Development and evaluation of strategies to support rural secondments for junior physiotherapists

Gabrielle van Balen ¹, Mitchell Smith ¹, Laura Parish ¹, Ryan Gallagher ^{1, 2}

Abstract

Purpose: Rural workforce shortages are a national issue. One strategy to address shortages involves using secondments from larger healthcare sites to staff rural sites. Numerous strategies have been proposed to prepare staff for rural practice. This evaluation aims to explore the self-reported impact of the development and implementation of an educational, training, supervision and competency framework package. This will support junior physiotherapists undertaking rural secondments in NSW who are seconded from a large physiotherapy department.

Design/Methodology/Approach: Pre- and post-evaluation of the implemented training, education, supervision and competency framework supporting junior physiotherapists undertaking rural secondments across northern NSW. A baseline survey of physiotherapists who undertook a secondment in the previous 12 months defined current practice and limitations. A targeted education, training, supervision and competency framework was developed from this. Post-implementation surveying for 12 months was undertaken to evaluate the package’s framework.

Findings: Statistically significant improvements were reported by staff. They reported that they felt supported and were aware of escalation processes for patients under their care. Additionally, staff reported improved access to and completing competencies relevant to their secondment.

Research Implications: These findings provide evidence for the translation of initiatives to support junior physiotherapists working rurally and the importance of structured education, training and support mechanisms.

Practical Implications: These findings support the translation of competency frameworks, structured access to professional development and supervision to successfully support a rural allied health workforce.

Originality/Value: These findings support the need for structured and target training, education and supervision for staff undertaking rural secondments. These findings provide evidence that these strategies empower staff with the confidence to work rurally.

Limitations: Larger response rates for post-implementation survey results may produce different reported outcomes than pre-implementation results.

Keywords: physiotherapy, rural practice, clinical supervision

INTRODUCTION

Rural clinical practice is healthcare delivered in regional and remote locations, and presents challenges for health professionals (including physiotherapists) across Australia (Cosgrave, Maple & Hussain 2018; Keane et al. 2011). Recruitment, retention, access to professional development, professional and social isolation and a wide range of clinical presentations have all been identified as challenges to rural practice (Cosgrave, Maple & Hussain 2018; Keane et al. 2011; Kumar et al. 2020; Lienesch et al. 2021; Struber 2004). Rural health is plagued by staff shortages, with rural areas having 60% fewer allied health professionals per 100,000 people than capital cities (Struber 2004). Physiotherapy registration board data (Australian Health Practitioner Regulation Agency 2020) showed that 18% of physiotherapists worked in regional and remote locations, with negligible change in workforce numbers in the previous five years (Agency 2022). This is exacerbated by high turnover rates, particularly in early career stages (Cosgrave, Maple & Hussain 2018). Rural physiotherapists working in public health settings are likely to be sole practitioners with a generalist scope of practice; however, in rural areas there is a demand for physiotherapists to be multi-skilled to correspond with lower numbers of resident medical specialists and other allied health professionals (Sheppard 2001; Williams, D’Amore & McMeeken 2007).

To address issues of staffing, retention and training strategies, solutions overcoming these barriers have been developed; namely, the development and implementation of clinical competency frameworks, rural recruitment and training pipelines, and the linkage of rural workforces to metropolitan services for staffing, support and training (Durey, Haigh & Katzenellenbogen 2015; Keane et al. 2011).

To address rural workforce shortages in rural northern NSW, the John Hunter Hospital (JHH) physiotherapy department provides a rural secondment program, staffed by junior physiotherapists, to support rural physiotherapy workforce needs across Hunter New England Local Health District (HNELHD). Representing as one of the largest geographical health districts in NSW, HNELHD covers an area larger than England and stretches from Lake Macquarie to the Manning River, inland across the Hunter and New England regions all the way to the Queensland border (HNELHD 2022). Since 2005, physiotherapists employed at JHH between second-year postgraduate to fourth year are required to complete an annual rural secondment as part of their yearly employment contract. Secondment sites vary yearly based on workforce needs across the district. Secondments are typically for a period of three months, with a rural site receiving four secondments per year. The majority of these secondments are to sites with only one physiotherapist.

The total number of annual rural secondments from 2017–2020 ranged from 10–14, as outlined in Table 1. The Remoteness Area rating for these secondment sites ranged from 1–3 (Major Cities to Outer Regional Geographic Areas) (Australian Bureau of Statistics 2018).

Table 1: Number of rural secondments and the number of physiotherapists in their second year of practice per annum

Year	Number of three-month secondments	Number completed by junior staff
2017	14	8 (57%)
2018	10	4 (40%)
2019	10	5 (50%)
2020	11	4 (36%)

It was subjectively identified by seconding physiotherapists that they felt less supported on secondments and reported decreased confidence in decision-making. This was exacerbated when acting as a sole practitioner at a rural site. Additionally, challenges were flagged regarding moving between a large department with readily available senior support to rural sites with limited or no support. This has been associated with self-reported decreases in job satisfaction (O’Sullivan & Worley 2020; Sheppard 2001; Williams, D’Amore & McMeeken 2007).

Based on this feedback, a team of senior and junior physiotherapists from JHH formed and sought to review the current evidence for supporting allied health professionals to undertake rural practice. A rapid evidence review identified a structured competency framework, access to professional development and strong clinical support as reported initiatives to improve allied health professionals’ experience in rural health settings. From this, a redesign of the rural secondment process was launched to identify the experiences of physiotherapists on rural secondment and develop an education, training, support and competency framework supporting the needs of physiotherapists undertaking rural secondments.

The question we sought to answer from this redesign was: does the implementation of an evidence-based, targeted package of professional development, competency framework, senior clinician and administrative supervision improve the self-reported experience of physiotherapists undertaking a rural secondment in HNELHD?

METHODS

A multistage project was undertaken to redesign the support and training provided to physiotherapists undertaking rural secondments. Stage 1 consisted of a baseline survey, aiming to define current practice for rural secondments. Stage 2 developed a training, education and competency framework based on the results of Stage 1 findings. Stage 3 consisted of data collection and monitoring to quantify the effectiveness of these strategies.

It was identified via informal feedback to members of the project team. The feedback revealed that seconded staff felt a lack of clinical support, site orientation and limited skills in the broad spectrum of clinical presentations seen in their confidence to practice rurally. In response, the project team developed a detailed survey focusing on these themes. This was distributed to physiotherapists that had previously completed a rural secondment. The survey aimed to measure current attitudes on secondments, identify what worked well and areas for improvement. The survey consisted of 22 questions of mixed design. Topics included orientation processes, onsite staff contact frequency and access to clinical and teaching resources.

The survey results were analysed and grouped by common themes and secondment sites. From these results, the project team developed evidence-based strategies tailored to survey responses. Identified strategies were implemented for 12 months before re-surveying secondees over this period to evaluate their impact. Questions from the initial survey were reused for direct comparison and evaluation.

Statistical analysis

Statistical analysis of pre- and post-survey results was undertaken using chi-square tests on the proportion of respondents who responded ‘yes’ to each question. Thematic analysis of survey responses was undertaken via two team members manually labelling themes identified in text responses. Where noticeable differences occurred in themes identified for responses, a third project member could be asked to determine theme labels. Analysis was undertaken using the R Studio platform and version 4.0.2 of the R programming language (R Studio Team 2020).

RESULTS

STAGE 1: BASELINE CLINIICIAN SURVEY

From the baseline survey, 15 responses were received. Surveyed staff provided their preference for frequency and method of contact to guide project direction (Table 2). A copy of the survey used can be found in Appendix 1. Less than half of respondents pre-survey identified that:

• site orientation was adequate
• they felt supported in their role
• they were up-to-date with professional news and developments across HNELHD
• they knew how to access HNELHD professional development while on secondment
• they had undertaken clinical competency assessment relevant to rural practice.

Additionally, respondents were asked to identify how often and by what method of contact would they prefer if a system to improve professional communication and support was developed. Results can be found in Table 2.

Table 2: Contact preferences for offsite staff (pre-survey results)

How regularly did you have contact from offsite staff?	Frequently	2 (14%)
	Occasionally	3 (21%)
	Rarely	6 (43%)
	Never	3 (21%)
Preferred frequency of contact	Weekly	5 (33%)
	Fortnightly	9 (60%)
	Monthly	1 (7%)
Preferred method of contact	Email	9 (60%)
	Phone	7 (45%)
	Telehealth	8 (35%)

Thematic analysis identified the following themes: site orientation, clinical training and clinical isolation. Sub-analysis of clinical training themes identified consistent indications of needing training and upskilling in paediatrics and hand therapy. A small number of respondents also identified maternity and gynaecology.

STAGE 2: TRAINING, EDUCATION AND COMPETENCY FRAMEWORK DEVELOPMENT

Based on these survey results and identified initiatives from published research, the project team sought to develop:

• site orientation manuals and checklists
• a secondment staff buddy system
• a clinical competency framework
• targeted upskilling in specialty clinical areas (paediatrics and hand therapy)
• embedding above strategies into clinical governance.

Buddy System

Surveyed physiotherapists stated feeling isolated with minimal contact. As a result, a buddy system was introduced involving a more senior physiotherapist (who had previously completed a secondment to the rural site) acting as a support person for the seconded physiotherapist. The buddy contacted the seconded physiotherapist fortnightly via email in the first month of the secondment, followed by monthly to provide advice on site-specific matters. The buddy could also be contacted by the rural seconder as required.

Orientation and Manuals

Orientation was viewed as limited by 53% of respondents. Resources were developed and provided to address this site-specific orientation prior to staff commencing a rural secondment. This included a summary of the buddy system, location of orientation material specific to the site, clinical and non-clinical issue escalation frameworks and a suggested list of clinical competencies to complete prior to the secondment.

Each secondment site received a specific electronic orientation manual covering topics such as introduction to site, hours of work, responsibilities, travel, accommodation, network access, contact lists and relevant emergency procedures. This involved standardising and updating or developing all existing secondment site orientation manuals. Staff were notified at the time of these changes, which was also communicated to staff as part of an orientation email sent out prior to each secondment. To support future secondment sites, a template was created to assist with creating new orientation manuals. A contact list for physiotherapists across the health district was collated and shared to streamline interfacility communication for handovers and local clinical escalation.

Clinical Competencies

Prior to completing rural secondment, only 27% of staff members felt they had completed relevant clinical competencies. Senior physiotherapy staff from various clinical backgrounds reviewed existing clinical competency frameworks to identify competencies with the highest rates of use at rural sites. A collaborative approach between project staff and senior physiotherapists (including staff who undertook secondments) defined a list of clinical competencies that should be completed before undertaking a rural secondment. This took into account the expected caseloads and staff profiles at secondment sites. Table 3 provides a list of the competencies identified.

Table 3: Recommended competencies to complete prior to rural secondment

Clinical Competency	Description
Communication and documentation	Effective written and verbal communication and documentation with colleagues, patients and family/carers. Maintains accurate documentation.
Statistics collection	Completes timely and accurate statistics.
EMR training	Completes EMR user training prior to secondment.
Use of supplemental oxygen	Appropriate patient assessment and use of supplemental oxygen when indicated.
Use of standing lifter	Appropriate and safe use of standing lifters.
Stair mobility of the ambulant patient	Conducts safe stairs assessment.
Mobility assessment	Conducts safe mobility assessment.
Respiratory assessment of the medical patient	Conducts appropriate assessment and management of medical patients.
Spirometry	Conducts spirometry appropriately.
Assessment of the geriatric patient	Conducts appropriate assessment and management of geriatric patients.
Neurological assessment	Conducts appropriate assessment of neurological patients.
Application of cervical collars	Application of Miami J/Vista and Philadelphia collars for acute cervical pathology.
Assessment and treatment of general surgery patients	Conducts appropriate assessment and management post-operative surgical patients.
Application of general slabs 1a	Application of short arm, long arm, Spica, short leg and long leg back slabs for immobilisation of acute fractures.
Application of general slabs 1b	Application of POSI, equinus and sandwich slabs for acute fractures.
Removal of casts	Removal of back slabs and fibreglass casts.
Application of hinged braces (elbow and knee)	Application of hinged braces (elbow and knee).
Application of a Zimmer splint	Application of a Zimmer splint.
Spinal assessment and treatment	Conducts appropriate assessment and basic treatment of outpatient musculoskeletal spinal presentations.
Peripheral assessment and treatment	Conducts appropriate assessment and basic treatment of outpatient musculoskeletal upper and lower limb presentations.
Application of functional wrist brace	Application of grenace splint.
Use of respiratory device	Ability to understand and demonstrate the use of PEP mask/PariPEP/oscillatory PEP device.
Application of thoraco-lumbar-sacral orthosis (TLSO)	Application of TLSO brace and provision of education for patient and family members.
Assessment and treatment of amputees	Conducts appropriate assessment and basic treatment of amputee patients.
Outcome measures	Utilising and accurately documenting specific outcome measures for patient populations.

A specific competency framework and training program was implemented with senior physiotherapists to ensure competencies were completed prior to rotation. Competency completion included theory and practical components requiring assessment by a senior physiotherapist in a clinical encounter.

Upskilling in Speciality Areas

Working as a sole rural physiotherapist presents the challenge of exposure to unfamiliar occurances typically seen by specialist/senior physiotherapists at metropolitan sites (O’Sullivan & Worley 2020; Struber 2004). In response to this feedback, formal upskilling opportunities were implemented.

The John Hunter Children’s Hospital’s physiotherapy department facilitated a paediatric physiotherapy upskilling development day. This included a self-directed education package and a half-day training session. Senior physiotherapists in acute surgery and hands facilitated development days on plaster application and the assessment and management of hands patients.

There was an emphasis during these development days on recognising presentations outside the scope of practice for a seconding physiotherapist. Strategies on how and when to contact more specialised clinicians for advice or to refer further treatment were embedded into development day content. Additionally, internal professional development opportunities, typically delivered face to face, were transitioned online or through a hybrid delivery system, allowing seconded physiotherapists to dial in remotely and participate in ongoing professional development.

Embedding into Routine Clinical Governance

To ensure implemented strategies remain successful, annual review, revision and dissemination of the developed resources and in-services have been embedded into clinical governance for rural secondments within the health district. A short survey was created to be circulated to seconding staff at the end of each secondment to provide feedback and ongoing or emerging issues to be acted on as they arise. Orientation and training resources have been developed and supplemented with policies, procedures and formal approval of training material for use annually.

Paediatric, plastering and hand therapy assessment and management professional development days for rural seconding staff have been annually standardised.

STAGE 3: RESULTS OF DATA COLLECTION

Re-survey of seconded staff occurred for 12 months post-implementation of the training, education and competency framework. Results can be found in Table 4. Occasions of contact with offsite staff were recorded to track compliance and establish the feasibility of the buddy program.

Table 4: Pre- and post-survey results

Question	Pre-survey respondents (n=15) Yes responses	Post-survey respondents (n=7) Yes responses	P-value (95% CI)
Did orientation include:
Written manual?	6 (40%)	3 (43%)	0.77 (-0.18, 0.12)
Verbal?	13 (87%)	6 (86%)	1 (-0.09, 0.11)
Tour of site?	13 (87%)	6 (86%)	1 (-0.09, 0.11)
Orientation adequate?	7 (47%)	4 (57%)	0.20 (-0.25, 0.05)
Access to contact lists:
JHH	8 (53%)	7 (100%)	<0.01 (-0.58, -0.36)
Secondment site	10 (67%)	6 (86%)	<0.01 (-0.31, -0.07)
Physiotherapists within LHD	7 (47%)	5 (71%)	<0.01 (-0.38, -0.10)
Did you feel supported in your role?	7 (47%)	6 (86%)	<0.01 (-0.52, -0.26)
Aware of how to escalate issues if they arose?	10 (67%)	7 (100%)	<0.01 (-0.43, -0.023)
Kept up-to-date with professional news/developments across HNELHD?	6 (40%)	4 (57%)	0.11 (-0.26, 0.03)
Know how to access HNELHD professional development?	7 (47%)	6 (86%)	<0.01 (-0.52, -0.26)
Relevant competencies completed?	4 (27%)	4 (57%)	<0.01 (-0.46., -0.19)

Overall, the project implementation had positive results on several surveyed factors. The number of junior physiotherapists that felt supported in their role increased, with 100% of respondents aware of how to escalate issues if they arose. Staff felt more prepared to commence rural secondments post-implementation, with 57% of staff members completing relevant competencies prior to secondment, increasing from 27% prior. There was also an increase in the number of junior physiotherapists who knew how to access in-services and educational material. No significant difference was found between pre- and post-survey results in relation to whether orientation was adequate. A greater number of staff were able to access contact lists across the health district, increasing from 56% to 86% after implementation.

Thematic analysis of post-survey responses identified improvements in support while on secondment along with the networking opportunities. However, a theme around orientation to the facility and clinical caseload remained.

DISCUSSION

This work sought to evaluate the self-reported impact of developing and implementing an evidence-based training, competency and buddy system in response to an identified need to better support physiotherapists undertaking rural secondments. The challenges of rural healthcare are well documented, with allied health professionals suggested to be heavily impacted (Brown et al. 2017; Cosgrave, Maple & Hussain 2018). Strategies have been identified over several years to address these, including training pipelines, targeted professional development and professional supervision links (Keane et al. 2011). Through secondments from metropolitan sites, HNELHD has for several years addressed the rural physiotherapy workforce shortages. This, however, represented the first attempt we could identify quantifying the impact of applied evidence-based measures to improve the perceived support, education and ability of physiotherapists providing care in rural settings.

However, the issues faced in rural practice are widely reported across Australia (Francis 2005; O’Sullivan & Worley 2020; Sheppard 2001). Our results may be transferrable to other health services and allied health disciplines faced with these issues, as they exist across all allied health professions. Other allied health professions within HNELHD have been keen to develop similar staffing models used in physiotherapy.

Surveyed physiotherapists identified that rural secondments were a ‘great learning experience’ that created opportunities to ‘build confidence’ and ‘increase diversity of knowledge’. This supported the overall positive sentiment towards undertaking rural secondments by surveyed physiotherapists. Additionally, we have been able to show that physiotherapists feel more supported when provided with a structured training, education and clinical competency framework. This is significant as it provides evidence of the transferability of these initiatives from previously published research (Lin et al. 2009; O’Sullivan & Worley 2020). Through the implementation of these initiatives, we have been able to show an increased feeling of support and higher levels of confidence, linking to improved workforce retention (Cosgrave, Maple & Hussain 2018).

Reflecting on the project, we have identified limitations that affect the transferability of results. The sample size of clinicians surveyed was limited. The number of staff available for re-survey was limited to those who had completed secondments since changes were implemented. A wider pool of respondents may have resulted in different identified areas needing support and upskill. Differences in the scope of practice between allied health professionals across Australia may also impact the clinical competencies required for rural sites in other areas of Australia.

During this project, several ongoing areas for further development and potential uses have been identified. The scope for the development of additional paediatric training days has been identified. It has also been identified that maternity and gynaecology physiotherapy is an area where benefit in further upskilling prior to undertaking a secondment is warranted.

CONCLUSION

Through comprehensive written orientation manuals, suggested competencies for upskilling, a buddy support program and regular contact from onsite clinicians, seconded staff have reported an increased level of support and therefore confidence to act within their roles while seconded to rural sites. This has corresponded with decreased feelings of isolation and separation from their host site, increasing overall job satisfaction during rural secondments.

Acknowledgements

Damien Smith, Service Manager, John Hunter Hospital & Belmont Hospital Physiotherapy Department.

Funding

No funding was received for this work. All work was completed from in-kind funding from the John Hunter Hospital Physiotherapy Department.

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APPENDIX 1: SITE SURVEY