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Aust. J. Rural Health (2014) 22, 273–279
Special Issue – Psychology in the Bush Original Research Knowledge, skills and attitudes of rural and remote psychologists Carly Rose Sutherland, B.Psych (Hons) and Anna Chur-Hansen, PhD, FAPS FHERSA School of Psychology, University of Adelaide, Adelaide, South Australia, Australia
Abstract Objective: To develop a list of knowledge, skills and attitudes (KSAs, components of competencies) considered required or desirable by rural and remote psychologists for rural and remote psychology practice. Design: Semi-structured qualitative telephone interviews. Data were analysed thematically. Setting: Rural and remote regions of South Australia. Participants: Nine registered psychologists living and working in rural and remote South Australia (as defined by ARIA++ classification categories excluding Highly Accessible communities). All participants were women. Results: Seven competencies were identified, relating to two broad themes: ‘Professional Isolation’ (competencies arising from being the sole psychologist or one of few in the community); and ‘rural life’ (competencies relating to the need to manage features of the rural context). The seven competencies (managing professional development, supervision, the lack of other services, dual relationships, visibility, confidentiality and appreciation of the rural context) encompassed a number of corresponding and overlapping KSAs. Personality characteristics, including autonomy, resilience and confidence were also identified as important for working in rural areas. Conclusions: Competencies and KSAs identified were consistent with issues identified in previous research for rural and remote psychologists and other health professionals. The present study contributes by providing a comprehensive checklist of KSAs for rural practice identified by rural psychologists. With further development, the competencies outlined could be used in conjunction with rural placements as part of competency-based training.
Correspondence: Ms Carly Rose Sutherland, School of Psychology, University of Adelaide, Level 4 Hughes Building, North Terrace, Adelaide, South Australia, 5005, Australia. Email: [email protected] Accepted for publication 19 September 2014. © 2014 National Rural Health Alliance Inc.
KEY WORDS: competency-based training, health professional education, professional development, rural workforce, teaching and learning.
Introduction Psychology as an applied profession is moving towards an emphasis on competency-based models of assessment and training.1 This focus is reflected in the development of the recent Australian Psychology Accreditation Council (APAC) standards that specify core capabilities which must be demonstrated before psychologists are considered fit to practice.2 Competencies in psychological practice are best defined as the requisite knowledge, skills and attitudes (KSAs) for professional functioning3 and have been outlined for each area of practice endorsement4 and developed in specific areas including geropsychology5 and clinical health psychology.6 Rural and remote competencies have been developed for other health professions including medicine,7 nursing8 and social work9 and include maintaining confidentiality and work life balance, demonstrating independence and selfreliance and electronic literacy skills.7 Competencies specifically for rural and remote psychology are yet to be developed. There are a number of issues for both rural populations and rural psychologists which may mean the practice of rural psychology requires specific competencies. Challenges for rural populations include well-documented disparities between rural and urban health outcomes,10 the unique and unpredictable nature of rural stressors, including weather events such as drought11 and higher levels of unemployment, poverty and financial stressors.12 Rural Australians may face these challenges in the context of media criticism and a lack of understanding from non-rural people, and with far less access to psychological services than their urban counterparts.13,14 Data from the 2010 Australian Psychology Workforce Survey indicate that approximately 5300 fully registered psychologists work in regional, rural and remote Australia, comprising 21.5% of the psychology workforce, with 14.1% of psychologists working in doi: 10.1111/ajr.12152
274
What is already known on this subject: • Competency-based training is widely used in health professional education, including in psychology. • Rural and remote competencies have been developed for other health professions including medicine, nursing and social work. • Given challenges for both rural populations and rural psychologists, the practice of rural psychology may also require specific competencies.
regional areas, 6.6% in rural and 0.8% in remote.13 In South Australia (the location of the present study) approximately 14% of psychologists are based in a nonmetropolitan location. The low population density, distance from urban centres and lack of access to resources mean that psychologists working in rural areas face unique challenges. In recognition of this, the Australian Psychological Society (APS) has published ethical guidelines for practice in rural and remote settings which address dimensions of difference between rural and urban practice, including professional isolation, confidentiality, professional competence and boundary management.15 While these issues have been described in the literature, less is known about the competencies required for practitioners to manage these challenges.16 Identifying rural and remote competencies is important in ensuring graduates are better prepared for and supported in rural practice, facilitating quality teaching and learning, recognising the distinctive contexts of rural practice and reinforcing a holistic, interprofessional and community-based approach to health.7 While some competencies for other health professions may be applicable to psychologists to some degree, there have been little empirical work investigating competencies for rural and remote psychologists. Preliminary findings from a pilot survey of urban and non-urban psychologists indicate that competencies required to work as a psychologist in rural Australia may include breadth of professional knowledge and experience, the ability to maintain boundaries and manage dual relationships as well as having personality traits such as independence and flexibility.12 The present study aimed to develop a list of KSAs considered required or desirable for rural and remote psychology practice by rural and remote psychologists.
C. R. SUTHERLAND AND A. CHUR-HANSEN
What this study adds: • The present study is the first to provide a comprehensive checklist of the KSAs required for rural psychology practice identified by rural psychologists. • The list of KSAs may be used as part of competency-based training for students and the rural psychology workforce.
need to elicit detailed, rich data. Following ethics approval, a purposive sampling approach was employed, with participants recruited from a professional development group open to rural and metropolitan psychologists with an interest in rural psychology. Eligibility criteria included being a registered psychologist and living and working in a rural community, with rurality defined using ARIA++ classifications, excluding ‘Highly Accessible’ communities.17 The first author attended a meeting of the group, and an invitation to participate in a telephone interview was subsequently sent via email to the group mailing list. Two participants volunteered at the initial meeting, with three responding to the email. Four participants were recruited through snowball sampling. The first author conducted all interviews by telephone, which ranged from 45 to 90 min (M = 65). All interviews were digitally recorded and transcribed verbatim by the interviewer. Transcripts were emailed to participants, allowing for a process of participant validation. Data saturation was achieved, with no new themes emerging by the ninth interview. The interview was open-ended, but included questions about training, work history and current work setting, as well as perceptions of KSAs that were either unique to or desirable for rural practice, including perceived differences between working as a psychologist in a rural area compared to an urban area. Data were analysed using thematic analysis as outlined by Braun and Clarke.18 Interviews were analysed using a method of constant comparison, with each interview transcribed and subjected to preliminary analysis before the following interview.19 The maintenance of an audit trail enhanced rigour and trustworthiness of findings.19,20 The second author checked themes against the raw data, as a further method of increasing rigour and trustworthiness.21
Method
Results
A qualitative interview design was considered most appropriate given the limited previous research and the
Participants (N = 9), all women, ranged in age from mid-20s to early 60s (M = 39, SD = 12.39). All were © 2014 National Rural Health Alliance Inc.
275
COMPETENCIES RURAL PSYCHOLOGISTS
registered psychologists, but six had master’s level qualifications while three had qualified via either 5 + 1 or 4 + 2 supervision pathways. Years of experience as a psychologist ranged from six months to 17 years (M = 6.61, SD = 5.20), with years of rural experience (defined using the range of ARIA++ categories included in the study of ‘accessible’, ‘moderately accessible’, ‘remote’ and ‘very remote’) ranging from six months to 16 years (M = 5.83, SD = 4.82). Four psychologists had experience working in both rural and urban areas, ranging from one to four years urban experience. Participants represented almost all regions in South Australia and captured the full range of ARIA++ categories (accessible, moderately accessible, remote and very remote) included in the study, with three participants from ‘accessible’, three from ‘moderately accessible’, two from ‘remote’ and one from ‘very remote’ regions.
Competencies Seven competencies were identified, relating to two broad themes: ‘professional isolation’ (competencies arising from being the sole psychologist or one of few in the community); and ‘rural life’ (competencies relating to the need to manage features of the rural context). The seven competencies were: managing continuing professional development (CPD); managing supervision; managing the lack of other services; managing dual relationships; managing visibility; managing confidentiality; and having an appreciation of the rural context.
Knowledge Knowledge described as important by participants included knowledge of one’s own limitations, having a diverse knowledge base, local knowledge, knowledge of Indigenous culture and knowledge of rural presentations (Table 1).
Skills Technology and networking skills were described as important, along with the ability to work outside psychology, generalist–specialist skills, the ability to set boundaries, self-care skills, strategies for managing accidental meetings, the ability to adapt interventions, community education skills and the ability to compartmentalise information (Table 2).
Attitudes Attitudes considered important were being willing to travel, proactive and resourceful, flexible, willing to step out of comfort zone, approachable and down to earth, © 2014 National Rural Health Alliance Inc.
community minded, appreciative of rural lifestyle and passionate about rural psychology (Table 3).
Personality Personality factors were also highlighted as important in working in a rural area. These included being autonomous, self-directed, open to new experiences, resilient, resourceful, confident and comfortable with a high level of responsibility.
Training The importance of having rural content in university programs, including lectures and placements, in developing KSAs for rural practice was discussed, with rural placements considered the optimal method of preparing students for work in rural areas.
Discussion This study aimed to identify the knowledge, skills and attitudes (KSAs) deemed important for rural and remote psychology practice, as perceived by rural and remote psychologists. The competencies and KSAs identified were consistent with issues and challenges for rural psychologists previously identified in the literature.11,12,14,21 The finding that personality factors may be important as working as a psychologist in a rural area is also consistent with previous research.12 Furthermore, the competencies and KSAs identified were consistent with other health professions, including medicine,7 nursing8 and social work.9 While these previous studies have identified and described issues and challenges for rural psychologists, the present study contributes to the existing literature through the development of a comprehensive checklist of KSAs identified by rural and remote psychologists as important to manage the challenges and unique features of rural psychology practice. Strengths of this study include the inclusion of participants from a range of remoteness categories, capturing almost all of South Australia’s rural regions. The coding and comparison of an interview transcript by the second author ensured consensus of the final themes included and enhanced trustworthiness and rigour. In addition, data saturation was achieved, suggesting sufficient data were collected to support claims.20 Sincerity was enhanced through the maintenance of an audit trail, documenting decisions made during the research process, analysis and synthesis of themes, and correspondence with participants.20 A reflexive approach was taken: the position of the interviewer and researcher (CS) as a student of psychology from a rural background was highlighted to participants at the initial presentation and during interviews.
276 TABLE 1:
C. R. SUTHERLAND AND A. CHUR-HANSEN
Knowledge
Knowledge Knowledge of own limitations
The importance of knowing one’s own limitations and not practising outside one’s area of competence was emphasised; however, this was considered challenging given the lack of other available services.
Diverse knowledge base Local knowledge
Being the only psychologist (or one of few) required a diverse knowledge base of a broad range of presentations. Local knowledge was described as important for enhancing rapport; however, perceived confidentiality was more important for some clients.
Knowledge of Indigenous culture
This included an understanding of concerns about confidentiality in close-knit Indigenous communities.
Knowledge of rural presentations
While presenting problems in rural areas may not be different, the triggers behind them may be, such as the impact of drought.
South Australia’s unique population characteristics may result in differences in experience of service delivery, as the state is characterised by a smaller, more dispersed rural population than the Eastern states. Therefore, findings of this study may be state specific, and further work is required to examine the perceptions of psychologists from other states. Similarly, there is a need for future research to examine the influence of rural psychologists’ training backgrounds on their perceptions of KSAs, as the present study included both psychologists with master’s level qualifications and those who had completed supervision pathways to practice. In addition, the present study focused on psychologists providing clinical or mental health services. Further research is required to investigate the KSAs of rural psychologists working in other areas of practice endorsement. Finally, all participants
I’ve been asked to do in the past diagnostic ah assessments for autism and Asperger’s and that’s something I’m not specifically trained in, I don’t feel comfortable in and – in the end I turned them down and said no but that’s a very difficult thing to do because it means that that assessment will never get done because the client doesn’t have the resources to travel to Adelaide to see a specialist. (Participant 2) I spoke to a metro psychologist and they don’t see half of what I see. (Participant 9) . . . some of the clients will come to me because I am local and because I do know the area . . . other people will choose to go and see the fly-in fly-out person because when you live in a small community like ours, confidentiality is a huge factor. (Participant 3) . . . in a rural area . . . you need knowledge of Aboriginal health . . . I have had clients who are Indigenous that don’t want to access the Aboriginal services because of confidentiality issues . . . (Participant 6) . . . I would say within a rural community you still get the um – I get a lot of depression anxiety symptoms . . . but the triggers behind that can be quite different like in a rural community. We’re farming industry so drought. . . . uh so they’re still presenting with um – with you know depression symptoms, but the context of it is very different. So in the city people wouldn’t understand you know what it’s like. . . . (Participant 6)
were women; therefore further research is also required to determine the perspectives of rural psychologists who are men. Many KSAs identified by the participants in this study may also apply to urban psychologists. What may differ between urban and rural psychologists, perhaps, is the degree or constancy of these experiences.21 Future research is required to compare the perspectives of urban and non-urban psychologists, and to explore dimensions of difference between regional, rural and remote practice. The present study only examined perceptions of psychologists who both live and work in rural communities, and further research with psychologists who provide fly-in fly-out and drive-in drive-out services is indicated. Further research is also needed to examine the perceptions of rural consumers of psychological services as well as the perceptions of other rural © 2014 National Rural Health Alliance Inc.
COMPETENCIES RURAL PSYCHOLOGISTS
TABLE 2:
277
Skills
Skills Technology skills
Networking skills
Ability to work outside psychology
Generalist-specialist skills
Ability to set boundaries
Self-care skills
Strategies for managing accidental meetings
Ability to adapt interventions
Community education skills
Ability to compartmentalise
Given isolation, skills in using technology were considered important in managing professional requirements. Interdisciplinary networking was considered important in managing the lack of referral options. Participants described a need to take on roles outside the traditional scope of work for psychologists due to the lack of other services. The need for broad range of high-level ‘generalist’ skills in working with diverse presentations was highlighted. The need to set clear boundaries was identified, particularly regarding after hours contact, as personal and professional lives were considered difficult to separate. The need for self-care was highlighted given challenges such as dual relationships and complex caseloads. Managing social encounters included discussing appropriate contact outside of session with clients at the initial consultation. Adapting initiatives and therapeutic approaches developed in urban areas to suit rural client groups was identified. This included providing professional development to other health professionals and presentations at community events. Given the likelihood of dual relationships, participants described the need to compartmentalise information gathered (often inadvertently) about clients from other sources.
health practitioners (including general practitioners) regarding the roles and skills of psychologists in their communities. Upon incorporating these other perspectives, the list of competencies developed here could be used for training and professional development for rural psycholo© 2014 National Rural Health Alliance Inc.
. . . you have to be very good at doing things over the phone like supervision . . . most of my supervision has happened since I started as a psychologist . . . has happened over the phone. (Participant 7) . . . it helps with referrals as well, if you get your face out there then people know that there’s um – the services available for them to refer patients. (Participant 7) . . . you kind of – take off the – the psychologist hat and – like I’ve kind of worked with young people, clients, to contact Centrelink . . . doing some of those more practical roles . . . sometimes you tend to do a bit more of that maybe. (Participant 5) I try to make sure that I’m trained in lots of different kind of therapies . . . whereas maybe in the cities you may really specialise . . . (Participant 6) . . . when I walk through this community whether I’m at work or not I am our local psychologist . . . and unless I want to start wearing wigs, sunglasses and a hat . . . that’s your identity, you are the local psychologist. (Participant 9) . . . good self-care skills are really important in a – in a rural psych . . . some of that’s about managing dual relationships . . . being able to – to cope with seeing clients in settings away from work. (Participant 1) . . . it’s not ok for them to come and talk to me, or hand me a Medicare cheque at the supermarket, which has certainly happened. (Participant 1) . . . I can often deal with people who have very limited literacy and numeracy skills . . . so I don’t use a lot of tests . . . because I have found over the years that that really almost puts up a barrier. (Participant 3) . . . I have certainly been involved in drug and alcohol education, I have been involved in um a giving a – conflict resolution talk . . . it’s part of what you need to do. (Participant 3) . . . keeping – the bits and pieces of information that you have in your head clear about where it’s come from and not sort of divulging it in other places . . . (Participant 8)
gists, consistent with the competency-based training approach.1,3 As highlighted by participants, this could take the form of rural content in university courses (for example lectures highlighting KSAs required by rural psychologists) and increased support for rural placements, with rural placements considered by participants
278 TABLE 3:
C. R. SUTHERLAND AND A. CHUR-HANSEN
Attitudes
Attitudes Willing to travel
Proactive/resourceful
Flexible
Willing to step out of comfort zone
Managing travel in rural areas was described as both challenging and necessary, particularly for professional development. Given the lack of other services, participants highlighted the need to be resourceful and proactive. Flexibility encompassed the nature of work (e.g. adapting interventions) and location (e.g. seeing clients out of the office given confidentiality concerns). The need to work with ‘whatever walks through the door’ was highlighted as both a challenge and a benefit of rural work.
I suppose if you didn’t like travel or – yeah that would be an issue – that’s probably more so than in the city. (Participant 4) I had to seek that out and organise [supervision] on my own. (Participant 5) I think you – you don’t cope unless you have a lot of flexibility out here . . . people who do survive are the ones who can be flexible. (Participant 3)
. . . you are asked to step outside your own comfort zone and that’s – professionally I think that’s actually really good to do – providing you are aware of what – what those challenges are. (Participant 1) Approachable/down to Being approachable was described as important Well you have to be very approachable basically if earth but challenging, given confidentiality you’re not approachable you may as well pack up concerns. Being ‘down to earth’ was and go away . . . I still have to be approachable but important as rural people were thought to be also have to make sure that people understand that ‘put off’ by credentials. when they do come and speak to me that it’s totally confidential . . . (Participant 3) Community minded Community involvement was considered helpful . . . it’s really good to know if you are living here that in enhancing relationships and maintaining a you need to be involved in the community. passion for rural work. (Participant 6) Appreciative of rural An appreciation of the rural lifestyle was . . . I guess it would simply be an interest and a love lifestyle described as a key difference between rural of country life you know that. . . . would be the and urban psychologists. difference between a rural and an urban psychologist – maybe a rural and urban professional in any capacity. (Participant 4) Passionate about rural This included a willingness to advocate for I think really you do need to have quite a passion and psychology rural services and to promote psychology in an energy for rural psychology . . . because of some rural areas. of the demands of the role . . . (Participant 2)
to be the optimal method of developing the KSAs required for rural practice.
Acknowledgements We would like to thank the rural and remote psychologists who participated in and supported the project.
Author contributions Carly Rose Sutherland – 80%. Professor Anna ChurHansen – 20%.
References 1 Rubin NJ, Bebaeu M, Leigh IW et al. The competency movement within psychology: an historical perspective.
Professional Psychology, Research and Practice 2007; 39: 452–462. 2 Australian Psychology Accreditation Council. Rules for accreditation and accreditation standards for psychology courses [Internet]. 2010. [Cited 8 Jul 2013]. Available from URL: http://www.psychologycouncil.org.au/standards-and -guidelines/ 3 Bourg EF, Bent RJ, McHolland J, Stricker G. Standards and evaluation of the education and training of professional psychologists: The National Council of Schools of Professional Psychology Mission Bay conference. American Psychologist 1989; 44: 66–72. 4 Psychology Board of Australia. Guidelines on psychology area of practice endorsements [Internet]. 2012. [Cited 8 Jul 2013]. Available from URL: http://www .psychologyboard.gov.au/Standards-and-Guidelines/Codes -Guidelines-Policies.aspx © 2014 National Rural Health Alliance Inc.
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5 Karel MJ, Knight BG, Duffy M, Hinrichsen GA, Zeiss AM. Attitude, knowledge and skill competencies for practice in professional geropsychology: implications for training and building a geropsychology workforce. Training and Education in Professional Psychology 2010; 4: 75–84. 6 France CR, Masters KS, Belar CD et al. Application of the competency model to clinical health psychology. Professional Psychology, Research and Practice 2008; 39: 573– 580. 7 Bell E, Walker J, Allen R, MacCarrick G, Albert E. Non clinical rural and remote competencies: can they be defined? Focus on Health Professional Education: A MultiDisciplinary Journal 2010; 11: 28–41. 8 Stanton M. Rural nurse competencies: experts, advocates and activities. Online Journal of Rural Nursing & Health Care [Internet]. 2009. [Cited 8 Apr 2013]. Available from URL: http://rnojournal.binghamton.edu/index.php/RNO/ article/view/81 9 O’Sullivan D, Ross D, Young S. A framework for the use of competencies in rural social work field practice placements. Australian Social Work 1997; 50: 31–38. 10 Australian Institute of Health and Welfare. Australia’s Health 2010 [Internet]. Cat. No. AUS 122. Canberra, ACT: AIHW, 2010. [Cited 20 Jun 2013]. Available from URL: www.aihw.gov.au/publication-detail/?id =6442468376 11 Barbopoulos A, Clark JM. Practising psychology in rural settings: issues and guidelines. Canadian Psychology 2003; 44: 410–424. 12 Vines R. Equity in health and wellbeing: why does regional rural and remote Australia matter? InPsych: The Bulletin of the Australian Psychological Society Ltd [Internet]. 2011. [Cited 8 Apr 2013]. Available from URL: http:// www.psychology.org.au/Content.aspx?ID=3960 13 Mathews R, Stokes D, Crea K, Grenyer BFS. The Australian Psychology Workforce 1: a national profile of
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psychologists in practice. Australian Psychologist 2010; 45: 154–167. Roufeil L, Lipzker A. Psychology services in rural and remote Australia. InPsych: The Bulletin of the Australian Psychological Society Ltd [Internet]. 2007. [Cited 8 Apr 2013]. Available from URL: http://www.psychology .org.au/publications/inpsych/rural_remote/ Australian Psychological Society. Ethical Guidelines Complementing the APS Code of Ethics, 10th edn. Melbourne: APS, 2010. Maybery D, Sutton K, Moore T. Training and recruiting psychologists for regional, rural and remote Australia. InPsych: The Bulletin of the Australian Psychological Society Ltd [Internet]. 2012. [Cited 9 Jul 2013]. Available from URL: http://www.psychology.org.au/publications/ inpsych/2010/october/maybery/?ID=3394 Australian Institute of Health and Welfare. Rural, Regional and Remote Health: A Guide to Remoteness Classifications [Internet]. Cat. No. PHE 53. Canberra, ACT: AIHW, 2004. [Cited 8 Jul 2013]. Available from URL: http:// www.aihw.gov.au/publication-detail/?id=6442467589 &libID=6442467587 Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006; 3: 77–101. Pope C, Ziebland S, Mays N. Analysing qualitative data. In: Pope C, Mays N, eds. Qualitative Research in Health Care, 3rd edn. Carlton, Vic: Blackwell, 2006; 63–81. Tracy SJ. Qualitative quality: eight ‘big-tent’ criteria for excellent qualitative research. Qualitative Inquiry 2010; 16: 837–851. Oxnam E, Griffiths S. Inquiry and investigation: ethical investigation for psychologists working in rural and remote regions of Australia. Australian Journal of Counselling Psychology 2005; 6: 4–10.
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Aust. J. Rural Health (2014) 22, 273–279
Special Issue – Psychology in the Bush Original Research Knowledge, skills and attitudes of rural and remote psychologists Carly Rose Sutherland, B.Psych (Hons) and Anna Chur-Hansen, PhD, FAPS FHERSA School of Psychology, University of Adelaide, Adelaide, South Australia, Australia
Abstract Objective: To develop a list of knowledge, skills and attitudes (KSAs, components of competencies) considered required or desirable by rural and remote psychologists for rural and remote psychology practice. Design: Semi-structured qualitative telephone interviews. Data were analysed thematically. Setting: Rural and remote regions of South Australia. Participants: Nine registered psychologists living and working in rural and remote South Australia (as defined by ARIA++ classification categories excluding Highly Accessible communities). All participants were women. Results: Seven competencies were identified, relating to two broad themes: ‘Professional Isolation’ (competencies arising from being the sole psychologist or one of few in the community); and ‘rural life’ (competencies relating to the need to manage features of the rural context). The seven competencies (managing professional development, supervision, the lack of other services, dual relationships, visibility, confidentiality and appreciation of the rural context) encompassed a number of corresponding and overlapping KSAs. Personality characteristics, including autonomy, resilience and confidence were also identified as important for working in rural areas. Conclusions: Competencies and KSAs identified were consistent with issues identified in previous research for rural and remote psychologists and other health professionals. The present study contributes by providing a comprehensive checklist of KSAs for rural practice identified by rural psychologists. With further development, the competencies outlined could be used in conjunction with rural placements as part of competency-based training.
Correspondence: Ms Carly Rose Sutherland, School of Psychology, University of Adelaide, Level 4 Hughes Building, North Terrace, Adelaide, South Australia, 5005, Australia. Email: [email protected] Accepted for publication 19 September 2014. © 2014 National Rural Health Alliance Inc.
KEY WORDS: competency-based training, health professional education, professional development, rural workforce, teaching and learning.
Introduction Psychology as an applied profession is moving towards an emphasis on competency-based models of assessment and training.1 This focus is reflected in the development of the recent Australian Psychology Accreditation Council (APAC) standards that specify core capabilities which must be demonstrated before psychologists are considered fit to practice.2 Competencies in psychological practice are best defined as the requisite knowledge, skills and attitudes (KSAs) for professional functioning3 and have been outlined for each area of practice endorsement4 and developed in specific areas including geropsychology5 and clinical health psychology.6 Rural and remote competencies have been developed for other health professions including medicine,7 nursing8 and social work9 and include maintaining confidentiality and work life balance, demonstrating independence and selfreliance and electronic literacy skills.7 Competencies specifically for rural and remote psychology are yet to be developed. There are a number of issues for both rural populations and rural psychologists which may mean the practice of rural psychology requires specific competencies. Challenges for rural populations include well-documented disparities between rural and urban health outcomes,10 the unique and unpredictable nature of rural stressors, including weather events such as drought11 and higher levels of unemployment, poverty and financial stressors.12 Rural Australians may face these challenges in the context of media criticism and a lack of understanding from non-rural people, and with far less access to psychological services than their urban counterparts.13,14 Data from the 2010 Australian Psychology Workforce Survey indicate that approximately 5300 fully registered psychologists work in regional, rural and remote Australia, comprising 21.5% of the psychology workforce, with 14.1% of psychologists working in doi: 10.1111/ajr.12152
274
What is already known on this subject: • Competency-based training is widely used in health professional education, including in psychology. • Rural and remote competencies have been developed for other health professions including medicine, nursing and social work. • Given challenges for both rural populations and rural psychologists, the practice of rural psychology may also require specific competencies.
regional areas, 6.6% in rural and 0.8% in remote.13 In South Australia (the location of the present study) approximately 14% of psychologists are based in a nonmetropolitan location. The low population density, distance from urban centres and lack of access to resources mean that psychologists working in rural areas face unique challenges. In recognition of this, the Australian Psychological Society (APS) has published ethical guidelines for practice in rural and remote settings which address dimensions of difference between rural and urban practice, including professional isolation, confidentiality, professional competence and boundary management.15 While these issues have been described in the literature, less is known about the competencies required for practitioners to manage these challenges.16 Identifying rural and remote competencies is important in ensuring graduates are better prepared for and supported in rural practice, facilitating quality teaching and learning, recognising the distinctive contexts of rural practice and reinforcing a holistic, interprofessional and community-based approach to health.7 While some competencies for other health professions may be applicable to psychologists to some degree, there have been little empirical work investigating competencies for rural and remote psychologists. Preliminary findings from a pilot survey of urban and non-urban psychologists indicate that competencies required to work as a psychologist in rural Australia may include breadth of professional knowledge and experience, the ability to maintain boundaries and manage dual relationships as well as having personality traits such as independence and flexibility.12 The present study aimed to develop a list of KSAs considered required or desirable for rural and remote psychology practice by rural and remote psychologists.
C. R. SUTHERLAND AND A. CHUR-HANSEN
What this study adds: • The present study is the first to provide a comprehensive checklist of the KSAs required for rural psychology practice identified by rural psychologists. • The list of KSAs may be used as part of competency-based training for students and the rural psychology workforce.
need to elicit detailed, rich data. Following ethics approval, a purposive sampling approach was employed, with participants recruited from a professional development group open to rural and metropolitan psychologists with an interest in rural psychology. Eligibility criteria included being a registered psychologist and living and working in a rural community, with rurality defined using ARIA++ classifications, excluding ‘Highly Accessible’ communities.17 The first author attended a meeting of the group, and an invitation to participate in a telephone interview was subsequently sent via email to the group mailing list. Two participants volunteered at the initial meeting, with three responding to the email. Four participants were recruited through snowball sampling. The first author conducted all interviews by telephone, which ranged from 45 to 90 min (M = 65). All interviews were digitally recorded and transcribed verbatim by the interviewer. Transcripts were emailed to participants, allowing for a process of participant validation. Data saturation was achieved, with no new themes emerging by the ninth interview. The interview was open-ended, but included questions about training, work history and current work setting, as well as perceptions of KSAs that were either unique to or desirable for rural practice, including perceived differences between working as a psychologist in a rural area compared to an urban area. Data were analysed using thematic analysis as outlined by Braun and Clarke.18 Interviews were analysed using a method of constant comparison, with each interview transcribed and subjected to preliminary analysis before the following interview.19 The maintenance of an audit trail enhanced rigour and trustworthiness of findings.19,20 The second author checked themes against the raw data, as a further method of increasing rigour and trustworthiness.21
Method
Results
A qualitative interview design was considered most appropriate given the limited previous research and the
Participants (N = 9), all women, ranged in age from mid-20s to early 60s (M = 39, SD = 12.39). All were © 2014 National Rural Health Alliance Inc.
275
COMPETENCIES RURAL PSYCHOLOGISTS
registered psychologists, but six had master’s level qualifications while three had qualified via either 5 + 1 or 4 + 2 supervision pathways. Years of experience as a psychologist ranged from six months to 17 years (M = 6.61, SD = 5.20), with years of rural experience (defined using the range of ARIA++ categories included in the study of ‘accessible’, ‘moderately accessible’, ‘remote’ and ‘very remote’) ranging from six months to 16 years (M = 5.83, SD = 4.82). Four psychologists had experience working in both rural and urban areas, ranging from one to four years urban experience. Participants represented almost all regions in South Australia and captured the full range of ARIA++ categories (accessible, moderately accessible, remote and very remote) included in the study, with three participants from ‘accessible’, three from ‘moderately accessible’, two from ‘remote’ and one from ‘very remote’ regions.
Competencies Seven competencies were identified, relating to two broad themes: ‘professional isolation’ (competencies arising from being the sole psychologist or one of few in the community); and ‘rural life’ (competencies relating to the need to manage features of the rural context). The seven competencies were: managing continuing professional development (CPD); managing supervision; managing the lack of other services; managing dual relationships; managing visibility; managing confidentiality; and having an appreciation of the rural context.
Knowledge Knowledge described as important by participants included knowledge of one’s own limitations, having a diverse knowledge base, local knowledge, knowledge of Indigenous culture and knowledge of rural presentations (Table 1).
Skills Technology and networking skills were described as important, along with the ability to work outside psychology, generalist–specialist skills, the ability to set boundaries, self-care skills, strategies for managing accidental meetings, the ability to adapt interventions, community education skills and the ability to compartmentalise information (Table 2).
Attitudes Attitudes considered important were being willing to travel, proactive and resourceful, flexible, willing to step out of comfort zone, approachable and down to earth, © 2014 National Rural Health Alliance Inc.
community minded, appreciative of rural lifestyle and passionate about rural psychology (Table 3).
Personality Personality factors were also highlighted as important in working in a rural area. These included being autonomous, self-directed, open to new experiences, resilient, resourceful, confident and comfortable with a high level of responsibility.
Training The importance of having rural content in university programs, including lectures and placements, in developing KSAs for rural practice was discussed, with rural placements considered the optimal method of preparing students for work in rural areas.
Discussion This study aimed to identify the knowledge, skills and attitudes (KSAs) deemed important for rural and remote psychology practice, as perceived by rural and remote psychologists. The competencies and KSAs identified were consistent with issues and challenges for rural psychologists previously identified in the literature.11,12,14,21 The finding that personality factors may be important as working as a psychologist in a rural area is also consistent with previous research.12 Furthermore, the competencies and KSAs identified were consistent with other health professions, including medicine,7 nursing8 and social work.9 While these previous studies have identified and described issues and challenges for rural psychologists, the present study contributes to the existing literature through the development of a comprehensive checklist of KSAs identified by rural and remote psychologists as important to manage the challenges and unique features of rural psychology practice. Strengths of this study include the inclusion of participants from a range of remoteness categories, capturing almost all of South Australia’s rural regions. The coding and comparison of an interview transcript by the second author ensured consensus of the final themes included and enhanced trustworthiness and rigour. In addition, data saturation was achieved, suggesting sufficient data were collected to support claims.20 Sincerity was enhanced through the maintenance of an audit trail, documenting decisions made during the research process, analysis and synthesis of themes, and correspondence with participants.20 A reflexive approach was taken: the position of the interviewer and researcher (CS) as a student of psychology from a rural background was highlighted to participants at the initial presentation and during interviews.
276 TABLE 1:
C. R. SUTHERLAND AND A. CHUR-HANSEN
Knowledge
Knowledge Knowledge of own limitations
The importance of knowing one’s own limitations and not practising outside one’s area of competence was emphasised; however, this was considered challenging given the lack of other available services.
Diverse knowledge base Local knowledge
Being the only psychologist (or one of few) required a diverse knowledge base of a broad range of presentations. Local knowledge was described as important for enhancing rapport; however, perceived confidentiality was more important for some clients.
Knowledge of Indigenous culture
This included an understanding of concerns about confidentiality in close-knit Indigenous communities.
Knowledge of rural presentations
While presenting problems in rural areas may not be different, the triggers behind them may be, such as the impact of drought.
South Australia’s unique population characteristics may result in differences in experience of service delivery, as the state is characterised by a smaller, more dispersed rural population than the Eastern states. Therefore, findings of this study may be state specific, and further work is required to examine the perceptions of psychologists from other states. Similarly, there is a need for future research to examine the influence of rural psychologists’ training backgrounds on their perceptions of KSAs, as the present study included both psychologists with master’s level qualifications and those who had completed supervision pathways to practice. In addition, the present study focused on psychologists providing clinical or mental health services. Further research is required to investigate the KSAs of rural psychologists working in other areas of practice endorsement. Finally, all participants
I’ve been asked to do in the past diagnostic ah assessments for autism and Asperger’s and that’s something I’m not specifically trained in, I don’t feel comfortable in and – in the end I turned them down and said no but that’s a very difficult thing to do because it means that that assessment will never get done because the client doesn’t have the resources to travel to Adelaide to see a specialist. (Participant 2) I spoke to a metro psychologist and they don’t see half of what I see. (Participant 9) . . . some of the clients will come to me because I am local and because I do know the area . . . other people will choose to go and see the fly-in fly-out person because when you live in a small community like ours, confidentiality is a huge factor. (Participant 3) . . . in a rural area . . . you need knowledge of Aboriginal health . . . I have had clients who are Indigenous that don’t want to access the Aboriginal services because of confidentiality issues . . . (Participant 6) . . . I would say within a rural community you still get the um – I get a lot of depression anxiety symptoms . . . but the triggers behind that can be quite different like in a rural community. We’re farming industry so drought. . . . uh so they’re still presenting with um – with you know depression symptoms, but the context of it is very different. So in the city people wouldn’t understand you know what it’s like. . . . (Participant 6)
were women; therefore further research is also required to determine the perspectives of rural psychologists who are men. Many KSAs identified by the participants in this study may also apply to urban psychologists. What may differ between urban and rural psychologists, perhaps, is the degree or constancy of these experiences.21 Future research is required to compare the perspectives of urban and non-urban psychologists, and to explore dimensions of difference between regional, rural and remote practice. The present study only examined perceptions of psychologists who both live and work in rural communities, and further research with psychologists who provide fly-in fly-out and drive-in drive-out services is indicated. Further research is also needed to examine the perceptions of rural consumers of psychological services as well as the perceptions of other rural © 2014 National Rural Health Alliance Inc.
COMPETENCIES RURAL PSYCHOLOGISTS
TABLE 2:
277
Skills
Skills Technology skills
Networking skills
Ability to work outside psychology
Generalist-specialist skills
Ability to set boundaries
Self-care skills
Strategies for managing accidental meetings
Ability to adapt interventions
Community education skills
Ability to compartmentalise
Given isolation, skills in using technology were considered important in managing professional requirements. Interdisciplinary networking was considered important in managing the lack of referral options. Participants described a need to take on roles outside the traditional scope of work for psychologists due to the lack of other services. The need for broad range of high-level ‘generalist’ skills in working with diverse presentations was highlighted. The need to set clear boundaries was identified, particularly regarding after hours contact, as personal and professional lives were considered difficult to separate. The need for self-care was highlighted given challenges such as dual relationships and complex caseloads. Managing social encounters included discussing appropriate contact outside of session with clients at the initial consultation. Adapting initiatives and therapeutic approaches developed in urban areas to suit rural client groups was identified. This included providing professional development to other health professionals and presentations at community events. Given the likelihood of dual relationships, participants described the need to compartmentalise information gathered (often inadvertently) about clients from other sources.
health practitioners (including general practitioners) regarding the roles and skills of psychologists in their communities. Upon incorporating these other perspectives, the list of competencies developed here could be used for training and professional development for rural psycholo© 2014 National Rural Health Alliance Inc.
. . . you have to be very good at doing things over the phone like supervision . . . most of my supervision has happened since I started as a psychologist . . . has happened over the phone. (Participant 7) . . . it helps with referrals as well, if you get your face out there then people know that there’s um – the services available for them to refer patients. (Participant 7) . . . you kind of – take off the – the psychologist hat and – like I’ve kind of worked with young people, clients, to contact Centrelink . . . doing some of those more practical roles . . . sometimes you tend to do a bit more of that maybe. (Participant 5) I try to make sure that I’m trained in lots of different kind of therapies . . . whereas maybe in the cities you may really specialise . . . (Participant 6) . . . when I walk through this community whether I’m at work or not I am our local psychologist . . . and unless I want to start wearing wigs, sunglasses and a hat . . . that’s your identity, you are the local psychologist. (Participant 9) . . . good self-care skills are really important in a – in a rural psych . . . some of that’s about managing dual relationships . . . being able to – to cope with seeing clients in settings away from work. (Participant 1) . . . it’s not ok for them to come and talk to me, or hand me a Medicare cheque at the supermarket, which has certainly happened. (Participant 1) . . . I can often deal with people who have very limited literacy and numeracy skills . . . so I don’t use a lot of tests . . . because I have found over the years that that really almost puts up a barrier. (Participant 3) . . . I have certainly been involved in drug and alcohol education, I have been involved in um a giving a – conflict resolution talk . . . it’s part of what you need to do. (Participant 3) . . . keeping – the bits and pieces of information that you have in your head clear about where it’s come from and not sort of divulging it in other places . . . (Participant 8)
gists, consistent with the competency-based training approach.1,3 As highlighted by participants, this could take the form of rural content in university courses (for example lectures highlighting KSAs required by rural psychologists) and increased support for rural placements, with rural placements considered by participants
278 TABLE 3:
C. R. SUTHERLAND AND A. CHUR-HANSEN
Attitudes
Attitudes Willing to travel
Proactive/resourceful
Flexible
Willing to step out of comfort zone
Managing travel in rural areas was described as both challenging and necessary, particularly for professional development. Given the lack of other services, participants highlighted the need to be resourceful and proactive. Flexibility encompassed the nature of work (e.g. adapting interventions) and location (e.g. seeing clients out of the office given confidentiality concerns). The need to work with ‘whatever walks through the door’ was highlighted as both a challenge and a benefit of rural work.
I suppose if you didn’t like travel or – yeah that would be an issue – that’s probably more so than in the city. (Participant 4) I had to seek that out and organise [supervision] on my own. (Participant 5) I think you – you don’t cope unless you have a lot of flexibility out here . . . people who do survive are the ones who can be flexible. (Participant 3)
. . . you are asked to step outside your own comfort zone and that’s – professionally I think that’s actually really good to do – providing you are aware of what – what those challenges are. (Participant 1) Approachable/down to Being approachable was described as important Well you have to be very approachable basically if earth but challenging, given confidentiality you’re not approachable you may as well pack up concerns. Being ‘down to earth’ was and go away . . . I still have to be approachable but important as rural people were thought to be also have to make sure that people understand that ‘put off’ by credentials. when they do come and speak to me that it’s totally confidential . . . (Participant 3) Community minded Community involvement was considered helpful . . . it’s really good to know if you are living here that in enhancing relationships and maintaining a you need to be involved in the community. passion for rural work. (Participant 6) Appreciative of rural An appreciation of the rural lifestyle was . . . I guess it would simply be an interest and a love lifestyle described as a key difference between rural of country life you know that. . . . would be the and urban psychologists. difference between a rural and an urban psychologist – maybe a rural and urban professional in any capacity. (Participant 4) Passionate about rural This included a willingness to advocate for I think really you do need to have quite a passion and psychology rural services and to promote psychology in an energy for rural psychology . . . because of some rural areas. of the demands of the role . . . (Participant 2)
to be the optimal method of developing the KSAs required for rural practice.
Acknowledgements We would like to thank the rural and remote psychologists who participated in and supported the project.
Author contributions Carly Rose Sutherland – 80%. Professor Anna ChurHansen – 20%.
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