when communicating with this population. Studies have suggested that simulation can be an effective means to train healthcare personnel to develop context-appropriate communication skills for this specific population. This editorial will explore how the Speech Codes Theory (SCT) can structure simulation encounters to enhance healthcare personnel's proficiency in conversing and connecting with this patient population.

Exploring the impact of rural health system factors on physician burnout: a mixed-methods study in Northern Canada

BACKGROUND

Burnout among physicians is a consequence of chronic occupational stresses and emotionally intense work demands. However, much of the evidence exploring burnout is derived from urban settings and may not reflect the work and social contexts of physicians in Indigenous communities or in rural and resource-constrained areas. We sought to characterize health system factors that influence burnout among physicians practicing in the three northern territories of Canada.

METHODS

We conducted a mixed-methods study that included an online survey and qualitative interviews with physicians practicing in Nunavut, Northwest Territories, or Yukon in 2019. The survey adapted content from the Maslach Burnout Inventory. Results were analyzed with logistic regression to assess the association between health system factors and burnout. We conducted in-depth interviews with 14 physicians. Qualitative data was coded and analyzed for themes using the ATLAS.ti software.

RESULTS

Thirty-nine percent of survey respondents (n = 22/57) showed features associated with burnout. Factors associated with burnout included use of electronic medical records (β = - 0.7, p < .05), inadequate financial remuneration (β = - 1.0, p < .05), and cross-cultural issues (β = - 1.1, p < .05). Qualitative analysis further identified physician perceptions of lack of influence over health system policies, systemic failures in cultural safety, discontinuity of care, administrative burden, and physician turnover as important drivers of burnout.

CONCLUSIONS

Physicians practicing in northern regions in Canada experience stress and burnout related to health system factors and cross-cultural issues. The relationship between cross-cultural issues and burnout has not previously been reported. This work may have implications for physician wellbeing and workforce attrition in other resource-constrained or culturally diverse clinical settings.