Rural research projects engaged with communities

Rural research projects engaged with communities

What was the main aim of this program?

The program of Rural Health Projects (RHPs) run by University of Queensland (UQ) provides medical students the opportunity to undertake scholarly research projects that encourage critical thinking and logical reasoning – an essential part of students’ learning and development for a medical career. [1,2,3]

More than 270 RHPs are conducted every year through UQ’s Rural and Remote Medicine (RRM) unit, in over 50 rural and remote (MMM3-7) communities. Each RHP is undertaken with ~40-47 students during a 6-week block placement, as part of the Year 3 medical curriculum (MD).

Using a Quality Improvement (QI) framework, students develop an understanding of rural health service delivery, while learning to work with others in improving health outcomes for the community in which they are placed. Students collaboratively investigate a specific aspect of a chosen topic and use scientific methods in data collection, analyses and reporting to meet a community’s ongoing needs. Students are assessed based on their written academic reports, which aim to highlight potential solutions or resources for the local communities, relevant to the chosen topic.

The RHPs harness the opportunity of placement at a rural site to provide the following learning outcomes for students:

• gain an understanding of rural communities, including Aboriginal health issues and cultural safety
• identify relevant population health issues associated with a clinical topic as it affects a rural community
• engage with relevant health professionals, organisations, patients, and carers
• design and evaluate an intervention to address health-related rural issues, specific to a local population
• apply past learning about research skills to a practical task using a quality improvement framework
• reflect upon ethical issues
• gain experience collating a written academic report
• obtain insight into research possibilities in the maintenance of standards and achievement of optimum health outcomes for rural communities.

Learning Theory

The RHP approach is underpinned by a sociocultural theory. [4,5,6] Students work under interactive guidance, supervision and modelling regarding the cognitive and experiential aspects of their work, with intensive immersion in the tasks being carried out, and rely on self-motivation, initiative and problem-solving to achieve outcomes.

Integration with the MD/MBBS curriculum

The RHPs are integrated with the flow of Phase 1 pre-clinical programs and fit in with other RRM assessments and practical experiences. RHP students can apply previously taught research skills during their learning. Students motivated to continue research after completing their RHP are referred to the Medicine School’s Regional Clinical Research units to take advantage of other available research opportunities.

How was the program implemented?

The RHPs are designed to be carried out within a QI framework – a systematic formal approach to the analysis of practice performance and effort to improve performance and patient outcomes. The methodologies and research methods used are compliant with the guidelines of Queensland Health and other organisations related to QI activities.

Students undertake these projects for the services where they are placed, as ‘temporary members of their staff working under delegation and supervision’, and are not engaged in publishable original research. The wide variety of student placement sites, the short timeframe of the placements, and the finding of a suitable topic in collaboration with the community only on arrival, preclude engagement with research and ethics committees. The projects are expected to comply with the ethical and research standards of the Human Research Ethics Committee, learned by students during the pre-clinical years.

During the students’ time on site in a rural location, the RHPs are carried out alongside clinical teaching and training in a rural hospital, general practice or a combination of both. Students also have the option of conducting their project with another health-related service (e.g. community health or a relevant non-government organisation), with an approved supervisor who can support their work.

The data, information, and practical resources the students construct for the project belong to the health service where they are placed. The topic, and need to be addressed, is identified in conjunction with key health providers in the local health service and community, and must be approved through consultation and submission of a plan to the RHP Academic Coordinator, as well as endorsed for suitability by the student’s local clinical preceptor and/or other involved stakeholders. Students can negotiate an equivalent to a half-day per week to carry out practical tasks such as interviews, community visits or data audits associated with the QI component of their project, with other tasks such as literature and document review, data analysis and collation, and assembling their report occurring outside of clinical working hours.

Assessment

Completion of the QI investigation culminates in the presentation or production of resources for the health service’s staff and patients, about which students can obtain feedback. The completed report, with attachments illustrating the work done, is submitted via the Academic Coordinator to the RHP team, who organises examination and feedback to inform a student’s future learning.

The submitted report is assessed against ten key criteria, encompassing:

• ability to present a written academic report and abstract
• understanding of health-related rural issues and the selection and overview of a relevant topic to be investigated
• ability to plan, organise and evaluate data relating to a QI task
• involvement with key stakeholders in the health service and community, and contribution of practical resources or outcomes for them
• ability with critical analysis and problem-solving regards ongoing needs and solutions.

The RHP program is an integral part of the decision-making and operational processes of the RRM clinical unit. The RHP Academic Coordinator, employed part-time as a Senior Lecturer specifically to fulfil this role, is responsible for leading the RHP program.

Four Level B lecturers are employed on a casual basis for the assessment and marking of the RHPs. Recruitment for these positions uses a targeted approach to employ professionals within an interprofessional team, with extensive rural health experience, postgraduate qualifications in a variety of areas, experience with research or health-related projects and an interest in student teaching. This team also has access to university staff and academic title holders from various areas of medicine and nursing, Indigenous Health, and research, for advice and assistance, as well as collaboration with other members of the RRM unit and designated support officers.

How has the impact of this program been evaluated?

The RHPs provide students an opportunity to gain valuable understanding of the process of QI research activities and develop important outcomes or resources relevant to their rural placement communities.

Figure 1. Number of Rural Health Projects conducted within Australia during 2011-2021.

From 2011 to 2021, more than 2,974 RHPs were conducted in rural or remote communities (Figure 1). Most of these RHPs were conducted in Queensland (Figure 2), in small rural towns (MMM 3-5).

Figure 2. Number of Rural Health Projects conducted within Queensland during 2011-2021.

The RHPs not only provided a practical, beneficial approach for medical students to use in their research projects, they also addressed key issues relevant to the local communities through the development of practical resources or important baseline information for future research.

Staff reflections

The impact of the RHPs is further described in the reflections provided by staff and students below.

• ‘I have been involved for well over 11 years and in that time, these projects have developed from an essay-style report around a topic to something much more beneficial and useful to both the GP/ medical staff and the rural community as a whole. The QI component has become more strongly developed and the necessary research skills have been refined… Having to work the full process, from deciding a topic, reviewing what is happening now, then working through evidence and collected data to devise a hypothesis and recommendations is quite unique. Being placed in rural and remote medical surrounds, gives these students a view of how to provide good health care for patients when they do not have the easy access to equipment and specialists that city-based practitioners do.’

• ‘Rural health is an area where diversity can often be overlooked, and the variety of student projects we have seen over the years is encouraging. Another gratifying aspect of the RHPs has been to witness the responsiveness of student work to situations affecting rural communities. Student projects have responded to major events such as flooding or the pandemic, as well as to more localised events impacting on specific communities. One of the greatest strengths of the project format in my view is that it encourages students to develop a response to current community needs and to do work that addresses the challenges of a particular place and time. Both for the practical learning experience this provides students, and the creativity and energy students can bring to the work being done in rural communities, the Rural Health Project is a highly rewarding program. It has been a pleasure to see how it has developed over time and built a body of student work which reflects the variety of rural communities and the health challenges they experience.’
• ‘The program has had to evolve to keep up with the dynamic nature of the health industry. The ways in which students see and access their target communities has evolved and so have project outcomes to involve more innovative solutions, such as using Telehealth. For me the most academically rewarding aspect of the program is that it helps students learn that a one-size-fits-all approach doesn’t work in health care, particularly when you’re in rural and remote healthcare, so they are learning to take the research and best practice evidence and to adapt and use their local health teams to make it fit the community need, not make the community fit the best practice research.’
• ‘A positive aspect of the RHP is finding most students listen and discover the complex nature of healthcare from a patient perspective. The benefits of feedback and reflection as a result of critical analysis are also evident in the projects.’
• ‘Where ‘research skills’ are concerned, there will always be diverse expectations and motivations in student groups: for some, the program has produced a basic working knowledge of how to apply assessment and planning of services and specific projects to their daily clinical practice and an appreciation of different types of investigation; for many more it has motivated an interest in extending or sharing the work they have done or being involved with original research. Much of the Quality Improvement activity has produced pilot data or observations which indicate areas in which more extensive rural health research could be undertaken, and our coding over the entire life of the RHP program, of the topic choices and issues students have chosen to address, certainly has indicated the evolving trends which would benefit from meticulous researching.’

Student Reflections

• (The program was) ‘very hands on and very diligent…. Offered great feedback and ways for students to improve their work in the future.’
• ‘…there was so much of value in this feedback that just wasn’t communicated or able to be interpreted from marked criteria alone. … it has exposed me to a higher level of academic rigour than I’ve been exposed to in this or previous degrees.’
• ‘I’m currently writing up two papers for a research project ongoing through…hospital.’
• ‘…extremely helpful and reassuring… thank you for the time and thought put into it…’
• ‘It was really informative and has given me a lot of pointers and directions to go into…’.

References

[1] Alrefaie Z, Al-Hayani A, Hassanien M, et al. Implementing group research assignment in undergraduate medical curriculum; impact on students’ performance and satisfaction. BMC Med Educ 2020;20(1):229. doi: 10.1186/s12909-020-02137-x [published Online First: 2020/07/22]

[2] Conroy MB, Shaffiey S, Jones S, et al. Scholarly Research Projects Benefit Medical Students’ Research Productivity and Residency Choice: Outcomes From the University of Pittsburgh School of Medicine. Acad Med 2018;93(11):1727-31. doi: 10.1097/ACM.0000000000002328 [published Online First: 2018/06/21]

[3] Zee M, de Boer M, Jaarsma AD. Acquiring evidence-based medicine and research skills in the undergraduate medical curriculum: three different didactical formats compared. Perspect Med Educ 2014;3(5):357-70. doi: 10.1007/s40037-014-0143-y [published Online First: 2014/11/15]

[4] Bleakley A. Broadening conceptions of learning in medical education: the message from teamworking. Med Educ 2006;40(2):150-7. doi: 10.1111/j.1365-2929.2005.02371.x [published Online First: 2006/02/03]

[5] Badyal D, Singh T. Learning Theories: The Basics to Learn in Medical Education. Int J App Basic Med Res 2017;7

[6] International Clinical Educators Blog. Sociocultural Theory. Education Theory Made Practical 2021; 5(10).