Influence of a rural interprofessional education placement on the rural health workforce: working in primary care, rural settings, and with Māori

Keywords: free-text analysis, health workforce, indigenous health, interdisciplinary placement, interprofessional education, longitudinal survey, non-randomised trial, rural health.

Pre-registration exposure to rural/remote clinical practice provides healthcare students with an opportunity to encounter, often for the first time, challenges faced by rural communities, such as poverty, inequities and marginalisation.¹ Clinical placements can influence attitudes towards rural careers and decisions to work rurally.^2,3 Year-long rural immersion placements increased Australian allied health graduates’ rural practice participation after 1 year² and Aotearoa New Zealand (NZ) medical graduates’ rural/regional practice intentions;⁴ however, less is known about the impact of shorter rural placements. It is also unknown whether rural intentions translate to actual rural workforce participation, and whether early increased participation is maintained over time. Furthermore, there is inadequate understanding of long-term impacts of hauora Māori (indigenous Māori health) placements. This report describes the influence of a 5-week rural interprofessional education (IPE) programme on graduates’ choices to work in primary care, rurally, and with Māori patients and Māori health beliefs and practices. This is part of a larger study investigating attitudes to, and experience of, collaborative practice and teamwork over the first 3 years of healthcare professional practice.⁵

The Tairāwhiti IPE (TIPE) programme was established in 2012. TIPE runs for 5 weeks, five times per year, involving final-year pre-registration students from a mix of health disciplines. Groups of 12–18 students live together for the duration of the immersion programme, with teaching and learning provided across diverse town (Gisborne or Wairoa) and rural settings across Tairāwhiti and Wairoa, regions that have a high Māori and remote/rural population with low levels of income and employment.^6,7 TIPE aims to provide a clinically based IPE programme, which fosters interprofessional collaborative practice, enhances hauora Māori (indigenous Māori health), implements principles of long-term condition management, and encourages graduates to work in rural and primary healthcare settings in Aotearoa New Zealand. Selection to attend TIPE is not random and varies between disciplines. Many (but not all) students deliberately choose to attend the programme, and this may be related to their interest in interprofessional practice, rural health and/or hauora Māori. Many students who express interest are not able to be provided a place; further detail is available in the study protocol proposed by Darlow et al.⁸

The Longitudinal Interprofessional Study was a 5-year, non-randomised trial of students who did and did not attend the TIPE program in 2015 and 2016. The study aimed to assess whether TIPE influenced career trajectories (clinical setting and geographical location; Supplementary Table S1) and attitudes towards interprofessional practice during health professionals’ final year of training and the first 3 years of clinical practice (with final data collection in November 2019). The methods are described comprehensively elsewhere.⁸

Data were collected annually for 5 years via electronic surveys. Surveys included quantitative and free-text items relating to the clinical setting (primary care/community, hospital, working in healthcare overseas, have not worked in a clinical setting, or other) and geographical location (small town/rural/remote town, regional city, major city, overseas, or other) in which graduates were working. TIPE participants completed additional free-text items about the influence of the TIPE programme.

Clinical setting and location data were compared between those who participated in the TIPE programme and those who did not, with mixed-model logistic regression with terms for discipline, baseline demographics, Attitudes Toward Health Care Teams Scale and Team Skills Scale, TIPE programme, time, interaction of TIPE programme and time, and a random term for student. Free-text responses were analysed with Template Analysis, a flexible form of thematic analysis that organises and analyses large volumes of textual data.⁹ Hierarchical coding was used to analyse fine details within an evolving template that organised themes and represented the relationships between themes. The analytic method used with this dataset, and the decision-making when coding data and reporting themes, have been described in detail previously.¹⁰

The study received approval from the University of Otago Ethics Committee (D13/019; 3/10/2014). Participants gave written consent.

Pre-registration students from dentistry, dietetics, medicine, nursing, occupational therapy, oral health, pharmacy and physiotherapy took part (see baseline characteristics; Supplementary Table S2). The final survey at 3 years’ post-graduation was completed by 114 of 132 TIPE participants (86%) and 305 of 479 non-TIPE participants (64%). Participants were predominantly female (70%) and 9% self-identified as Māori, broadly reflecting the demographic make-up of the overall health professional student population.

There was no significant difference in the rates that TIPE and non-TIPE graduates worked in primary care/community (OR 0.91; 95% CI 0.51, 1.62; P = 0.74). During their third-year post-registration, 57.1% of TIPE graduates and 61.3% of non-TIPE graduates worked in primary care/community (P = 0.47; Supplementary Tables S3, S4).

TIPE graduates were slightly less likely to work outside a major city during their first 3 years of clinical practice (OR 0.58; 95% CI 0.34, 0.99) due to fewer TIPE graduates working outside of a major city at 1-year post-graduation (46% of TIPE graduates and 54% of non-TIPE graduates). During their third-year post-registration, 51.0% of TIPE graduates and 51.6% of non-TIPE graduates worked outside of a major city (P = 0.36; Supplementary Tables S5, S6).

When viewed as a whole cohort, regardless of TIPE participation, 51.4% (95% CI 46.3%, 56.5%) worked outside of a major urban city in their third-year post-graduation and 66.1% (95% CI 60.7%, 71.2%) of those answering all post-graduate surveys had worked outside of a major city during at least one of their first three post-graduate years. Students who came from small towns/rural/remote locations (OR 5.92; 95% CI 2.11, 16.6; P = 0.0008) or regional cities (OR 3.04; 95% CI 1.52, 6.08; P = 0.002) were more likely to be working outside of a major city at 3 years’ post-graduation than students originating from a major city (irrespective of TIPE participation; Fig. 1).

Fig. 1.  Proportion of the whole cohort working outside of a major city according to the last location they lived in prior to commencing their health training.

TIPE graduates made 308 free-text responses about the impact of TIPE on their career (101 at year 1, 104 at year 2, 103 at year 3). TIPE graduates made unprompted comments that the programme fostered interest or passion in working rurally or regionally. They stated TIPE made them good candidates for these roles, through new understanding of rural health and the inequities and challenges faced by rural patients. Perceived impacts included the ability to apply this understanding in city-based clinical practice when encountering patients from rural and low socio-economic backgrounds. Some graduates referred to TIPE as the key reason they decided to work rurally. Many participants commented that they intend to work rurally in the future; for example, after gaining more clinical experience or when they are ready to settle down. It was more common for graduates to report that TIPE changed their preconceptions and made them more open-minded about working rurally than it was for them to state that TIPE confirmed an existing interest. Table 1 presents some examples of graduate comments.

Table 1.  Influence of Tairāwhiti Interprofessional Education programme on rural work choices.

Many TIPE graduates made unprompted comments about the impact of the programme on their confidence to work more closely with Māori and Māori communities. Some participants reported that the programme offered cultural opportunities they would otherwise not have had. These opportunities fostered respect for Māori culture and assisted in forming better relationships with clients from Māori and other cultural backgrounds. For some, it increased their interest in Māori health and Māori health models, and inspired a desire to make a difference and give back to populations with health inequities. Table 2 presents examples of comments.

Table 2.  Influence of the Tairāwhiti Interprofessional Education programme on working with Māori.

A 5-week rural interprofessional placement did not result in more healthcare graduates working in rural/regional settings or primary care/community settings in the first 3 years of professional practice. However, qualitative data demonstrated long-term perceived influences on desire and skills to work in rural locations, and on desire and ability to work with Māori.

Although the TIPE programme did not increase the proportion of graduates working in the community, over half of the whole cohort were working outside hospital settings, matching the aspirations of the NZ health system. There were substantial disciplinary differences, with higher proportions of medical and nursing graduates in hospital settings; this may reflect required medical training pathways or common career advice for early career nurses.

Our study suggests that short rural immersion placements do not increase rural workforce participation during the early stages of healthcare careers. This is consistent with medical student research findings that long, but not short, rural immersion programmes increased rural practice intentions.⁴ Three years' post-graduation may be too early; however, to determine whether short rural immersion placements ultimately help to meet rural health workforce needs. Many early-career clinicians are still undertaking prescribed training programmes (eg medical pre-vocational training) or moving around to gain wide experience around the country or world. Graduates described the TIPE programme motivating their (often, newfound) interest in rural work and influenced their intention to work in rural locations later in their careers. Importantly, graduates perceived that TIPE improved their ability to care for people from rural backgrounds, even when encountered in a city setting. This suggests that just assessing where health professionals are working may be too blunt a tool to evaluate the success of rural placement programmes.

Focus groups with students at the end of their TIPE placement have found that the programme’s hauora Māori experience provides opportunities for authentic learning framed by cultural values that most students otherwise only learn in a classroom; this was described as a positive learning experience by students, and overtly transformative for some.¹¹ Our study found that TIPE graduates continue to describe these cultural effects on clinical practice throughout the first 3 years of their careers, indicating that TIPE helps prepare students to address the health inequities that exist throughout NZ. Bennett et al.¹² similarly found improved Australian nursing student confidence to deliver culturally competent care following a 4- to 8- week rural/remote immersion experience. TIPE graduates also discussed wanting to give back to communities involved in their training and address unmet health needs. Raising a service-oriented and socially accountable health workforce has been described as a challenge for IPE programmes;¹³ our findings suggest the TIPE programme is meeting this challenge for some students.

The TIPE programme represents just 5 weeks of 3- to 6- year degree programmes. The fact that graduates continue to describe influences on the way in which they practice clinically more than 3 years after participation indicates the value they ascribe to the programme. We utilised a mixed-methods approach that qualitatively analysed free-text comments within the context of their related quantitative responses. This approach enabled more detailed exploration of students’ views and experiences. However, free-text data about the influence of pre-registration training were not collected from participants who had not attended TIPE, meaning that there were no data against which to compare the TIPE participants’ comments. Pre-existing interest in interprofessional practice, hauora Māori or rural health may have influenced volunteering for TIPE and providing free-text comments.

Throughout their first 3 years of professional practice, health professionals who had participated in the TIPE programme described positive influences on their skills and ambitions to work with Māori and to work rurally, but there was no impact on rural workforce participation at 3 years' post-registration.

Supplementary material is available online.

De-identified participant quantitative data (including data dictionaries) will be available 6 months after publication by request to the corresponding author by researchers whose proposed use of data has been approved by an independent review committee. Proposals should be directed to ben.darlow@otago.ac.nz. To gain access, data requestors will need to sign a data access agreement. Qualitative participant data cannot be made available due to the risk of identifying participants.

The authors report there are no competing interests to declare. The authors alone are responsible for the content and writing of this article.

This study was supported by a grant from the University of Otago Division of Health Sciences (no grant number).

B. D., L. G., E. M., and S. P. contributed to the conception and design of the study and obtained funding. B. D., G. P. and S. P. developed the analysis plan. B. D. is the guarantor and drafted the initial protocol. G. P. analysed quantitative data and M. B. and B. D. analysed free-text data with support from E. M. and S. P. B. D. and M. B. wrote the first draft. B. D., M. B., L. G., E. M., G. P., and S. P. revised the manuscript for important intellectual content and read and approved the final version of the manuscript to be published.