Browsing by Author "Blitz, Julia"
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- ItemClinical teaching on an expanding training platform : designing a fit-for-purpose faculty development framework for emerging clinical teachers in a resource-constrained environment(Stellenbosch : Stellenbosch University, 2018-12) Blitz, Julia; Van Schalkwyk, Susan Camille; De Villiers, Marietjie René; Stellenbosch University. Faculty of Medicine and Health Sciences. Centre for Health Professions Education.ENGLISH SUMMARY: The research presented in this dissertation was catalysed by a preliminary phase of research which described the journey undertaken by specialist clinicians as they took on the role of clinical teacher. This gave rise to the question of how other clinicians might be assisted on a similar journey, particularly in the context of an under-resourced environment and an expanding clinical training platform. Training in the clinical environment forms a crucial part of medical curricula. Particularly in the later years of the curriculum, it is the component in which students may develop their identity as doctor. Clinicians involved in this phase play a crucial role in the training of medical students. Medical schools are needing to expand their clinical training platforms in order to provide opportunities for greater numbers of students, as well as to offer clinical training that covers the full spectrum of healthcare. In this expansion, medical schools have an obligation to maintain the quality of teaching in the clinical context. Faculty development is a means to strengthen such clinical teaching. In a resource-constrained environment, it is incumbent upon us to consider how best to design faculty development offerings for these emerging clinical teachers. This research was approached from an interpretivist stance, therefore qualitative methods were used. Based on Kern’s six step approach to curriculum development, the targeted needs of emerging clinical teachers were identified by using four different data sets to develop an understanding of current clinical teaching and strategies used to strengthen it. Senior medical students, clinical teachers and staff responsible for faculty development were interviewed and clinical teaching episodes were recorded. Each data set was analysed individually and thereafter all four sets of findings were synthesized and presented as the situational analysis. The findings informed the development of a fit-for-purpose faculty development framework for emerging clinical teachers. The outcome of the study is a fit-for-purpose faculty development framework that is based on four constituent elements. The first is that faculty development be situated within the network of clinical practice, involving not only individuals, but also their clinical practice community and their academic discipline. The second addresses clinical teaching as supervision; the offering of affordances. The third emphasises clinical learning as student engagement, with an essential interplay between the offering of affordances, and the development and exercising of student agency for engagement. The fourth is to tailor-make faculty development offerings that are informed by students’ evaluations of clinical teaching effectiveness. Learning in the workplace needs to be mirrored by teaching in the workplace. This fit-forpurpose framework is offered as a means to assist those responsible for faculty development to meaningfully assist clinicians on the journey to becoming confident clinical teachers.
- ItemCommunity v. non-community assault among adults in Khayelitsha, Western Cape, South Africa : a case count and comparison of injury severity(Health & Medical Publishing Group, 2014-04) Forgus, Sheron; Delva, Wim; Hauptfleisch, Christine; Govender, Srinivasan; Blitz, JuliaBackground. Community assault (CA) or vigilantism is widespread in the township of Khayelitsha, Cape Town, South Africa (SA). Anecdotal evidence suggests that victims of CA are worse off than other assault cases. However, scientific data on the rate and severity of CA cases are lacking for SA. Objectives. To contribute to CA prevention and management strategies by estimating the rate of CA among adults in Khayelitsha and comparing the injury severity and survival probability between cases of CA and other assault (non-CA) cases. Methods. We studied four healthcare centres in Khayelitsha during July - December 2012. A consecutive case series was conducted to capture all CA cases during this period. A retrospective folder review was performed on all cases of CA and on a control group of non-CA cases to compare injury severity and estimate survival probability. Results. A total of 148 adult cases of CA occurred (case rate 1.1/1 000 person-years) over the study period. The Injury Severity Scores (ISSs) in the CA group were significantly higher than in the non-CA group (p<0.001), with a median (interquartile range) ISS of 3 (2 - 6) in CA cases v. 1 (1 - 2) in non-CA cases. Comparison between the CA v. non-CA groups showed that a Glasgow Coma Scale <15 (20.1% v. 5.4%, respectively), referral to the tertiary hospital (33.8% v. 22.6%, respectively), and crush syndrome (25.7% v. 0.0%, respectively) were all more common in CA cases. Survival probabilities were similar in both groups (CA v. non-CA 99.2% v. 99.3%, respectively). Conclusion. The rate of CA among adults in Khayelitsha is high, and the severity of injuries sustained by CA victims is substantially higher than in other assault cases.
- ItemConsequences, conditions and caveats : a qualitative exploration of the influence of undergraduate health professions students at distributed clinical training sites(BMC (part of Springer Nature), 2018-12-19) Van Schalkwyk, Susan; Blitz, Julia; Couper, Ian; De Villiers, Marietjie; Lourens, Guin; Muller, Jana; Van Heerden, BenBackground: Traditionally, the clinical training of health professionals has been located in central academic hospitals. This is changing. As academic institutions explore ways to produce a health workforce that meets the needs of both the health system and the communities it serves, the placement of students in these communities is becoming increasingly common. While there is a growing literature on the student experience at such distributed sites, we know less about how the presence of students influences the site itself. We therefore set out to elicit insights from key role-players at a number of distributed health service-based training sites about the contribution that students make and the influence their presence has on that site. Methods: This interpretivist study analysed qualitative data generated during twenty-four semi-structured interviews with facility managers, clinical supervisors and other clinicians working at eight distributed sites. A sampling grid was used to select sites that proportionally represented location, level of care and mix of health professions students. Transcribed data were subjected to thematic analysis. Following an iterative process, initial analyses and code lists were discussed and compared between team members after which the data were coded systematically across the entire data set. Results: The clustering and categorising of codes led to the generation of three over-arching themes: influence on the facility (culturally and materially); on patient care and community (contribution to service; improved patient outcomes); and on supervisors (enriched work experience, attitude towards teaching role). A subsequent stratified analysis of emergent events identified some consequences of taking clinical training to distributed sites. These consequences occurred when certain conditions were present. Further critical reflection pointed to a set of caveats that modulated the nature of these conditions, emphasising the complexity inherent in this context. Conclusions: The move towards training health professions students at distributed sites potentially offers many affordances for the facilities where the training takes places, for those responsible for student supervision, and for the patients and communities that these facilities serve. In establishing and maintaining relationships with the facilities, academic institutions will need to be mindful of the conditions and caveats that can influence these affordances.
- ItemDecentralised training for medical students : a scoping review(BioMed Central, 2017-11-09) De Villiers, Marietjie; Van Schalkwyk, Susan; Blitz, Julia; Couper, Ian; Moodley, Kalavani; Talib, Zohray; Young, TarynBackground: Increasingly, medical students are trained at sites away from the tertiary academic health centre. A growing body of literature identifies the benefits of decentralised clinical training for students, the health services and the community. A scoping review was done to identify approaches to decentralised training, how these have been implemented and what the outcomes of these approaches have been in an effort to provide a knowledge base towards developing a model for decentralised training for undergraduate medical students in lower and middle-income countries (LMICs). Methods: Using a comprehensive search strategy, the following databases were searched, namely EBSCO Host, ERIC, HRH Global Resources, Index Medicus, MEDLINE and WHO Repository, generating 3383 references. The review team identified 288 key additional records from other sources. Using prespecified eligibility criteria, the publications were screened through several rounds. Variables for the data-charting process were developed, and the data were entered into a custom-made online Smartsheet database. The data were analysed qualitatively and quantitatively. Results: One hundred and five articles were included. Terminology most commonly used to describe decentralised training included ‘rural’, ‘community based’ and ‘longitudinal rural’. The publications largely originated from Australia, the United States of America (USA), Canada and South Africa. Fifty-five percent described decentralised training rotations for periods of more than six months. Thematic analysis of the literature on practice in decentralised medical training identified four themes, each with a number of subthemes. These themes were student learning, the training environment, the role of the community, and leadership and governance. Conclusions: Evident from our findings are the multiplicity and interconnectedness of factors that characterise approaches to decentralised training. The student experience is nested within a particular context that is framed by the leadership and governance that direct it, and the site and the community in which the training is happening. Each decentralised site is seen to have its own dynamic that may foreground certain elements, responding differently to enabling student learning and influencing the student experience. The insights that have been established through this review have relevance in informing the further expansion of decentralised clinical training, including in LMIC contexts.
- ItemDecentralised training for medical students : towards a South African consensus(AOSIS publishing, 2017-09) De Villiers, Marietjie R.; Blitz, Julia; Couper, Ian; Kent, Athol; Moodley, Kalavani; Talib, Zohray; Van Schalkwyk, Susan; Young, TarynIntroduction: Health professions training institutions are challenged to produce greater numbers of graduates who are more relevantly trained to provide quality healthcare. Decentralised training offers opportunities to address these quantity, quality and relevance factors. We wanted to draw together existing expertise in decentralised training for the benefit of all health professionals to develop a model for decentralised training for health professions students. Method: An expert panel workshop was held in October 2015 initiating a process to develop a model for decentralised training in South Africa. Presentations on the status quo in decentralised training at all nine medical schools in South Africa were made and 33 delegates engaged in discussing potential models for decentralised training. Results: Five factors were found to be crucial for the success of decentralised training, namely the availability of information and communication technology, longitudinal continuous rotations, a focus on primary care, the alignment of medical schools’ mission with decentralised training and responsiveness to student needs. Conclusion: The workshop concluded that training institutions should continue to work together towards formulating decentralised training models and that the involvement of all health professions should be ensured. A tripartite approach between the universities, the Department of Health and the relevant local communities is important in decentralised training. Lastly, curricula should place more emphasis on how students learn rather than how they are taught.
- ItemDesigning faculty development : lessons learnt from a qualitative interpretivist study exploring students’ expectations and experiences of clinical teaching(BMC (part of Springer Nature), 2019) Blitz, Julia; De Villiers, Marietjie; Van Schalkwyk, SusanBackground: Clinical teaching plays a crucial role in the transition of medical students into the world of professional practice. Faculty development initiatives contribute to strengthening clinicians’ approach to teaching. In order to inform the design of such initiatives, we thought that it would be useful to discover how senior medical students’ experience of clinical teaching may impact on how learning during clinical training might be strengthened. Methods: This qualitative study was conducted using convenience sampling of medical students in the final two months of study before qualifying. Three semi-structured focus group discussions were held with a total of 23 students. Transcripts were analysed from an interpretivist stance, looking for underlying meanings. The resultant themes revealed a tension between the students’ expectations and experience of clinical teaching. We returned to our data looking for how students had responded to these tensions. Results: Students saw clinical rotations as having the potential for them to apply their knowledge and test their procedural abilities in the environment where their professional practice and identity will develop. They expected engagement in the clinical workplace. However, their descriptions were of tensions between prior expectations and actual experiences in the environment. They appreciated that learning required them to move out of their “comfort zone”, but seemed to persist in the idea of being recipients of teaching rather than becoming directors of their own learning. Students seem to need help in participating in the clinical setting, understanding how this participation will construct the knowledge and skills required as they join the workplace. Students did not have a strong sense of agency to negotiate participation in the clinical workplace. Conclusions: There is the potential for clinicians to assist students in adapting their way of learning from the largely structured classroom based learning of theoretical knowledge, to the more experiential informal workplacebased learning of practice. This suggests that faculty developers could broaden their menu of offerings to clinicians by intentionally incorporating ways not only of offering students affordances in the clinical learning environment, but also of attending to the development of students’ agentic capability to engage with those affordances offered.
- ItemEmergency contraceptive knowledge, attitudes and practices among female students at the University of Botswana : a descriptive survey(AOSIS publishing, 2018-09) Kgosiemang, Bobby; Blitz, JuliaBackground: Unintended pregnancies are associated with unsafe abortions and maternal deaths, particularly in countries such as Botswana, where abortion is illegal. Many of these unwanted pregnancies could be avoided by using emergency contraception, which is widely available in Botswana. Aim: To assess the level of knowledge, attitudes and practices of female students with regard to emergency contraception at the University of Botswana. Setting: Students from University of Botswana, Gaborone, Botswana. Methods: A descriptive survey among 371 students selected from all eight faculties at the university. Data were collected using a self-administered questionnaire and analysed using the Statistical Package for Social Sciences. Results: The mean age was 20.6 years (SD 1.62), 58% were sexually active, 22% had used emergency contraception and 52% of pregnancies were unintended. Of the total respondents, 95% replied that they had heard of emergency contraception; however, only 53% were considered to have good knowledge, and 55% had negative attitudes towards its use. Students from urban areas had better knowledge than their rural counterparts (p = 0.020). Better knowledge of emergency contraception was associated with more positive attitudes towards actual use (p < 0.001). Older students (p < 0.001) and those in higher years of study (p = 0.001) were more likely to have used emergency contraception. Conclusion: Although awareness of emergency contraception was high, level of knowledge and intention to use were low. There is a need for a targeted health education programme to provide accurate information about emergency contraception.
- ItemEmergency contraceptive knowledge, attitudes and practices among female students at the University of Botswana : a descriptive survey(AOSIS, 2018-09) Kgosiemang, Bobby; Blitz, JuliaBackground: Unintended pregnancies are associated with unsafe abortions and maternal deaths, particularly in countries such as Botswana, where abortion is illegal. Many of these unwanted pregnancies could be avoided by using emergency contraception, which is widely available in Botswana. Aim: To assess the level of knowledge, attitudes and practices of female students with regard to emergency contraception at the University of Botswana. Setting: Students from University of Botswana, Gaborone, Botswana. Methods: A descriptive survey among 371 students selected from all eight faculties at the university. Data were collected using a self-administered questionnaire and analysed using the Statistical Package for Social Sciences. Results: The mean age was 20.6 years (SD 1.62), 58% were sexually active, 22% had used emergency contraception and 52% of pregnancies were unintended. Of the total respondents, 95% replied that they had heard of emergency contraception; however, only 53% were considered to have good knowledge, and 55% had negative attitudes towards its use. Students from urban areas had better knowledge than their rural counterparts (p = 0.020). Better knowledge of emergency contraception was associated with more positive attitudes towards actual use (p < 0.001). Older students (p < 0.001) and those in higher years of study (p = 0.001) were more likely to have used emergency contraception. Conclusion: Although awareness of emergency contraception was high, level of knowledge and intention to use were low. There is a need for a targeted health education programme to provide accurate information about emergency contraception.
- ItemA framework for distributed health professions training : using participatory action research to build consensus(BMC (part of Springer Nature), 2020-05-14) Van Schalkwyk, Susan; Couper, Ian D.; Blitz, Julia; De Villiers, Marietjie R.Background: There is a global trend towards providing training for health professions students outside of tertiary academic complexes. In many countries, this shift places pressure on available sites and the resources at their disposal, specifically within the public health sector. Introducing an educational remit into a complex health system is challenging, requiring commitment from a range of stakeholders, including national authorities. To facilitate the effective implementation of distributed training, we developed a guiding framework through an extensive, national consultative process with a view to informing both practice and policy. Methods: We adopted a participatory action research approach over a four year period across three phases, which included seven local, provincial and national consultative workshops, reflective work sessions by the research team, and expert reviews. Approximately 240 people participated in these activities. Engagement with the national department of health and health professions council further informed the development of the Framework. Results: Each successive ‘feedback loop’ contributed to the development of the Framework which comprised a set of guiding principles, as well as the components essential to the effective implementation of distributed training. Analysis further pointed to the centrality of relationships, while emphasising the importance of involving all sectors relevant to the training of health professionals. A tool to facilitate the implementation of the Framework was also developed, incorporating a set of ‘Simple Rules for Effective distributed health professions training’. A national consensus statement was adopted. Conclusions: In this project, we drew on the thinking and practices of key stakeholders to enable a synthesis between their embodied and inscribed knowledge, and the prevailing literature, this with a view to further enaction as the knowledge generators become knowledge users. The Framework and its subsequent implementation has not only assisted us to apply the evidence to our educational practice, but also to begin to influence policy at a national level.
- ItemImplications for faculty development for emerging clinical teachers at distributed sites : a qualitative interpretivist study(James Cook University, 2018) Blitz, Julia; De Villiers, Marietjie; Van Schalkwyk, SusanIntroduction : Medical faculties have the responsibility to graduate competent health professionals and a consequent obligation to assure the quality and effectiveness of their students’ clinical teaching. Many institutions are responding to rural workforce needs by extending clinical training from the traditional academic teaching hospital to include rural and remote sites distributed away from the central training institution. It is incumbent upon medical schools to consider how this might impact on the faculty development of these clinicians as teachers. The research reported here sought to develop an understanding of how clinicians working at distant resource-constrained and new training sites view their early experiences of having been delegated the task of clinical teaching. This was with a view to informing the development of initiatives that could strengthen their role as teachers. Methods: Qualitative research using an interpretive approach was used to reach an understanding of the views and subjective experiences of clinicians taking on the role of clinical teaching. Participants were emerging clinical teachers at distant peri-urban, rural and remote sites in South Africa. They were deemed to be emerging by virtue of either having recently taken on the role of clinical teacher, or working at sites newly used for clinical teaching. In-depth interviews were conducted with all nine clinicians meeting these criteria. The interviews were coded inductively looking for underlying meanings, which were then grouped into categories. Results: The findings clustered into three inter-related themes: relationships, responsibilities and resources. The clinicians take pleasure in developing learning relationships that enable students to have a good experience by participating actively in the clinical environment, value what students bring from the medical school in terms of clinical advances and different perspectives, and in the contribution that they feel they are making to creating a more appropriately trained future healthcare workforce. However, they yearn for a closer relationship with the medical school, which they think could acknowledge the contributions they make, while also offering opportunities for them to become more effective clinical teachers. They also feel that they have a role to play in both curriculum re-alignment and student evaluation. These clinicians felt that the medical school has a responsibility to let them know if they are doing ‘the right thing’ as clinical teachers. Interestingly, these participants see trusted clinical colleagues and mentors as a resource when needing advice or mentorship concerning clinical teaching. Conclusion: This study adds to an understanding around designing faculty development initiatives that meet the needs of clinicians at distant sites that take on the role of clinical teaching. There remains the need to impart particular strategies to support the learning of particular kinds of knowledge that is commonly dealt with in faculty development. However, there may be an additional need for faculty developers to embrace what is known about rural doctor social learning systems by overtly designing for incorporation of the foundational three Rs: relationships, responsibilities and resources.
- ItemImproving the quality of clinical training in the workplace : implementing formative assessment visits(South African Academy of Family Physicians, 2019-12-09) Mash, Bob; Malan, Zelra; Blitz, Julia; Edwards, JillFamily physicians have a key role to play in strengthening district health services in South Africa. There are a number of barriers to the supply of these specialists in family medicine, one of which is the quality of workplace-based training and low pass rate in the national exit examination. The South African Academy of Family Physicians in collaboration with the Royal College of General Practitioners has adopted a short course to train clinical trainers and a process of formative assessment visits (FAVs) for clinical trainers in the workplace. Training programmes have struggled to implement the FAVs and this article reports on the experience at Stellenbosch University and the issues identified. Clinical trainers who participated in FAVs mostly set developmental goals for themselves that focused on improving the learning environment and consolidating personal skills in training and assessment. The FAVs were beneficial for the family physician trainers, their managers and the academic family physicians at the university. The tools and process for conducting the FAVs may be of value to other programmes. Conclusion: Although overall transmission is low with the PMTCT programme, the majority of remaining HIV infections among children under two years could be prevented by addressing the modifiable factors identified in this study.
- ItemPIQUE-ing an interest in curriculum renewal(Health & Medical Publishing Group, 2014-03) Blitz, Julia; Kok, Norma; Van Heerden, Ben; Van Schalkwyk, SusanBackground. The primary aim of undergraduate medical training at South African medical schools is to prepare the graduates adequately for internship. If we are to attain this objective, it is crucial to evaluate the ability of our graduates to cope with the demands of internship. Objective. To determine the extent to which first-year interns from Stellenbosch University (SU) considered that their undergraduate education prepared them for internship. Methods. The Preparedness for Internship Questionnaire (PIQUE) is based on Hill’s Preparation for Hospital Practice Questionnaire, with additional questions covering core competencies and exit outcomes that SU has determined for its medical curriculum. Participants were asked to respond to a series of statements preceded by ‘My undergraduate medical training prepared me to … ’, and also two open-ended questions. SU’s MB ChB graduates of 2011 (N=153) were invited to participate in the online survey. Results. Although the response rate was only 37%, graduates generally thought they had been well prepared for most mainstream clinical activities. However, there were areas in which respondents considered they could have been better prepared, specifically pharmacology, medicolegal work, minor surgery and the non-clinical roles that interns encounter. Conclusion. PIQUE appears to be a useful tool that can assist with curriculum renewal by highlighting areas that graduates feel they could be better prepared for. This challenges us to identify how curricula and teaching can be adjusted accordingly.
- ItemTraining of workplace-based clinical trainers in family medicine, South Africa : before-and-after evaluation(AOSIS, 2018-05) Mash, Robert; Blitz, Julia; Edwards, Jill; Mowle, SteveBackground: The training of family physicians is a relatively new phenomenon in the district health services of South Africa. There are concerns about the quality of clinical training and the low pass rate in the national examination. Aim: To assess the effect of a five-day course to train clinical trainers in family medicine on the participants’ subsequent capability in the workplace. Setting: Family physician clinical trainers from training programmes mainly in South Africa, but also from Ghana, Uganda, Kenya, Malawi and Botswana. Methods: A before-and-after study using self-reported change at 6 weeks (N = 18) and a 360-degree evaluation of clinical trainers by trainees after 3 months (N = 33). Quantitative data were analysed using the Statistical Package for Social Sciences, and qualitative data were analysed thematically. Results: Significant change (p < 0.05) was found at 6 weeks in terms of ensuring safe and effective patient care through training, establishing and maintaining an environment for learning, teaching and facilitating learning, enhancing learning through assessment, and supporting and monitoring educational progress. Family physicians reported that they were better at giving feedback, more aware of different learning styles, more facilitative and less authoritarian in their educational approach, more reflective and critical of their educational capabilities and more aware of principles in assessment. Despite this, the trainees did not report any noticeable change in the trainers’ capability after 3 months. Conclusion: The results support a short-term improvement in the capability of clinical trainers following the course. This change needs to be supported by ongoing formative assessment and supportive visits, which are reported on elsewhere.
- ItemTraining of workplace-based clinical trainers in family medicine, South Africa : before-and-after evaluation(AOSIS publishing, 2018-05) Mash, Robert; Blitz, Julia; Edwards, Jill; Mowle, SteveBackground: The training of family physicians is a relatively new phenomenon in the district health services of South Africa. There are concerns about the quality of clinical training and the low pass rate in the national examination. Aim: To assess the effect of a five-day course to train clinical trainers in family medicine on the participants’ subsequent capability in the workplace. Setting: Family physician clinical trainers from training programmes mainly in South Africa, but also from Ghana, Uganda, Kenya, Malawi and Botswana. Methods: A before-and-after study using self-reported change at 6 weeks (N = 18) and a 360-degree evaluation of clinical trainers by trainees after 3 months (N = 33). Quantitative data were analysed using the Statistical Package for Social Sciences, and qualitative data were analysed thematically. Results: Significant change (p < 0.05) was found at 6 weeks in terms of ensuring safe and effective patient care through training, establishing and maintaining an environment for learning, teaching and facilitating learning, enhancing learning through assessment, and supporting and monitoring educational progress. Family physicians reported that they were better at giving feedback, more aware of different learning styles, more facilitative and less authoritarian in their educational approach, more reflective and critical of their educational capabilities and more aware of principles in assessment. Despite this, the trainees did not report any noticeable change in the trainers’ capability after 3 months. Conclusion: The results support a short-term improvement in the capability of clinical trainers following the course. This change needs to be supported by ongoing formative assessment and supportive visits, which are reported on elsewhere.
- ItemWhat keeps health professionals working in rural district hospitals in South Africa?(AOSIS Publishing, 2015-06) Jenkins, Louis S.; Gunst, Colette; Blitz, Julia; Coetzee, Johan F.Background: The theme of the 2014 Southern African Rural Health Conference was ‘Building resilience in facing rural realities’. Retaining health professionals in South Africa is critical for sustainable health services. Only 12% of doctors and 19% of nurses have been retained in the rural areas. The aim of the workshop was to understand from health practitioners why they continued working in their rural settings. Conference workshop: The workshop consisted of 29 doctors, managers, academic family physicians, nurses and clinical associates from Southern Africa, with work experience from three weeks to 13 years, often in deep rural districts. Using the nominal group technique, the following question was explored, ‘What is it that keeps you going to work every day?’ Participants reflected on their work situation and listed and rated the important reasons for continuing to work. Results: Five main themes emerged. A shared purpose, emanating from a deep sense of meaning, was the strongest reason for staying and working in a rural setting. Working in a team was second most important, with teamwork being related to attitudes and relationships, support from visiting specialists and opportunities to implement individual clinical skills. A culture of support was third, followed by opportunities for growth and continuing professional development, including teaching by outreaching specialists. The fifth theme was a healthy work-life balance. Conclusion: Health practitioners continue to work in rural settings for often deeper reasons relating to a sense of meaning, being part of a team that closely relate to each other and feeling supported.