Building a sustainable rural physician workforce.

CHAPTER 1: CHARACTERISING AUSTRALIA'S RURAL SPECIALIST PHYSICIAN WORKFORCE: THE PROFESSIONAL PROFILE AND PROFESSIONAL SATISFACTION OF JUNIOR DOCTORS AND CONSULTANTS: Objective: To assess differences in the demographic characteristics, professional profile and professional satisfaction of rural and metropolitan junior physicians and physician consultants in Australia. Cross-sectional, population level national survey of the Medicine in Australia: Balancing Employment and Life longitudinal cohort study (collected 2008-2016). Participants were specialist physicians from four career stage groups: pre-registrars (physician intent); registrars; new consultants (< 5 years since Fellowship); and consultants. Level of professional satisfaction across various job aspects, such as hours worked, working conditions, support networks and educational opportunities, comparing rural and metropolitan based physicians. Participants included 1587 pre-registrars (15% rural), 1745 physician registrars (9% rural), 421 new consultants (20% rural) and 1143 consultants (13% rural). Rural physicians of all career stages demonstrated equivalent professional satisfaction across most job aspects, compared with metropolitan physician counterparts. Some examples of differences in satisfaction included rural pre-registrars being less likely to agree they had good access to support and supervision from qualified consultants (odds ratio [OR], 0.6; 95% CI, 0.3-0.9) and rural consultants being more likely to agree they had a poorer professional support network (OR, 1.9; 95% CI, 1.2-2.9). In terms of demographics, relatively more rural physicians had a rural background or were trained overseas. Although most junior physicians were women, female consultants were less likely to be working in a rural location (OR, 0.6; 95% CI, 0.4-0.8). Junior physicians in metropolitan or rural settings have a similar professional experience, which is important in attracting future trainees. Increased opportunities for rural training should be prioritised, along with addressing concerns about the professional isolation and poorer support network of those in rural areas, not only among junior doctors but also consultants. Finally, making rural practice more attractive to female junior physicians could greatly improve the consultant physician distribution. CHAPTER 2: GENERAL PHYSICIANS AND PAEDIATRICIANS IN RURAL AUSTRALIA: THE SOCIAL CONSTRUCTION OF PROFESSIONAL IDENTITY: Objective: To explore the construction of professional identity among general physicians and paediatricians working in non-metropolitan areas. In-depth qualitative interviews were conducted with general physicians and paediatricians, plus informants from specialist colleges, government agencies and academia who were involved in policy and programs for the training and recruitment of specialists in rural locations across three states and two territories. This research is part of the Training Pathways and Professional Support for Building a Rural Physician Workforce Study, 2018-19. Individual and collective descriptors of professional identity. We interviewed 36 key informants. Professional identity for general physicians and paediatricians working in regional, rural and remote Australia is grounded in the breadth of their training, but qualified by location - geographic location, population served or specific location, where social and cultural context specifically shapes practice. General physicians and paediatricians were deeply engaged with their local community and its economic vulnerability, and they described the population size and dynamics of local economies as determinants of viable practice. They often complemented their practice with formal or informal training in areas of special interest, but balanced their practice against subspecialist availability, also dependent on demographics. While valuing their professional roles, they showed limited inclination for industrial organisation. Despite limited consensus on identity descriptors, rural general physicians and paediatricians highly value generalism and their rural engagement. The structural and geographic bias that preferences urban areas will need to be addressed to further develop coordinated strategies for advanced training in rural contexts, for which collective identity is integral. CHAPTER 3: SUSTAINABLE RURAL PHYSICIAN TRAINING: LEADERSHIP IN A FRAGILE ENVIRONMENT: Objectives: To understand Royal Australasian College of Physicians (RACP) training contexts, including supervisor and trainee perspectives, and to identify contributors to the sustainability of training sites, including training quality. A cross-sectional mixed-methods design was used. A national sample of RACP trainees and Fellows completed online surveys. Survey respondents who indicated willingness to participate in interviews were purposively recruited to cover perspectives from a range of geographic, demographic and training context parameters. Fellows' and trainees' work and life satisfaction, and their experiences of supervision and training, respectively, by geographic location. Fellows and trainees reported high levels of satisfaction, with one exception - inner regional Fellows reported lower satisfaction regarding opportunities to use their abilities. Not having a good support network was associated with lower satisfaction. Our qualitative findings indicate that a culture of undermining rural practice is prevalent and that good leadership at all levels is important to reduce negative impacts on supervisor and trainee availability, site accreditation and viability. Trainees described challenges in navigating training pathways, ensuring career development, and having the flexibility to meet family needs. The small number of Fellows in some sites poses challenges for supervisors and trainees and results in a blurring of roles; accreditation is an obstacle to provision of training at rural sites; and the overlap between service and training roles can be difficult for supervisors. Our qualitative findings emphasise the distinctive nature of regional specialist training, which can make it a fragile environment. Leadership at all levels is critical to sustaining accreditation and support for supervisors and trainees. CHAPTER 4: PRINCIPLES TO GUIDE TRAINING AND PROFESSIONAL SUPPORT FOR A SUSTAINABLE RURAL SPECIALIST PHYSICIAN WORKFORCE: Objective: To draw on research conducted in the Building a Rural Physician Workforce project, the first national study on rural specialist physicians, to define a set of principles applicable to guiding training and professional support action. We used elements of the Delphi approach for systematic data collection and codesign, and applied a hybrid participatory action planning approach to achieve consensus on a set of principles. Eight interconnected foundational principles built around rural regions and rural people were identified: FP1, grow your own "connected to" place; FP2, select trainees invested in rural practice; FP3, ground training in community need; FP4, rural immersion - not exposure; FP5, optimise and invest in general medicine; FP6, include service and academic learning components; FP7, join up the steps in rural training; and FP8, plan sustainable specialist roles. These eight principles can guide training and professional support to build a sustainable rural physician workforce. Application of the principles, and coordinated action by stakeholders and the responsible organisations, are needed at national, state and local levels to achieve a sustainable rural physician workforce.

Ostini R ，McGrail MR ，Kondalsamy-Chennakesavan S ，Hill P ，O'Sullivan B ，Selvey LA ，Eley DS ，Adegbija O ，Boyle FM ，Dettrick Z ，Jennaway M ，Strasser S ... -  《-》

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia.

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia. Rapid review of articles published between January 2000 and May 2020. We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries. Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding. Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries. We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references. We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence. Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle. There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia. Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews. We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria. Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma. We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities. Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km . We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway. We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3). Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce. We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool. We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites. During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool. We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings. Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards. English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing, deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar. Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation. Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

Osborne SR ，Alston LV ，Bolton KA ，Whelan J ，Reeve E ，Wong Shee A ，Browne J ，Walker T ，Versace VL ，Allender S ，Nichols M ，Backholer K ，Goodwin N ，Lewis S ，Dalton H ，Prael G ，Curtin M ，Brooks R ，Verdon S ，Crockett J ，Hodgins G ，Walsh S ，Lyle DM ，Thompson SC ，Browne LJ ，Knight S ，Pit SW ，Jones M ，Gillam MH ，Leach MJ ，Gonzalez-Chica DA ，Muyambi K ，Eshetie T ，Tran K ，May E ，Lieschke G ，Parker V ，Smith A ，Hayes C ，Dunlop AJ ，Rajappa H ，White R ，Oakley P ，Holliday S ... -  《-》

Rural specialists: The nature of their work and professional satisfaction by geographical location of work.

Systematically describe the characteristics of rural specialists, their work and job satisfaction by geographical location of work. Cross-sectional. Three thousand, four hundred and seventy-nine medical specialists participating in the 2014 Medicine in Australia: Balancing Employment and Life (MABEL) survey of doctors. Location of practice, whether metropolitan, large (>50 000 population) or small regional centres (<50 000 population). Specialists working in large regional centres had similar characteristics to metropolitan specialists, however, those in small regional centres were more likely men, later career, overseas-trained and less likely to work privately. Rural specialists had more on-call requirements and poorer professional development opportunities. However, satisfaction with work hours, remuneration, variety of work, level of responsibility, opportunities to use abilities and overall satisfaction did not differ. Specialists in general medicine and general surgery were significantly more likely to work rurally compared with anaesthetists, particularly in small regional centres, whereas a range of other relevant specialists had lower than the average rural distribution and paediatricians and endocrinologists were significantly less likely to work in large regional centres. Rural specialists are just as satisfied as metropolitan counterparts reporting equivalent variety and responsibility at work. Better support for on-call demands and access to professional development could attract more specialists to rural practice. Increased rural training opportunities and regional workforce planning is needed to develop and recruit relevant specialties. Specifically, targeted support is warranted for training and development of specialists in general medicine and general surgery and overseas-trained specialists, who provide essential services in smaller regional centres.

O'Sullivan B ，McGrail M ，Russell D 《-》

Impact of summer programmes on the outcomes of disadvantaged or 'at risk' young people: A systematic review.

Many intervention studies of summer programmes examine their impact on employment and education outcomes, however there is growing interest in their effect on young people's offending outcomes. Evidence on summer employment programmes shows promise on this but has not yet been synthesised. This report fills this evidence gap through a systematic review and meta-analysis, covering summer education and summer employment programmes as their contexts and mechanisms are often similar. The objective is to provide evidence on the extent to which summer programmes impact the outcomes of disadvantaged or 'at risk' young people. The review employs mixed methods: we synthesise quantitative information estimating the impact of summer programme allocation/participation across the outcome domains through meta-analysis using the random-effects model; and we synthesise qualitative information relating to contexts, features, mechanisms and implementation issues through thematic synthesis. Literature searches were largely conducted in January 2023. Databases searched include: Scopus; PsychInfo; ERIC; the YFF-EGM; EEF's and TASO's toolkits; RAND's summer programmes evidence review; key academic journals; and Google Scholar. The review employed PICOSS eligibility criteria: the population was disadvantaged or 'at risk' young people aged 10-25; interventions were either summer education or employment programmes; a valid comparison group that did not experience a summer programme was required; studies had to estimate the summer programme's impact on violence and offending, education, employment, socio-emotional and/or health outcomes; eligible study designs were experimental and quasi-experimental; eligible settings were high-income countries. Other eligibility criteria included publication in English, between 2012 and 2022. Process/qualitative evaluations associated with eligible impact studies or of UK-based interventions were also included; the latter given the interests of the sponsors. We used standard methodological procedures expected by The Campbell Collaboration. The search identified 68 eligible studies; with 41 eligible for meta-analysis. Forty-nine studies evaluated 36 summer education programmes, and 19 studies evaluated six summer employment programmes. The number of participants within these studies ranged from less than 100 to nearly 300,000. The PICOSS criteria affects the external applicability of the body of evidence - allowances made regarding study design to prioritise evidence on UK-based interventions limits our ability to assess impact for some interventions. The risk of bias assessment categorised approximately 75% of the impact evaluations as low quality, due to attrition, losses to follow up, interventions having low take-up rates, or where allocation might introduce selection bias. As such, intention-to-treat analyses are prioritised. The quality assessment rated 93% of qualitative studies as low quality often due to not employing rigorous qualitative methodologies. These results highlight the need to improve the evidence. Quantitative synthesis The quantitative synthesis examined impact estimates across 34 outcomes, through meta-analysis (22) or in narrative form (12). We summarise below the findings where meta-analysis was possible, along with the researchers' judgement of the security of the findings (high, moderate or low). This was based on the number and study-design quality of studies evaluating the outcome; the consistency of findings; the similarity in specific outcome measures used; and any other specific issues which might affect our confidence in the summary findings.Below we summarise the findings from the meta-analyses conducted to assess the impact of allocation to/participation in summer education and employment programmes (findings in relation to other outcomes are also discussed in the main body, but due to the low number of studies evaluating these, meta-analysis was not performed). We only cover the pooled results for the two programme types where there are not clear differences in findings between summer education and summer employment programmes, so as to avoid potentially attributing any impact to both summer programme types when this is not the case. We list the outcome measure, the average effect size type (i.e., whether a standardised mean difference (SMD) or log odds ratio), which programme type the finding is in relation to and then the average effect size along with its 95% confidence interval and the interpretation of the finding, that is, whether there appears to be a significant impact and in which direction (positive or negative, clarifying instances where a negative impact is beneficial). In some instances there may be a discrepancy between the 95% confidence interval and whether we determine there to be a significant impact, which will be due to the specifics of the process for constructing the effect sizes used in the meta-analysis. We then list the I 2 statistic and the p-value from the homogeneity test as indications of the presence of heterogeneity. As the sample size used in the analysis are often small and the homogeneity test is known to be under-powered with small sample sizes, it may not detect statistically significant heterogeneity when it is in fact present. As such, a 90% confidence level threshold should generally be used when interpreting this with regard to the meta-analyses below. The presence of effect size heterogeneity affects the extent to which the average effects size is applicable to all interventions of that summer programme type. We also provide an assessment of the relative confidence we have in the generalisability of the overall finding (low, moderate or high) - some of the overall findings are based on a small sample of studies, the studies evaluating the outcome may be of low quality, there may be wide variation in findings among the studies evaluating the outcome, or there may be specific aspects of the impact estimates included or the effect sizes constructed that affect the generalisability of the headline finding. These issues are detailed in full in the main body of the review. -Engagement with/participation in/enjoyment of education (SMD):∘Summer education programmes: +0.12 (+0.03, +0.20); positive impact; I 2 = 48.76%, p = 0.10; moderate confidence.-Secondary education attendance (SMD):∘Summer education programmes: +0.26 (+0.08, +0.44); positive impact; I 2 = N/A; p = N/A; low confidence.∘Summer employment programmes: +0.02 (-0.03, +0.07); no impact; I 2 = 69.98%; p = 0.03; low confidence.-Passing tests (log OR):∘Summer education programmes: +0.41 (-0.13, +0.96); no impact; I 2 = 95.05%; p = 0.00; low confidence.∘Summer employment programmes: +0.02 (+0.00, +0.04); positive impact; I 2 = 0.01%; p = 0.33; low confidence.-Reading test scores (SMD):∘Summer education programmes: +0.01 (-0.04, +0.05); no impact; I 2 = 0.40%; p = 0.48; high confidence.-English test scores (SMD):∘Summer education programmes: +0.07 (+0.00, +0.13); positive impact; I 2 = 27.17%; p = 0.33; moderate confidence.∘Summer employment programmes: -0.03 (-0.05, -0.01); negative impact; I 2 = 0.00%; p = 0.76; low confidence.-Mathematics test scores (SMD):∘All summer programmes: +0.09 (-0.06, +0.25); no impact; I 2 = 94.53%; p = 0.00; high confidence.∘Summer education programmes: +0.14 (-0.09, +0.36); no impact; I 2 = 94.15%; p = 0.00; moderate confidence.∘Summer employment programmes: +0.00 (-0.04, +0.05); no impact; I 2 = 0.04%; p = 0.92; moderate confidence.-Overall test scores (SMD):∘Summer employment programmes: -0.01 (-0.08, +0.05); no impact; I 2 = 32.39%; p = 0.20; high confidence.-All test scores (SMD):∘Summer education programmes: +0.14 (+0.00, +0.27); positive impact; I 2 = 91.07%; p = 0.00; moderate confidence.∘Summer employment programmes: -0.01 (-0.04, +0.01); no impact; I 2 = 0.06%; p = 0.73; high confidence.-Negative behavioural outcomes (log OR):∘Summer education programmes: -1.55 (-3.14, +0.03); negative impact; I 2 = N/A; p = N/A; low confidence.∘Summer employment programmes: -0.07 (-0.33, +0.18); no impact; I 2 = 88.17%; p = 0.00; moderate confidence.-Progression to HE (log OR):∘All summer programmes: +0.24 (-0.04, +0.52); no impact; I 2 = 97.37%; p = 0.00; low confidence.∘Summer education programmes: +0.32 (-0.12, +0.76); no impact; I 2 = 96.58%; p = 0.00; low confidence.∘Summer employment programmes: +0.10 (-0.07, +0.26); no impact; I 2 = 76.61%; p = 0.02; moderate confidence.-Complete HE (log OR):∘Summer education programmes: +0.38 (+0.15, +0.62); positive impact; I 2 = 52.52%; p = 0.06; high confidence.∘Summer employment programmes: +0.07 (-0.19, +0.33); no impact; I 2 = 70.54%; p = 0.07; moderate confidence.-Entry to employment, short-term (log OR):∘Summer employment programmes: -0.19 (-0.45, +0.08); no impact; I 2 = 87.81%; p = 0.00; low confidence.∘Entry to employment, full period (log OR)∘Summer employment programmes: -0.15 (-0.35, +0.05); no impact; I 2 = 78.88%; p = 0.00; low confidence.-Likelihood of having a criminal justice outcome (log OR):∘Summer employment programmes: -0.05 (-0.15, +0.05); no impact; I 2 = 0.00%; p = 0.76; low confidence.-Likelihood of having a drug-related criminal justice outcome (log OR):∘Summer employment programmes: +0.16 (-0.57, +0.89); no impact; I 2 = 65.97%; p = 0.09; low confidence.-Likelihood of having a violence-related criminal justice outcome (log OR):∘Summer employment programmes: +0.03 (-0.02, +0.08); no impact; I 2 = 0.00%; p = 0.22; moderate confidence.-Likelihood of having a property-related criminal justice outcome (log OR):∘Summer employment programmes: +0.09 (-0.17, +0.34); no impact; I 2 = 45.01%; p = 0.18; low confidence.-Number of criminal justice outcomes, during programme (SMD):∘Summer employment programmes: -0.01 (-0.03, +0.00); no impact; I 2 = 2.17%; p = 0.31; low confidence.-Number of criminal justice outcomes, post-programme (SMD):∘Summer employment programmes: -0.01 (-0.03, +0.00); no impact; I 2 = 23.57%; p = 0.37; low confidence.-Number of drug-related criminal justice outcomes, post-programme (SMD):∘Summer employment programmes: -0.01 (-0.06, +0.06); no impact; I 2 = 55.19%; p = 0.14; moderate confidence.-Number of violence-related criminal justice outcomes, post-programme (SMD):∘Summer employment programmes: -0.02 (-0.08, +0.03); no impact; I 2 = 44.48%; p = 0.18; low confidence.-Number of property-related criminal justice outcomes, post-programme (SMD):∘Summer employment programmes: -0.02 (-0.10, +0.05); no impact; I 2 = 64.93%; p = 0.09; low confidence. We re-express instances of significant impact by programme type where we have moderate or high confidence in the security of findings by translating this to a form used by one of the studies, to aid understanding of the findings. Allocation to a summer education programme results in approximately 60% of individuals moving from never reading for fun to doing so once or twice a month (engagement in/participation in/enjoyment of education), and an increase in the English Grade Point Average of 0.08. Participation in a summer education programme results in an increase in overall Grade Point Average of 0.14 and increases the likelihood of completing higher education by 1.5 times. Signs are positive for the effectiveness of summer education programmes in achieving some of the education outcomes considered (particularly on test scores (when pooled across types), completion of higher education and STEM-related higher education outcomes), but the evidence on which overall findings are based is often weak. Summer employment programmes appear to have a limited impact on employment outcomes, if anything, a negative impact on the likelihood of entering employment outside of employment related to the programme. The evidence base for impacts of summer employment programmes on young people's violence and offending type outcomes is currently limited - where impact is detected this largely results in substantial reductions in criminal justice outcomes, but the variation in findings across and within studies affects our ability to make any overarching assertions with confidence. In understanding the effectiveness of summer programmes, the order of outcomes also requires consideration - entries into education from a summer employment programme might be beneficial if this leads towards better quality employment in the future and a reduced propensity of criminal justice outcomes. Various shared features among different summer education programmes emerged from the review, allowing us to cluster specific types of these interventions which then aided the structuring of the thematic synthesis. The three distinct clusters for summer education programmes were: catch-up programmes addressing attainment gaps, raising aspirations programmes inspiring young people to pursue the next stage of their education or career, and transition support programmes facilitating smooth transitions between educational levels. Depending on their aim, summer education programme tend to provide a combination of: additional instruction on core subjects (e.g., English, mathematics); academic classes including to enhance specialist subject knowledge (e.g., STEM-related); homework help; coaching and mentoring; arts and recreation electives; and social and enrichment activities. Summer employment programmes provide paid work placements or subsidised jobs typically in entry-level roles mostly in the third and public sectors, with some summer employment programmes also providing placements in the private sector. They usually include components of pre-work training and employability skills, coaching and mentoring. There are a number of mechanisms which act as facilitators or barriers to engagement in summer programmes. These include tailoring the summer programme to each young person and individualised attention; the presence of well-prepared staff who provide effective academic/workplace and socio-emotional support; incentives of a monetary (e.g., stipends and wages) or non-monetary (e.g., free transport and meals) nature; recruitment strategies, which are effective at identifying, targeting and engaging participants who can most benefit from the intervention; partnerships, with key actors who can help facilitate referrals and recruitment, such as schools, community action and workforce development agencies; format, including providing social activities and opportunities to support the formation of connections with peers; integration into the workplace, through pre-placement engagement, such as through orientation days, pre-work skills training, job fairs, and interactions with employers ahead of the beginning of the summer programme; and skill acquisition, such as improvements in social skills. In terms of the causal processes which lead from engagement in a summer programme to outcomes, these include: skill acquisition, including academic, social, emotional, and life skills; positive relationships with peers, including with older students as mentors in summer education programmes; personalised and positive relationships with staff; location, including accessibility and creating familiar environments; creating connections between the summer education programme and the students' learning at home to maintain continuity and reinforce learning; and providing purposeful and meaningful work through summer employment programmes (potentially facilitated through the provision of financial and/or non-financial incentives), which makes participants more likely to see the importance of education in achieving their life goals and this leads to raised aspirations. It is important to note that no single element of a summer programme can be identified as generating the causal process for impact, and impact results rather from a combination of elements. Finally, we investigated strengths and weaknesses in summer programmes at both the design and implementation stages. In summer education programmes, design strengths include interactive and alternative learning modes; iterative and progressive content building; incorporating confidence building activities; careful lesson planning; and teacher support which is tailored to each student. Design weaknesses include insufficient funding or poor funding governance (e.g., delays to funding); limited reach of the target population; and inadequate allocation of teacher and pupil groups (i.e., misalignment between the education stage of the pupils and the content taught by staff). Implementation strengths include clear programme delivery guidance and good governance; high quality academic instruction; mentoring support; and strong partnerships. Implementation weaknesses include insufficient planning and lead in time; recruitment challenges; and variability in teaching quality. In summer employment programmes, design strengths include use of employer orientation materials and supervisor handbooks; careful consideration of programme staff roles; a wide range of job opportunities; and building a network of engaged employers. Design weaknesses are uncertainty over funding and budget agreements; variation in delivery and quality of training between providers; challenges in recruitment of employers; and caseload size and management. Implementation strengths include effective job matching; supportive relationships with supervisors; pre-work training; and mitigating attrition (e.g., striving to increase take up of the intervention among the treatment group). Implementation weaknesses are insufficient monitors for the number of participants, and challenges around employer availability.

Muir D ，Orlando C ，Newton B 《-》

Critical Care Network in the State of Qatar.

Critical care is a multidisciplinary and interprofessional specialty providing comprehensive care to patients in an acute life-threatening, but treatable condition.1 The aim is to prevent further physiological deterioration while the failing organ is treated. Patients admitted to a critical care unit normally need constant attention from specialist nursing and therapy staff at an appropriate ratio, continuous, uninterrupted physiological monitoring supervised by staff that are able to interpret and immediately act on the information, continuous clinical direction and care from a specialist consultant-led medical team trained and able to provide appropriate cover for each critical care unit, and artificial organ support and advanced therapies which are only safe to administer in the above environment. It is an important aspect of medical care within a hospital as it is an underpinning service without which a hospital would not be able to conduct most or all of its planned and unplanned activities. As such, critical care requires a very intensive input of human, physical, and financial resources.2 It occupies a proportionately large fraction of a hospital's estate and infrastructure for a small number of patients. The resources that are invested into a critical care bed should therefore be valued against the activities and care throughout the hospital that the availability of that bed allows to happen. Given that demand for critical care beds will continue to grow, providing more critical care beds is unlikely to work on its own since experience has shown that additional capacity is soon absorbed within routine provision.3 Attention must therefore be given to maximising the efficient and effective use of existing critical care beds, necessitating an ability to cope with peaks in demand. Historically the world over, the development of critical care units has been unplanned and haphazard and largely relied on the interest of local clinicians to drive development. However, there is now an eminent body of opinion that supports an alternative approach to critical care provision - namely through a managed Critical Care Network with an agenda of integrated working and the focus on facilitating safe quality care that is cost-effective and patient-focused for acutely and critically ill patients across the various constituent organisations of a healthcare system. The Critical Care Service in Hamad Medical Corporation (HMC) has developed rapidly to address the increasing demand linked to the population growth in the State of Qatar with the aim of meeting the vision of the National Health Strategy (NHS). It is paralleled with HMC's vision to improve the delivery of critical care to patients and their families in a way that meets the highest international standards such as those set by the Joint Commission International by whom the Corporation has been accredited since 2007.4 For this reason, the organisation took the lead to perform a gap analysis with expert auditors from the United States of America and the United Kingdom who have experience in critical care service provision. The aim was to assess the Critical Care Service within HMC and identify potential short-term, medium-term, and long-term opportunities for improvement. This assessment focused on a very broad range of aspects such as: bed capacity, facilities and equipment, medical, nursing and allied healthcare staffing levels and their education, career development pathways, patient safety, quality metrics, clinical governance structure, clinical protocols and pathways, critical care outreach, and future planning for critical care at HMC. As a result of extensive review for the Critical Care Services at HMC, the Critical Care Network (CCNW) in the State of Qatar was established in 2014. It is a strategic and operational delivery network, which includes 12 hospitals across the country. The network functions through a combination of strategic programmes, working groups, and large multidisciplinary governance and professional development events. Through collaborative working with the leadership of the various facilities and critical care clinicians, the network reviews services and makes improvements where they are required, ensuring delivery of patient-focused care by appropriately educated and trained healthcare professionals as well as the appropriate utilisation of critical care beds for those patients who require such care. Detailed involvement and engagement from the clinical membership at every event and in the various working groups ensures that all decisions, reports, and improvement programmes are clinically-focused and benefit from a diversity of opinions that can be considered for implementation. All of this is carefully aligned to the requirements of the latest Qatar National Health Strategy.5 It aims to adopt evidence-based best practices to deliver the safest, most effective and most compassionate care to our critical care patients by setting the most appropriate care pathway to transform Critical Care Services across HMC hospitals. The key aims of the CCNW as stated in its Terms of Reference document are listed in Table 1.6 This enhances the quality and safety of patient care across HMC, promotes staff satisfaction, and improves customer service and patient outcome. The CCNW is structured in a way that involves all Critical Care Service stakeholders to maintain the stability and sustainability of delivering the best care to critically ill patients. The CCNW is steered by a multidisciplinary committee (Figure 1) that is empowered with the generative, managerial, and fiscal responsibilities to enable the required changes to take place. The committee oversees the HMC Critical Care Services through coordinating and standardising their activities and governance arrangements across the complete HMC healthcare system. It provides HMC clinical and managerial leadership at a corporate and local level, the opportunity to jointly develop critical care standards, policies, and operating procedures. In doing so, the CCNW decides on and implements recommendations on how to best plan and deliver critical care services using evidence-based practice set against the context of national and international practices. The HMC CCNW gives recommendations to various committees to improve the services in the following areas: 1. Defining the level of care and critical care core standards for HMC: The CCNW standardises critical care across the Corporation regardless of where it is being delivered. As such it develops the critical care core standards for the critical care units and gives recommendations regarding future critical care core facility planning within HMC. The CCNW helps the Ministry of Public Health (MoPH) develop the National Critical Care Core Standards. 2. Quality and safety: The CCNW works collaboratively with HMC leaders to ensure a culture of quality is embedded within all critical care services delivered within HMC. There is a continuous evaluation process in place to measure the quality of care for high performance critical care which is the goal. This is based upon ongoing observations, robust data collection and analysis, and a change management strategy implemented as required. 3. Clinical pathways, guidelines, and protocols: The CCNW develops, according to international best practice, clinical care pathways, guidelines, and protocols that govern critical care units throughout HMC. Critical care clinical practice is audited against these standards, compared with the international benchmark, and updated as required to ensure currency of all patient care aspects. 4. Transfer and transportation of critically ill patients: The CCNW develops HMC-wide criteria for patient intramural, extramural, and international transfers, and sets standards of care during transportation in collaboration with the HMC Ambulance Service Transfer and Retrieval team. This includes HMC-wide bed management consideration with the senior consultants on call, review of the patient's condition and medical needs, and assessment of the mission associated risks and mitigating strategies. This involves significant planning on the part of the team, clear communication and handovers, and the use of checklists at several stages to ensure the provision of safe and efficient patient transfers. 5. Education: The CCNW develops educational plans and ensures corresponding courses accredited by the Qatar Council for Healthcare Practitioners (QCHP) are designed and delivered to address the training needs of clinicians. The portfolio of courses is regularly reviewed to meet identified needs so clinicians always possess the appropriate knowledge and skills to manage critically ill patients. 6. Research and Critical Care Data Registry development: Being a key player in an Academic Health System, HMC fosters a relatively young but growing research environment4 of which the CCNW forms an integral part. Creating opportunities for epidemiological research and also fulfilling the needs for quality monitoring and benchmarking, the CCNW has enabled the creation of critical care data registries. Such registries provide a valuable source of information and have already been exploited at HMC to better understand the type of patients a service cares for and patient outcomes with respects various factors.7 The establishment of a CCNW at a corporate level (with membership from local leaders across HMC) has provided a level of oversight and leadership which has significantly contributed to optimizing and reshaping the way acutely ill patients are cared for. It has enabled the adoption of evidence-based best practices across the various critical care services of HMC as well as created a multidisciplinary forum for dialogue and collaboration. Innovative work focusing on providing effective, up-to-date, and patient-focused care are ongoing as well as HMC's pursuit of various international accreditation awards by prestigious organisations and professional bodies.

Hijjeh M ，Al Shaikh L ，Alinier G ，Selwood D ，Malmstrom F ，Hassan IF ... -  《-》