Using a Delphi process to extend a rural mental

the Journal of Mental Health Training,

Education and Practice Using a Delphi process to extend a rural mental health workforce recruitment initiative Julie Willems Keith Sutton Darryl Maybery Article information: To cite this document: Julie Willems Keith Sutton Darryl Maybery , (2015),"Using a Delphi process to extend a rural mental health workforce recruitment initiative", the Journal of Mental Health Training, Education and Practice, Vol. 10 Iss 2 pp. 91 - 100 Permanent link to this document: http://dx.doi.org/10.1108/JMHTEP-10-2014-0033 Downloaded on: 20 May 2015, At: 17:01 (PT) References: this document contains references to 24 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 4 times since 2015* Access to this document was granted through an Emerald subscription provided by Token:JournalAuthor:D7314473-52B540FF-9D13-C9756F5CD210:

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Using a Delphi process to extend a rural mental health workforce recruitment initiative Julie Willems, Keith Sutton and Darryl Maybery

Dr Julie Willems is an e-Learning Designer/ Educational Developer, Keith Sutton is a Lecturer in Rural Health and Associate Professor Darryl Maybery is a Director, all at the Department of Rural and Indigenous Health, Monash University, Moe, Australia.

Abstract Purpose – The Gippsland Mental Health Vacation School program has been shown to positively change student participants’ interest and attitudes to living and working in a rural area. A range of factors are impacting on the future viability of the initiative including: limitations on the number of student participants, the reusability of content, staffing, time pressures, a dwindling funding base, and a drop-off in interest in living and working in a rural setting. The paper aims to discuss these issues. Design/methodology/approach – A three-phase Delphi Study was employed to engage with expert knowledge of the program’s key stakeholder groups (student participants and service provider staff) in order to inform the initial steps of shifting the program toward a blended model, distributed across space and time. Findings – The results suggest that: first, the current mode of delivery, a week-long intensive face-to-face format, should be transitioned to a more sustainable blended learning approach that includes both on-line content and an in situ component; and second, trailing the use of social media as a mechanism to maintain student interest in rural mental health work following the vacation school. Originality/value – This study highlights how the transition to a sustainable approach to the delivery of a novel rural mental health workforce recruitment strategy was informed through a three-phase Delphi Study that involved the key stakeholders (groups of student participants and service provider staff). The study has important implications for addressing the shortage of mental health practitioners in rural areas. It will and be of interest to educators, administrators, researchers and bureaucrats. Keywords Recruitment, Mental health, Social media, Blended learning, Delphi Study, Rural workforce Paper type Research paper

Introduction

Received 22 October 2014 Revised 1 December 2014 Accepted 4 December 2014 This study and work would not have been possible without the willing participation of both students who attended the 2012 Gippsland Mental Health Vacation School program and staff from mental health and alcohol and drug services across Gippsland. No known conflicts of interest.

DOI 10.1108/JMHTEP-10-2014-0033

The mental health workforce consists of a range of professions, commonly including nurses, psychologists, social workers, occupational therapists, speech pathologists and doctors. In many parts of the world, however, the workforce is not equitably distributed across urban and rural areas, posing particular challenges for the rural population. The shortage of mental health practitioners in rural areas is well documented in Australia, Canada and the USA (Australian Institute of Health and Welfare, 2014; OECD, 2014; Spero and Fraher, 2014). There are multiple reasons for this situation. A major influence is the belief held by some students that rural is second best due to concerns over access to services and fear of isolation (Eley et al., 2008), trepidation over family and personal issues such as finding a partner, rewarding employment opportunities and quality education pathways for children (Rosenblatt et al., 2006). There is, however, little available empirical evidence in the mental health and allied health workforce literature of interventions designed to address rural mental health workforce shortages. That literature which is available on the rural health workforce principally focusses

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upon the supply of doctors to rural areas (Rural Health West, 2013). It suggests that most efficacious approach to attract a rural mental health workforce is for rural regions “to grow their own” mental health practitioners, as the strongest predictors of rural practice include: growing up and attending school in a rural setting; having a partner with a rural background; and/or undertaking extended and immersive pre-registration rural clinical placements (McGrail et al., 2011; Rabinowitz et al., 2013; Stagg et al., 2009; Walker et al., 2012). Currently it is unclear whether the results in the available

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literature are generalizable to nursing and the allied health professions as either there is a lack of evidence or only weak evidence available, apart from “rural origin” as a determinant of intent which is generalizable to nursing (Rural Health West, 2013). The limited available rural mental health literature either highlights and quantifies the urban-rural workforce disparities, or examines systemic, structural and individual factors found to contribute to the rural mental health workforce shortfall. In Australia, tertiary training in many of these professions is predominately located in metropolitan cities. The challenge of many rural regions is exemplified by Gippsland, a rural region in south-east Victoria. The only relevant pre-registration options available at the sole University campus located in Gippsland are undergraduate general nursing and social welfare training. The pre-registration training of other mental health professions is available outside the region, most commonly in Melbourne. Additionally, only very few pre-registration allied health students undertake their clinical placements in Gippsland. The Gippsland Mental Health Vacation School (GMHVS) was developed to fill this void through a program designed to encourage allied health and nursing students studying in Melbourne to consider commencing their mental health careers in Gippsland (Sutton et al., 2012). Developed by Monash University’s Department of Rural and Indigenous Health (MUDRIH) based in Moe, Gippsland, the vacation school program is not part of a University course but provides an addon orientation to rural mental health during the mid-semester break (hence the title “vacation school”). The program has run successfully (Sutton et al., 2012) in six cycles over five years. Additionally, the program has received positive qualitative and quantitative feedback from both participating students and representatives of Gippsland service providers (Willems et al., 2012). Research background Geographically, Gippsland is the broad region from the eastern perimeter of outer Melbourne across to the south-eastern border of New South Wales. Covering 41,524 km2, the region is bounded in the north by the Great Dividing Range and south by the Southern Ocean and encompasses mountainous terrain to an extensive lakes system and beaches. Industries in the region include dairy farming, fruit and crop production, timber and associated by-products, industrial mining and power generation. Gippsland comprises six local government areas and has a population of 255,716 (Australian Bureau of Statistics, 2011). Unlike other Victorian rural regions, Gippsland does not have a major and central provincial city. The population is dispersed in townships across the region, of which Traralgon is the largest with 23,837 residents (LaTrobe City, 2014). In the main, mental health services in Gippsland are provided by state-funded public mental health services and medicare-funded services including general practitioners, psychologists and a small number of consultant psychiatrists. The GMHVS project had four objectives: first, to orient future mental health professionals to the mental health employment opportunities in the region; second, to build positive attitudes toward working in the rural mental health sector; third, initiate relationships between the student participants and mental health organizations within the region; and fourth, to motivate participating students to consider working as mental health practitioners in Gippsland. Since 2010, the five-day vacation school has been delivered as an in situ face-to-face program, that includes seminar presentations, workplace visits, plenary discussions and social outings. Presentations include an overview of mental health services and the current policy reform agenda, an introduction to current trends in treatment and the implementation of evidence-based practice, and an overview of services in Gippsland. A core focus of the vacation school are the visits to mental health service providers across the region. Visits are undertaken in small groups in order to maximize the range for students, enable student – practitioner interaction and to cater for

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the restricted capacity of smaller agencies. Agency visits are scheduled during days two, three and four. Plenary sessions are hosted at the University campus in Moe (MUDRIH) on the first and final days of the current five-day face-to-face program structure. In addition, social activities are run for the participants during the program, such as a dinner and a visit to a local tourist destination, to promote social and lifestyle opportunities in the region. Created to address the need to grow one’s own rural mental health workforce; the vacation school program is now challenged on a number of levels. These include the limited number of student places able to be offered in the face-to-face program, the reusability of content, staffing and time pressures plus a dwindling funding base. While overlapping this is the desire to create a more selfsustaining, less time-intensive program that can be added to, rather than recreated each time the program is offered through the reusability of learning objects. Critically, however, are recent findings from a longitudinal study exploring the impact of the vacation school experience upon student participants (Sutton et al., in preparation). Matched pre to immediately post the vacation school survey results, highlighted a significant increase in student participants’ interest in undertaking both rural work and rural mental health work. The results were associated with a strong effect size and are consistent across all vacation school groups. At the six months participant follow-up, however, the positive gain in interest was not maintained and had retracted by almost 50 percent. This suggests that the vacation school had a strong impact upon interest in rural and rural mental health work in the short term but this impact wanes overtime. This finding is important as it not only shows decline in interest over time but it also highlights a need to intervene to maintain the immediate impact of the program in the longer term. This study therefore sought to determine from vacation school participants and local mental health agency staff involved in the program: first, how student interest in rural work and rural mental health work might be maintained following completion of the program; and second, how else the vacation school be delivered other than a fully face-to-face context. The study utilized a Delphi process to seek input from experts, the key stakeholders involved in the program, in order to address these questions. This paper also outlines the initial steps of shifting the successful face-to-face program to a blended, interactive model, distributed across space and time.

Method A Delphi methodology was selected as the most appropriate means to facilitate change by involving the input of the key stakeholder groups involved. A Delphi Study is a structured cyclical process for the purpose of collecting and condensing expert knowledge or feedback in the particular area of interest by means of a series of most typically three “rounds” of research (Hasson et al., 2000). In this study, the experts were those in the GMHVS program: the student participants and Gippsland mental health service providers (see Table I). At the end of each Delphi round, the gathered data are summarized and presented back to the same group of experts for confirmation and rating. The participants then have the possibility to provide further comments in this procedure up until the completion of the third round. Through this process of refinements, group consensus is reached. In this study, each round was open for approximately one month for data collection. Table I summarizes participants from each of the three rounds in this study. Monash University Human Research Ethics Committee provided ethics approval for the study.

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Total (N)

Participant attrition from prior round (%)

Round 1 of the Delphi Study involved separate focus group meetings for GMHVS student participants and representatives from the region’s mental health providers (participant numbers shown in Table I). The first round sought answers to the following questions: What are some of the things that could help maintain your interest following GMHVS?

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How do we help maintain student interest following GMHVS?

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If there was no vacation school, how could MUDRIH do what we have otherwise? Is there another way to do what we have this week?

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Themes and sub-themes were compiled from the responses from the first round. This summary was then presented in the second round of the Delphi Study to participants through an on-line survey. Participants were invited to rate the relative importance of each of the emerging themes and subthemes using a Likert scale of “no importance” (0) at one end, to “extremely important” (100) at the other. Participants were also invited to make comment regarding the Round 1 findings and add further comments. In the third round, again through an on-line survey participants were informed of the ranking in order of importance of the Round 2 themes and sub-themes, as rated by respondents. Participants were then asked to consider the findings of Round 2 and to re-rank items where necessary, comment on the changes in rankings and importance of these and make any final comments regarding the issues being investigated. The participant attrition rates for Rounds 2 and 3 are shown in Table I.

Results As there were minimal differences in ratings and rankings of the student respondents and mental health service providers, the data from the two groups are not differentiated in the results outlined below. Tables II, III and IV provide a summary of responses to the three Delphi rounds. Each table focusses on a single question: Question 1.

What are some of the things that could help maintain your interest following GMHVS?

In the first Delphi round participants indicated that their interest would be maintained following the vacation school with access to information following the completion of the vacation school. Specifically they thought that follow up information about Gippsland employment opportunities, placement opportunities, training and course opportunities, agency/service information, information about the Gippsland region and community and policy, funding and practice information would all be important. Participants also suggested that there should be updates about the vacation school developments and research outcomes and a capacity for person to person sharing within the vacation school cohort, with other students from the GMHVS cohort, the representatives of the Gippsland mental health and/or alcohol drug service providers, or MUDRIH staff following the completion of a vacation school. In addition, they thought that this communication should be targeted and timely following the completion of the vacation school.

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The Rounds 2 and 3 ratings and rankings emphasized the importance placed upon the capacity for person to person sharing of information after the vacation school, as this item was both rated (Round 2) and ranked (Round 3) highest in both rounds. In regard to the remaining themes, participants placed more importance upon access to information, compared to updates about the vacation school and least importance placed on the provision of timely communication. The types of access to information desired by the key stakeholder groups are also shown by rating and ranking in the above table. Most importance was placed upon access to job and/or employment opportunities, this scored almost 14 points higher than that for the next item: Question 2.How do we help you maintain student interest following GMHVS? Participants highlighted three themes and multiple sub-themes in response to this question (see Table III). The three themes to maintain student interest included the use of information communication technologies (such as Facebook, see Table II), hold special interest events (e.g. lectures) and introduce protocols for maintaining engagement. As shown in the above table, the most importance was placed on the use of a platform that employed available and desirable technology to the participants. In part, this theme overlaps and relates to the least highly rated and ranked theme protocols for maintaining engagement. Facebook was the most highly rated platform for use, with e-mail a close second priority. Protocols suggested using existing platforms and inviting agency collaboration and using regular updates. Other platforms and protocols were more lowly rated in comparison. The second ranked theme, special interest events such as information nights and lectures, suggested a face to face alternative to the use of available technology: Question 3. If there was no vacation school, how could MUDRIH do what we have otherwise? Is there another way to do what we have this week? In response to “if there was no vacation school,” the Delphi participants responded that they wanted to be provided with information about how the mental health, plus alcohol and drug sectors function, and how they operate in Gippsland (see Table IV).

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Participants also suggested adopting a blended delivery approach to the program through a mix of face to face and both asynchronous and synchronous e-learning methods and approaches. They also suggest ways to optimize engagement with students and service providers through the blended delivery approach. In terms of information about the sector the participants suggested as highest priorities outlining information about how the disciplines, agencies and service systems work on a daily basis (see Table IV). In regard to the second theme they suggested scheduling information at optimal times for students as most important. The ratings and rankings for the best type of blended delivery was also interesting with face-to-face visits to Gippsland agencies being considered as most important, and on-line information (e.g. video, audio, etc.) as least important.

Discussion The findings of this study are important from two perspectives. First, the results provide important information about how student participant interest in a rural career choice might be maintained following a brief intervention such as the vacation school. Second, the results highlighted the desired ways in which the participants, as key stakeholders in the program, conceptualized the blended delivery alternative to GMHVS without it having to be provided solely in a face-to-face context. Participants considered that the opportunity for direct individual-to-individual communication and ongoing access to information, particularly employment opportunities in Gippsland, as critical elements to maintain student interest in pursuing a rural career in mental health following the GMHVS. Participants indicated that achieving ongoing interest following the vacation school required the use of an existing and readily available technology, such as social media or e-mail, via an ICT platform. In addition, the Delphi participants highlighted a clear way forward to sustaining the program in the long term through a blended delivery approach. Participants emphasized the importance of maintaining an in-person/face-to-face approach, while also indicating that some material could be successfully delivered via a web-based modality. Participants suggested that the following crucial aspects needed to be incorporated: information about the sector; an explanation of how each discipline works in different agencies; a means whereby the respective agencies and service providers in the region could show what they offer potential employees; an explanation of how the various components of the service system work; the provision of how agencies operate on a daily basis; suggestions on how to optimize engagement within a potential blended delivery model; the scheduling of the program to run at an optimal time for participating students; and the provision of promotional materials. The implications of these results for education providers and others working to recruit health professionals to rural and remote areas include the potential to provide a blended model of recruitment. This would focus on students nearing completion of their pre-registration studies, a brief face-to-face orientation to potential employment opportunities (as provided by the current vacation school) and the shift to an on-line delivery approach for the supporting background and contextual information. For the latter, the findings from this study offer clear direction for the Gippsland region to extend its face-to-face model and potentially the current findings may also apply to other health workforce areas and regions. As a consequence of these findings, in Gippsland, the initial steps are being made to shift the successful face-to-face program to a blended and interactive model, distributed across space and time. The first of these steps will be to encompass the request for social media as a platform of delivery. The advantage of social media is that in breaking down access barriers it also enables social networks. Social networks are defined as enabling “communication among ever-widening circles of contacts [and] inviting convergence among the hitherto separate activities of email, messaging, website creation, diaries, photo albums and music or video uploading and downloading” (Livingston, 2008, p. 395).

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Facebook, as an exemplar of social media, originated in 2004 as a means of informally connecting university college students (Facebook, 2014). Today, Facebook (www.facebook. com) is selfdescribed as a form of social service – a utility – which connects people with others (“friends”). However, social media not only connects, but it also has synergies with educational possibilities. It “not only attracts people but also holds their attention, impels them to contribute, and brings them back time and again – all desirable qualities for educational materials” (Johnson et al., 2011, p. 12). According to Lampe et al. (2008), 95.5 percent of all enrolled students in higher education have indicated that they use Facebook. The initial steps of moving to a blended GMHVS program involved the creation of a “closed” group in Facebook. In a closed Facebook group, the name and constituent members are visible to everyone, however, the content is visible only to members and access is moderated by administrators of the page. Through this model, participants have subsequently reported through feedback beyond the parameters of this paper that they feel that they are part of a supportive collaborative community, are able to undertake activities such as learn about job vacancies as they arise, and are share individual updates including the attainment of rural mental health employment “success stories” (Willems et al., 2012). Of note is that the “blended” delivery via this Facebook model offers its members a broad notion of blended learning, in that it provides both asynchronous (through resource links) and synchronous (through the instant messaging function) learning opportunities. It is anticipated that future iterations of the vacation school will lead to a more self-sustaining model. This will encompass an on-line delivery component and a social collaboration component. Future research will continue to evaluate the transition of the program to the blended model and monitor its success in providing a key need to promote rural health and the ability to engage participants in the virtual space. There were a number of weaknesses in the study which warrant attention. The first, as with any Delphi research process, is the question of attrition or participants between each of the rounds. The overall attrition rate may have been the result of both the four-month time lag between the first and final phases of the study, and that the final phase was held during the months of January and February when traditionally many Australians are taking their summer vacations. The second issue, which may have had a greater impact upon the attrition numbers of student participants in the study, was that a number of them would have completed their tertiary studies. Conversely, we surmise that the lower attrition rate of service providers in the study might be due to the vested interest that many held for the success of this model to recruit a rural mental health workforce to the region. Another area of potential weakness in the study is that it could be argued that participants are not experts with a broad range of technology, so might not know all possible options in order to respond to this study. Also, our participants were not experts in rural and remote workforce recruitment which again questions their expertise to respond. However, participants were both students and mental health professionals working at the Gippsland mental health “coalface”. We believe this sufficiently endows them to know what works and what does not in terms of future work and the region. We argue, therefore, that these key stakeholders are precisely the ones who need to be involved in the change process. That being said, the range of stakeholders is a further limitation. Future studies should include a larger cross-section of key stakeholder groups (e.g. service users, educationalists and/or policy makers) as experts. A final limitation is in and around the trend for Facebook as key choice of social media tools among the cohorts. In part this was driven by the closed nature of the learning management system of the host institution for students belonging to other institutions. However, there are other forms of social media and, over time, these might prove to be viable alternatives for connectivity.

Conclusion The bane of rural existence is access to services that are considered a normal part of urban living. At the most basic level, the vacation school attempts to assist Gippsland mental health agencies to have access to potential mental health professional employees, and concluding students in the access to future employment opportunities in a rural setting.

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Having run successfully in a face-to-face context, the current findings offer important information regarding how the GMHVS program might transition to a blended delivery model. The on-line environment offers an opportunity to overcome the barriers which currently limit the capacity of the existing structure of the vacation school program to benefit the region. As part of the structure of the early transition to this blended learning model, a closed group Facebook page has been created. Moving from place to space can be a daunting process. Much is necessary to consider, especially in what aspects can be replicated, which cannot and which can be enhanced. The early indicators of this blended transition suggest that an exciting, dynamic model is forming and one which has involved not only key stakeholder “buy-in”, but also the active participation of the group members.

References Australian Bureau of Statistics (2011), Victoria (Local Government Area), Persons Place of Usual Residence, Australian Bureau of Statistics, Canberra, available at: www.censusdata.abs.gov.au/webapi/jsf/tableView/ crosstabTableView.xhtml (accessed 13 May 2013). Australian Institute of Health and Welfare (2014), Mental Health Workforce, Australian Institute of Health and Welfare, Canberra, available at: http://mhsa.aihw.gov.au/resources/workforce/ (accessed 31 July 2014). Eley, D., Young, L. and Shrapnel, M. (2008), “Rural temperament and character: a new perspective on retention of rural doctors”, Australian Journal of Rural Health, Vol. 16 No. 1, pp. 12-22. Facebook (2014), “Facebook: our mission”, available at: https://newsroom.fb.com/company-info/ (accessed 20 June 2014). Hasson, F., Keeney, S. and McKenna, H. (2000), “Research guidelines for the Delphi survey technique”, Journal of Advanced Nursing, Vol. 32 No. 4, pp. 1008-15. Johnson, L., Smith, R., Levine, A. and Haywood, K. (2011), “The 2011 Horizon report”, available at: http://net. educause.edu/ir/library/pdf/HR2011.pdf (accessed 21 May 2013). Lampe, C., Ellison, N. and Steinfeld, C. (2008), “Changes in use and perception of Facebook”, ACM 2008 Conference on Computer Supported Cooperative Work, New York, NY, 8-12 November, available at: http://dl.acm.org/citation.cfm?id¼1460563&picked¼prox&CFID¼440994292&CFTOKEN¼34485729

(accessed

27 May 2013). LaTrobe City (2014), “Population”, LaTrobe City Council, Traralgon, Victoria, available at: www.communityprofile. com.au/latrobe/population/age#!bar-chart;i=0 (accessed 11 April 2015). Livingston, S. (2008), “Taking risky opportunities in youthful content creation: teenagers’ use of social networking sites for intimacy, privacy and self-expression”, New Media & Society, Vol. 10 No. 3, pp. 393-411. McGrail, M.R., Humphreys, J.S. and Joyce, C.M. (2011), “Nature of association between rural background and practice location: a comparison of general practitioners and specialists”, BMC Health Serv Res. Vol. 11, pp. 1-8. OECD (2014), Making Mental Health Count: The Social and Economic Costs of Neglecting Mental Health Care, OECD Health Policy Studies, OECD Publishing, Paris, doi:10.1787/9789264208445-en. Rabinowitz, H.K., Diamond, M.J.J., Markham, F.W. and Santana, A.J. (2013), “Rural family physicians after 20-25 years: outcomes of a comprehensive medical school rural program”, Journal of the American Board of Family Medicine, Vol. 26 No. 1, pp. 24-7. Rosenblatt, R.A., Andrilla, C.H.A., Curtin, T. and Hart, L.G. (2006), “Shortages of medical personnel at community health centers: implications for planned expansion”, JAMA, Vol. 295 No. 9, pp. 1042-9. Rural Health West (2013), “Critical success factors for recruiting and retaining health professionals to primary health care in rural and remote locations: contemporary literature review”, Government of Western Australia, Perth, available at: www.ruralhealthwest.com.au/docs/publications/rhw_uwa_cucrh-contemporary-reviewofthe-literature-f-lr.pdf?sfvrsn¼2 (accessed 14 November 2014).

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Spero, J.C. and Fraher, E.P. (2014), “Running the numbers: the maldistribution of health care providers in rural and underserved areas in North Carolina”, North Carolina Medical Journal, Vol. 75 No. 1, pp. 74-9. Stagg, P., Greenhill, J. and Worley, P.S. (2009), “A new model to understand the career choice and practice location decisions of medical graduates”, Rural and Remote Health, Vol. 4, p. 1245, available at: www.rrh.org.au Sutton, K., Maybery, D. and Moore, T. (2012), “Bringing them home: a Gippsland mental health workforce recruitment strategy”, Australian Health Review, Vol. 36, pp. 79-82. Sutton, K., Patrick, K. and Maybery, D. (2015), “The longer term impact of a novel rural mental health recruitment strategy”, Asia Pacific Psychiatry. Walker, J.H., Dewitt, D.E., Pallant, J.F. and Cunningham, C.E. (2012), “Rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study”, Rural and Remote Health, Vol. 12, p. 1908, available at: www.rrh.org.au (accessed 14 November 2014). Willems, J., Sutton, K. and Maybery, D. (2012), “Consulting the ‘oracle’: using a Delphi process to facilitate change to a blended learning model for rural mental health professionals’ recruitment”, in Brown, M., Hartnett, M. and Stewart, T. (Eds), Future Challenges: Sustainable Futures, Proceedings ascilite 2012, Wellington, 25-28 November, pp. 1053-5, available at: www.ascilite.org/conferences/Wellington12/2012/ images/custom/willems,_julie__consulting.pdf (accessed 20 January 2014).

Further reading Monash University (2012), “Monash University Department of Rural and Indigenous Health”, available at: www.med.monash.edu.au/srh/mudrih/ (accessed 18 March 2013). Moore, T., Sutton, K. and Maybery, D. (2010), “Rural mental health workforce difficulties: a management perspective”, Rural and Remote Health, Vol. 3, pp. 1-10, available at: www.rrh.org.au Sutton, K., Maybery, D. and Moore, T. (2011), “Creating a sustainable and effective mental health workforce for Gippsland, Victoria: solutions and directions for strategic planning rural and remote health”, Rural and Remote Health, Vol. 11, pp. 1-11, available at: www.rrh.org.au Victorian Department of Planning and Community Development (2008), Victoria in Future, Victorian Department of Planning and Community Development, Melbourne, available at: www.dpcd.vic.gov.au/ __data/zassets/pdf_file/0016/32164/RegionalForums_Gippsland_Traralgon_1_47.pdf (accessed 27 May 2013).

About the authors Dr Julie Willems (http://wikieducator.org/User:Julie_Willems) holds qualifications in nursing, the humanities and education, and was a distance learner for 20 years. She has worked across all Australian education sectors. Her research interests include the i-Survive Project (http:// isurviveproject.wikispaces.com/i-Survive+Project), the media and technology of formal and informal learning (including the social media of Web 2.0, mobile learning and virtual worlds) and educational equity and access for the disadvantaged. She has served for three years on the National Executive of the Open and Distance Learning Association of Australia (ODLAA – www. odlaa.org). Julie currently works as an e-Learning Designer/Educational Developer in the School of Rural Health, Monash University. Keith Sutton is a Lecturer in Rural Mental Health at the Monash University Department of Rural and Indigenous Health. A Registered Psychiatric Nurse, he has extensive experience as a clinician, manager and bureaucrat in the mental health field. His research endeavors have principally focussed upon rural mental health workforce issue. Keith Sutton is the corresponding author and can be contacted at: [email protected] Associate Professor Darryl Maybery is the Director of the Monash University Department of Rural and Indigenous Health (MUDRIH) based at Moe in Gippsland. He is a psychologist with over 30 years of clinical and research experience in the psychology field in rural settings. His grant research history and over 60 publications focus upon mental health and rural workforce research domains.

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