Rapid evidence assessment of student-assisted assessment and brief intervention clinics: Addressing the gaps in rural and remote health care

Reported outcomes of student-assisted clinics in rural areas

When applying a service-learning model to a student-assisted clinic, Stuhlmiller and Tolchard ²⁶ measured outcomes using occasions of care/service and client numbers. Students in rural New South Wales, Australia, were reported to have delivered over 1000 occasions of care within the drop-in health clinic and had reached 1500 people through health promotion initiatives. ²⁶ Student placement hours were reported as averaging between 80 and 120 h per student, with some students volunteering more time. ²⁶ Frakes et al. ²⁴ also measured outcomes using occasions of care/service as a success measure for their interprofessional student-assisted collaborative placement model. Staff were reported to have supported 78 students to deliver 4565 occasions of care/service to 460 new patients, which was estimated to be a 124% increase over the reporting period. ²⁴ Increases in services provided were recorded over the two reporting periods included in the study, with an increase in new clients (11%) and an increase in student placements (52%) also reported. ²⁴ The results from the Frakes et al. ²⁴ study should be considered with caution because of the quality issues identified in Table 1 (see critical appraisal).

Grace and Coutts ³⁰ reported outcomes by the type of health issues/conditions identified by the students during the pop-up interprofessional student-assisted clinic in rural New South Wales, Australia, although the number of presentations were not provided. Students completed discipline-specific assessments, with medical practitioners (GPs) reviewing each participants’ results and referring to local services as required. ³⁰ The details of the referrals were not provided. Palma et al. ³³ found that when delivering tailored student-assisted mobile clinics, gaps in health service access and availability could be met, with success measured through return visits (54% of patients who use the service more than once) and patient satisfaction (98% rated service as good-excellent). Bartlett et al., ²⁹ in their study on rural immersion hubs for medical students in a rural district of England, reported patient attitudes as an outcome, with success being reported as patients’ willingness to see students (97%).

Similarly, Larsen et al. ³¹ reported success by two measures, the number of health assessments completed and the number of appropriate and timely referrals made by nursing students to other services in the region. ³¹ Health assessments assisted in early identification of students who required psychosocial and biomedical support. A 20% increase was reported in the number of health assessments completed during the reporting period; however, the completion rate of referrals to other services differed significantly across school clinic sites because of timing and available services. ³¹

Stuhlmiller and Tolchard ²⁷ reported on outcomes from a student-assisted free drop-in health service in rural New South Wales, Australia. The clinic was established using a community service consultation approach, addressing a community and student placement need. ²⁷ The study reported improved outcomes using demographic, lifestyle and chronic condition data; however, the analysis was a population-level analysis rather than an individual change analysis. ²⁷ The researchers also reported success through healthy lifestyle programs that were developed through this clinic, such as student-assisted soup kitchen and the healthy eating program for school-aged children. ²⁷ Improvements in identified health conditions were reported by other researchers, indicating student-assisted clinics can lead to health improvements for clients. ³²

Relatedly, advanced pharmacy students in rural Colorado delivered a student-assisted diabetes clinic program, focused on diabetes management and care over a 6-month period. ³² Nuffer et al. ³² reported successful outcomes based on measurable changes in diabetes point-of-care measurements, with all measurements reported as improving except for HDL-cholesterol values. ³² For a rural family nursing student-assisted home service in rural Ecuador, success was measured using quality of life outcome measures, with the student-assisted service resulting in significant improvements in aspects of physical health and function when compared to the control group. ²⁸ However, sample loss bias needs to be considered when interpreting these outcomes. ²⁸

Craig et al. ²⁵ found that by using a project model and placing interdisciplinary teams on social capital projects that would benefit the community/health services they were targeting (seven rural towns in New South Wales), they could create solutions to clinical problems without directly having students work with clients. ²⁵ The project was reported as a success, with nine of the 21 projects reported as being still in use at follow-up. ²⁵ Thackrah et al. ³⁴ used a project model to target culturally safe practices by students through cultural immersion in a student-assisted health promotion clinic in a remote Western Australian Aboriginal community. ²⁵ Outcomes were reported through engagement with the student service and reflective learning outcomes reported by the students and Aboriginal Health Workers. ³⁴ Client data was not reported. ³⁴

Reported experiences of student-assisted clinics in rural areas

Seven studies reported data on participant experiences, including consumers,^29,33 students,^{24,29,30,32,34} services/clinics^25,29 and educators/supervisors/health professionals.^25,29,30,34 Four studies only reported outcome data and did not report the experiences of the study participants.^26–28,31 One study did report case study data, following the care outcomes of particular consumers; however, the consumers and the students did not provide direct feedback to the researchers about their experiences with the health clinic. ²⁶ The following results are based on the studies that collected experience data from at least one source.^{24,25,29,30,32–34}

Consumer experiences were reported in two studies using questionnaires that included Likert scale questions^29,33 and free text questions. ²⁹ In their free text responses, consumers reported that they valued the presence of students overall, believing they were provided with more time and learned more about their condition when a student was involved. ²⁹ In two studies, consumers reported high satisfaction with the student service, with many reporting good outcomes based on either the student proving the medical care they needed or the extra attention they received from a qualified medical practitioner.^29,33 A small number of consumers reported concerns about confidentiality and not having a choice about students’ involvement in their care. ²⁹

Five studies reported student experiences,^{24,29,30,32,34} with one study identifying that approximately half of the students conveyed an increased willingness to pursue a rural career. ³² Positive experiences centred around professional and personal development, and teaching and learning.^24,30,32,34 One study discussed students mixed experiences in rural and remote placements, with travel and isolation the common issues reported, and internet access security and lack of recreation opportunities also listed as deterrents. ²⁹ Another study reported that trust, communication, and culturally appropriate health messages were reported by students as being important for the success of student-assisted clinics, allowing the service to draw on the knowledge and strengths of the culture and community. ³⁴ These experiences highlighted the importance of student-assisted clinics being purpose built for the community/health needs. One student shared her own learning:

I learned how presumptuous and abrupt I can be…it is easy is slip back into that and then people ignore you. I had to concentrate on being respectful. ^{34 (p329)}

Three studies reported that interprofessional learning was highly valued by students,^24,25,30 although in one study this was reported by informants (supervisors/staff/services) and not students. ²⁵

Some students felt they first needed to be immersed in their own profession, so they had a better understanding of what their role is in an interprofessional team. ³⁰ Stuhlmiller and Tolchard ²⁶ also reported the benefits of students learning through the collaborative learning model; however, these benefits were reported by the researchers and not the students.

Four studies reported the experiences of educators/supervisors/health professionals,^25,29,30,34 and two studies reported the experiences of services/clinics.^25,29 In one study, clinical educators noted that student involvement added value to their practice and kept their knowledge and skills up to date:

I have to polish my skills up definitely … because I know I’m having a student I feel motivated to read up a little bit more and brush up my skills … it definitely improves my consulting. ^{29 (p5)}

While in another study health professionals reported the benefit of students and interprofessional care to consumer outcomes:

To improve safety in [consumer] care, greater emphasis needs to be placed on the findings of the other professions and their concerns communicated better to each other (osteopathy supervisor 2). ^{30 (p117)}

One study reported the importance of health professionals in encouraging consumer attendance and supporting students to disseminate health information within the community using culturally safe practices. ³⁴ Other studies reported that services and health professionals found student involvement helpful, improving services, communication or awareness of health or service issues.^25,29 One clinic reported:

It’s added to our practice and it’s added to our enjoyment and its made us happy to come to work … and I think that’s definitely something the staff feel, you know, students literally breathe a breath of fresh air into the practice. ^{29 (p5)}

Operational models utilised to deliver student-assisted clinics

Each of the studies operationalised student-assisted clinics through practice models (university-driven learning need),^28,29,32 service delivery models (service driven need addressed through a student workforce),^24,25,31 community-need models (student delivered services primarily addressing a community health need),^33,34 and blended models (practice and community-need model).^26,27,30 The models utilised by each study has been summarised in Table 2. The free student-assisted clinics were considered a success because they improved access to health care for those who were disadvantaged and provided students with an opportunity to improve and develop their clinical skills in a culturally diverse setting.^27,33 One free student-assisted clinic applied a community-need model, operating outside of the university learning programs, ³³ while another applied a blended model that addressed both a university placement requirement and an unmet community need. ²⁷

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Table 2.

Student-assisted clinics: operational models utilised in included studies.

Study	Operational models utilised	Key elements	Comments
Bartlett et al. 29	Student rural immersion practice	Hub for students to become immersed in medicine in rural settings through 15 weeks rural practice placements	Program was focused on learning outcomes of students that were university program driven
Craig et al. 25	Interprofessional service-learning service delivery	Based in rural towns around locally relevant priorities. Service-based learning with students engaged with a community partner	The program was focused on meeting a service delivery need within service in six rural locations. The service need was identified by the health service, with the students responsible for delivering the outcomes
Frakes et al. 24	Interprofessional student-assisted collaborative service delivery	Students deliver chronic disease ambulatory services, under the supervision of experienced clinical staff from their own discipline. Includes participation in a transdisciplinary intake screening clinic and interdisciplinary case conferences	Although the service was community focused to address health and workforce challenges across the region, it was driven by service delivery needs
Grace and Coutts 30	Student interprofessional blended	Interprofessional student-assisted health clinic screening members of two rural sports team and their coaches and families, focused on initial screening and then referral and/or education. Students were supported by health professionals and clinical supervisors	Clinic was developed for supporting students learning in interprofessional practice while meeting identified community needs. Clinic was delivered as a one-off clinic with no recurrent funding
Larsen et al. 31	Student-assisted school-based health service delivery	Students were supported by nurse preceptor to deliver care to school-age students in rural areas at the school-based health centres – patients filled out self-report measure (GAP questionnaire looking at closing the gap in health care) and students reviewed/made referral as needed	Although there were direct client benefits, the students were meeting a service need, increasing health service outcomes for 5th and 6th grade school children. GAP questionnaire used for referrals included questions about sexual development and relationships, mental health, violence/safety, nutritious, school performance, drug/alcohol use and home environment
Nuffer et al. 32	Rural student remote practice	Self-care management and education to patients with diabetes, delivered by pharmacy students	The program was developed primarily to meet a university program learning need, targeting consumers with diabetes through health literacy and monitoring
Palma et al. 33	Mobile, student-run, community need	Free to access university clinic, student-led, interprofessional teams. Services were mobile and contextualised for each community’s needs, across nine clinic sites. Students model volunteered outside of their learning programs	The clinic was designed to meet a community need around access to health care
Stuhlmiller and Tolchard 26	Student-assisted service-learning blended	The model employed was driven by a university program learning need but based on community service needs. The approach used in the clinic was underpinned by the New England 4G framework of guided self-health developed by the researchers, which was expanded to include physical health conditions	The 4G approach guided students to work in a collaborative investigate manner with individuals and families to tackle health and wellbeing issues
			The approach included comprehensive assessment, SMART goal plans, psychoeducation/self-help materials and support to reach goals. The approach included brief follow-up phone calls of 5 min to make sure people were staying connected to their plan
Stuhlmiller and Tolchard 27	Student-assisted blended	University student-assisted free clinic offered drop-in health services including primary health, social care, health education, harm minimisation and mental health	Although the clinic was originally developed to provide placements to students, it was designed to meet local community health needs based on gaps in service access
Thackrah et al. 34	Remote cultural immersion, community need	Student-assisted health clinic, with health literacy increased through culturally appropriate message delivery and practice. Focus on health literacy at a community and individual level within a cultural framework	The clinic was addressing a remote community health service need
Walcott et al. 28	Student-assisted university community (home-visit) practice	Free to access, student-led, university-designed and monitored service. Service was designed on a hypothesised need, with recruitment using a community awareness/volunteer method	Although the model was student-learning and community-focused, it was based on a university-learning need rather than a community or service need. Positive outcomes were reported but high loss to follow-up and no student outcomes measured

The student-assisted programs that utilised service delivery models were argued to be successful because they were improving service provision, ²⁵ or meeting the demands in service which the current workforce could not meet alone.^24,31 Service delivery models^24,25,31 seemed to be the more vulnerable to current resources and management support when compared to practice models^28,29,32 that were led by university learning programs. However, students’ willingness to participate in rural and remote placement programs appeared to be dependent on perceived inclusion (in the main university program) and practical supports (accommodation and financial). ²⁹

Challenges and constraints of student-assisted clinics

Frakes et al. ²⁴ relied on stakeholder involvement to deliver the clinic, also making it vulnerable to stakeholder staffing changes that may not prioritise the initiative. Additionally, differences in curriculum, and placement timing and length, placed pressure on resources when initially setting up the student-assisted clinic. ²⁴ Grace and Coutts ³⁰ highlighted the high level of organisation required to make a clinic successful, with communication across professions and shared intake processes being a priority. In another study students reported that the way in which universities deliver their curriculum does not always support rural and remote placements, with some feeling a sense of injustice:

I still feel like we’re getting the bad end of the deal being in Ludlow, I don’t think there are benefits to being put here as opposed to Shrewsbury. I think we miss out on a lot; like facilities and library and having more people around, there is a much bigger student population in Shrewsbury and lots more to do. ^{29 (p.8)}

It was also reported that there were limitations in the number of professionals available to see clients (when a referral is made), impeding outcomes for clients.^25,30 Two studies identified that there was a danger that student-assisted clinics can cause fragmented health care because of referral follow-up and barriers around access to other services (e.g. financial or distance).^30,33

Evaluation was identified as a challenge, with some studies only using clinical records or routine feedback,^24,26,31 while one study may have been affected by recall bias because of the extended time the study covered. ²⁵ Some studies focused on occasions of service or service data outcomes as a measure of success rather than consumer and/or student experiences.^26,28,31 Studies that did focus on participant experiences did not always include all viewpoints, biasing the outcomes to a narrower perspective than otherwise would have been received.^{24,25,30,33,34}

None of the included studies included measures that reviewed the operational student-assisted clinic model, with only a few studies reporting on the likelihood that the student-assisted clinic would result in students choosing a rural health career.^24,29,32 Record keeping and consistent point-of-care results being recorded were identified as limitations of drop-in student-assisted clinics, identifying the need to include training in processes and procedures in student-assisted clinics, and regularly checking client data for completeness.^26,27,33 Some studies did not report response data for all participants and/or completeness of data.^{26,27,30,33,34} Studies that did include response data identified sample size as a concern, ²⁸ as well as participation rates,^28,29 lost to follow-up ²⁸ and incomplete data.^{27–29,31,33} It is recognised that with many research projects of this nature there is limited funding available to conduct more robust research; however, these identified issues limit the generalisability of outcomes across nations and communities.