Understanding and Enhancing the Preparedness of Medical Technicians of the Royal Australian Army Medical Corps

Health Workforce Readiness – understanding and enhancing the preparedness of Medical Technicians of the Royal Australian Army Medical Corps

George A Georgiadis

A thesis towards the degree of

Professional Doctorate in Public Health

School of Public Health and Community Medicine

Faculty of Medicine

2018

ii Dissertation sheet

iii Originality Statement

iv Dedication

This research is dedicated to the soldiers of Royal Australian Army Medical Corps who have given, and continue to give selfless service supporting the men and women of the Australian Army since before Federation.

Abstract

Health workforce preparedness relies on effective management of, and investment in an organisation’s workforce. As the largest clinical craft group in the Australian Army, Medical Technicians provide health care from point of injury; as independent health practitioners, through to mobile or fixed medical facilities as members of multi- disciplinary health care teams, usually at short notice.

By examining the preparedness of the Australian Army’s Medical Technician workforce, this research presents a conceptual model for developing and maintaining a high readiness and adaptive health workforce. Through a mixed methods convergent design, this study addresses the question of how to develop and maintain a high readiness and adaptive health workforce by examining the human capital areas of training and development, skills and knowledge maintenance. While human capital is generally limited to the skills, knowledge, and attitudes embodied in individuals, to be effective, human capital management must also consider workforce retention.

The lived experiences and perceptions of 179 Medical Technicians from Private to Warrant Officer Class Two were examined, using a mixed methods survey instrument, open forum discussion, and eight focus group discussions.

The research findings suggest that current Medical Technician training model is flawed by focusing on “front loading” soldiers with all the skills, knowledge, and attitudes they may require throughout their career, during their initial training. The trade model does not incorporate the concept of lifelong learning, or consider how one’s work changes as Medical Technicians are promoted. The study found that training towards nursing and paramedicine qualifications, and registration is failing to prepare Medical Technicians for the work they undertake for the majority of their time, primary care. It also found that operational tempo, the current approach to training, skills maintenance and professional development is a contributing factor to the high turnover of Medical Technicians at the ranks of Corporal and Sergeant.

This research recommends a review of current Medical Technician training and proposes a range of skills and knowledge development and maintenance initiatives that are evidence based, which will improve Medical Technicians preparedness in the Australian Army, and which can be applied to other high-readiness health workforces.

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Acknowledgements

This research was made possible through the support and assistance of so many people.

Firstly, I would like to acknowledge and thank my academic supervisors, Professor Raina Macintyre and Associate Professor David Heslop, for without their encouragement, advice, and guidance this research would never have seen the light of day. I must especially acknowledge and thank Associate Professor Graham Durant- Law, my workplace research supervisor, who not only taught me the value of knowledge, but encouraged me to question and challenge everything in the pursuit of knowledge and understanding.

I must also thank the following work colleagues for their support and encouragement over the past three and a half years: Major General Jeff Sengelman, Major General Marcus Thompson, Brigadier Leonard Brennan, Brigadier Susan Coyle, Brigadier Paul Nothard, Brigadier Georgeina Whelan, and Colonel Fleur Froggatt. I also thank the Commanding Officers of the 1st Close Health Battalion and the 2nd General Health Battalion, Colonel Caitlin Langford and Lieutenant Colonel Clark ‘Barney’ Flint.

A special thanks to Lieutenant Colonel Maureen Montalban, Major Tracy Allison, Major Damien Batty, Major Natasha Robinson, Major Lynda White, Captain Natalie Lehmann, Warrant Officer Class One Cheryl Elston, and Warrant Officer Class One Dave Leak for their support, understanding and assistance during my research.

I would also like to thank all the officers and soldiers who participated in this research by completing lengthy surveys and taking part in endless group discussions.

Finally, and most importantly I must thank my wife Kim and our three daughters, Stephanie, Caitlin and Jessica. For without their love, support and understanding this adventure, not unlike all others in life, would not have been possible. Everything I have achieved, both professionally and academically is due to them.

Thank you.

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Abbreviations

ADF Australian Defence Force

AHI Army Health Instruction

AHPRA Australian Health Practitioner Regulation Agency

AHS Army Health Services

AQF Australian Qualification Framework

ASH Army School of Health

CPL Corporal

DoD Department of Defence

FIC Fundamental Inputs to Capability

JHC Joint Health Command

KIA Killed in Action

LCPL Lance Corporal

Med Tech Medical Technician

Medic Medical Technician

NATO North Atlantic Treaty Organisation

NHMRC National Health and Medical Research Council

PTE Private

RAAMC Royal Australian Army Medical Corps

SGADF Surgeon General Australian Defence Force

SGT Sergeant

TCCC Tactical Combat Casualty Care

WHO World Health Organisation

WO2 Warrant Officer Class Two

Table of Contents

Copyright and Authenticity Statements ...... ii Dissertation sheet ...... iii Originality Statement ...... iv Dedication ...... v Abstract ...... vi Acknowledgements ...... viii Abbreviations ...... ix Table of Contents...... x List of Figures ...... xv List of Tables ...... xvi Chapter 1: Introduction ...... 1 Part 1: Overview ...... 1 Background ...... 1 Rationale for this research ...... 4 Hypothesis and Research Question ...... 5 Scope and limitations of this research ...... 6 Thesis structure ...... 7 Part 2: Situating the Research ...... 8 Overview ...... 8 Nature of Military Operations ...... 8 Australia’s Strategic Context ...... 10 The Australian Defence Force ...... 11 Generation of Capability ...... 11 Preparedness ...... 14 The Australian Army ...... 16 The Royal Australian Army Medical Corps ...... 19 Evolution of Military Medicine ...... 21 Medical Technicians ...... 29 Training, Education and Development in the Australian Army...... 34 Clinical Readiness Standards for Army Health Services Personnel ...... 36 Summary ...... 38

Chapter 2: Literature Review...... 39 Introduction ...... 39 Search Methodology ...... 39 Literature Sources ...... 41 Keywords and Phrases ...... 42 Search Results ...... 44 Military Health Workforce Preparedness ...... 46 Human Capital – An Investment is Workforce Learning ...... 48 Learning ...... 50 Maintaining Clinical Readiness ...... 56 Clinical Skills Decay ...... 60 Recruitment and Retention of Army Health Services Personnel ...... 63 Leadership ...... 66 Discussion ...... 69 Summary ...... 71 Chapter 3: Methodology and Methods ...... 72 Introduction ...... 72 Reflection on the Nature of Higher Level Research ...... 72 Applied Research ...... 74 A Question of Philosophy ...... 74 Research Paradigms ...... 77 Research Methodology ...... 77 Justification Worldview and Methodology Selected for this Research ...... 78 Research Design ...... 82 Reflecting on the Research Journey ...... 85 The Researcher ...... 87 Population and Sample Selection ...... 90 Inclusion / Exclusion Criteria ...... 91 Ethics ...... 92 Issues of Confidentiality ...... 92 Survey Instrument ...... 94 Data Collection ...... 99 Data Analysis ...... 102 Quantitative Data...... 102

Qualitative Data...... 102 Summary ...... 104 Chapter 4: Participant Profile ...... 105 Overview ...... 105 Survey Sample...... 105 Years of Army Service...... 105 Prior Health Sector Employment...... 106 Prior Military Service...... 107 Current Role...... 108 Chapter 5: Quantitative Results ...... 109 Motivation Factors for Joining the Australian Army...... 109 Member Expectations...... 111 Levels of satisfaction and importance...... 111 Level of satisfaction...... 112 Level of importance...... 117 Career Intentions...... 121 Level of Education...... 122 Continuing Education...... 122 Professional Membership...... 122 Continuing Professional Development...... 122 Military Training...... 123 Clinical Readiness...... 123 Clinical Placement...... 124 Simulation...... 125 Deployment...... 131 Chapter 6: Qualitative Findings ...... 132 Initial Employment Training ...... 134 Ongoing/Advanced Clinical Training ...... 137 Continuing Education ...... 141 Continuing Professional Development...... 143 Relevance of Training ...... 145 Skills Maintenance ...... 148 Sense of Duty ...... 151 Interest in Health ...... 152 xii

Civilian Qualifications ...... 152 Segue to other Health Professions ...... 153 Family History ...... 153 Miscellaneous Themes ...... 154 Expectation Management ...... 155 Career Management ...... 157 Operational Tempo ...... 158 Leadership, Supervision and Mentoring ...... 160 Chapter 7: Discussion and Conclusion ...... 164 Introduction ...... 164 Summary of the Research ...... 165 Review of the Research ...... 165 Limitations of the Research ...... 166 Integration of Quantitative and Qualitative Findings ...... 169 Section 1 – Training, Education and Development ...... 171 Initial Employment Training ...... 173 Continuing/Advanced Clinical Training ...... 189 Review of Medical Technician Training ...... 191 Considerations for future Medical Technicians training ...... 192 Section 2 – Skills Maintenance ...... 194 Medical Technician Scope of Clinical Practice...... 194 Clinical Placements ...... 195 Simulation ...... 197 Clinical Readiness Certification ...... 199 Section 3 – Workforce Retention ...... 202 Recommendations ...... 204 Future Research ...... 206 Conclusion ...... 208 References ...... 211 Appendices ...... 245 Appendix 1: Ethics Approval ...... 246 Appendix 2: Informed Consent ...... 249 Appendix 3: Expression of Interest ...... 250 Appendix 4: Survey Instrument ...... 251 xiii

Appendix 5: Results from first round open coding ...... 262

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List of Figures

Figure 1: Spectrum of Conflict ...... 9 Figure 2: Generation of Capability ...... 11 Figure 3: Relationship of Readiness to Capability ...... 15 Figure 4: Combat Health Operating System ...... 26 Figure 5: Clinical Readiness Standards ...... 36 Figure 6: Literature Review Process ...... 40 Figure 7: Literature Search Results: First and Second Round ...... 45 Figure 8: Kolb's Experiential Learning Cycle ...... 51 Figure 9: Experiential Learning Framework ...... 52 Figure 10: Typical Learning Curve ...... 53 Figure 11: Phases of Psychomotor Skills Acquisition ...... 54 Figure 12: Psychomotor skills acquisition ...... 54 Figure 13: Typical Forgetting Curve ...... 61 Figure 14: Convergent Parallel Mixed Methods ...... 84 Figure 15: Research Timeline ...... 86 Figure 16: Model for codifying qualitative data...... 103 Figure 17: Motivation Factors for Joining the Australian Army ...... 110 Figure 18: Level of Satisfaction of Workplace Issues ...... 115 Figure 19: Level of Importance of Workplace Issues ...... 120 Figure 20: Convergent Parallel Mixed Methods ...... 165 Figure 21: Relationship of Readiness to Capability ...... 166 Figure 22: Medical Technician Professional Mastery ...... 172 Figure 23: Elements of Clinical Professional Mastery ...... 172 Figure 24: Example of Future Medical Technician Training Continuum ...... 190 Figure 25: Suggested Structure of the Medical Technician Certification Program ... 201 Figure 26: Recommended Clinical Readiness Model ...... 201

List of Tables

Table 1: Fundamental Inputs to Capability ...... 13 Table 2: Physical Components of Fighting Power ...... 17 Table 3: Roles of the Army Health Services Corps ...... 24 Table 4: Elements of the Combat Health Operating System ...... 27 Table 5: ADF Medics Course Training Modules ...... 30 Table 6: Medical Technician Clinical and Non-Clinical Tasks ...... 31 Table 7: Tiers of Clinical Readiness ...... 37 Table 8: Search Keywords/Phrases ...... 43 Table 9: Worldview of this Research ...... 81 Table 10: Survey Instrument Description ...... 95 Table 11: Alignment of Survey Questions to People Capability Themes ...... 97 Table 12: Survey Instrument Questions used for Focus Group Discussion ...... 98 Table 13: Survey Instrument Questions used for Focus Group Discussion ...... 101 Table 14: Descriptive Statistics for Year of Enlistment ...... 105 Table 15: Frequency Distribution of Year of Enlistment and Years of Service ...... 106 Table 16: Civilian Health Sector Occupations ...... 106 Table 17: Previous Military Employment Categories ...... 107 Table 18: Length of Previous Military Service Descriptive Statistics ...... 108 Table 19: Motivation Factors Results ...... 110 Table 20: Descriptive Statistics – Motivation Factors ...... 111 Table 21: Level of Satisfaction of Workplace Issues ...... 114 Table 22: Descriptive Statistics – Satisfaction Levels of Workplace Issues ...... 116 Table 23: Level of Importance of Workplace Issues ...... 119 Table 24: Descriptive Statistics – Importance of Workplace Issues ...... 120 Table 25: Frequency Distribution of Medical Technician Career Intentions ...... 121 Table 26: Descriptive Statistics: Career Intentions ...... 121 Table 27: Frequency Distribution of Medical Technician Education Levels ...... 122 Table 28: Frequency Distribution of Military Courses ...... 123 Table 29: Distribution of Medical Technician Readiness ...... 123 Table 30: Frequency of Medical Technician’s Achieving Clinical Readiness ...... 124 xvi

Table 31: Descriptive Statistics: Clinical Placement ...... 124 Table 32: Distribution of Clinical Placement Settings ...... 125 Table 33: Descriptive Statistics: Hours of High Fidelity Simulation ...... 126 Table 34: Distribution of Simulation Models ...... 126 Table 35: Conduct of Simulation ...... 129 Table 36: Descriptive Statistics: Conduct of Simulation ...... 130 Table 37: Distribution of Number of Deployments ...... 131 Table 38: Themes identified from Thematic Analysis ...... 132 Table 39: Response Rates to Qualitative Questions ...... 133 Table 40: Training/Courses Identified by >70% of Respondents ...... 139

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Chapter 1: Introduction

“War isn’t hell. War is war and hell is hell, and of the two, war is a lot worse.” Captain Benjamin Franklin ‘Hawkeye’ Pierce The General’s Practitioner, MASH, 1977

Part 1: Overview

Background

The war in Afghanistan is the longest conflict in Australia’s history, which since 2001 has seen over 35,000 Australian men and women serve with distinction (Parliament of Australia, 2016). While 262 Australians have been wounded in action over the past 17 years, with a further 401 Australian soldiers killed in action (Department of Defence [DoD], 2014a); these casualty numbers represent a survival rate of 87%2, the highest combat survival rate in Australia’s history (Australian Bureau of Statistics, 2012). The care provided to the casualties in Afghanistan today is due to the evolution of military medicine dating back to the dawn of warfare (Gabriel & Metz, 1992a; Salazar, 2000; Rostker, 2013); built on lessons learned, continually tested, proven, and improved upon in battle. While “the clinical characteristics of modern casualties are different from those of the past, with death rates, amputations, disfigurement and disabilities at an all-time low” (Rostker, 2013, p. 1); the basic premise of military medicine remains the same today as it did in ancient Egypt over 4000 years ago; the conservation of life (Beebe & De Bakey, 1952; Gabriel & Metz, 1992a; Salazar, 2000; McCallum, 2008; Wright, 2011; Rostker, 2013).

The fundamental concept, or the nature of military medicine, is the provision of best ‘possible-practice’ medical care along a continuum that commences on the battlefield

1 As at 10 June 2017, 41 Australians have lost their lives while deployed to Afghanistan, 40 of whom have been classified as being Killed in Action (KIA) (DoD, 2014a). 2 According to Goldberg (2014) and Mabry (2014), there is no universally agreed method in calculating combat related survival rates. Therefore, for the purpose of this research, survival rate is calculated as (Total Casualties-Total KIA)/Total Battle Casualties x 100 = Survival Rate, i.e. (303-40)/303*100 = 87%.

1 with the provision of life support at the point of injury (Gabriel & Metz, 1992a; Gabriel & Metz, 1992b Salazar, 2000), with battlefield clearance through the collection of casualties (Gabriel & Metz, 1992; Haller, 1992; Salazar, 2000; Johnston, 2014), and the evacuation of casualties to the next higher level of medical care (Gabriel & Metz, 1992; Gabriel & Metz, 1992b; Salazar, 2000). This basic concept of military medicine has not changed in over 5,000 years (Gabriel & Metz, 1992; Gabriel & Metz, 1992b; Haller, 1992; Salazar, 2000; Johnston, 2014).

On the other hand, the character of military medicine; i.e. the level and type of medical care provided to battle casualties today is different to the medical care provided to casualties in earlier wars (Wright, 2011; Rostker, 2013). Advances in medical interventions, medical technologies and improved evacuation platforms have profoundly changed how wounded, injured and ill soldiers are treated within the area of operations (Salazar, 2000; McCallum, 2008; Rostker, 2013). Therefore, just like war itself (Lindley-French & Boyer, 2012), the character of military medicine has constantly changed through the ages, while its nature has remained the same.

Regardless of the nature or character of military medicine, and despite the advances made in the provision of medical care to the wounded and ill, one element of military medicine has remained constant throughout history, the selfless work of ‘medics’ who are responsible for the provision of such care. Since before Federation, medics have, like in previous conflicts, stood side by side with Australian and Allied combat troops in the thick of battle, providing emergency casualty care; usually under fire, to treat and save the lives of casualties. These soldiers of the Royal Australian Army Medical Corps (RAAMC) have severed, and continue to proudly serve their nation, both in times of peace and during war, providing the highest level of health care to the men and women under their care.

From the battlefields of Sudan in 1885, through to Iraq and Afghanistan today, Australian Army medics have fought, and continue to fight alongside combat personnel, witnessing first-hand the horrors of war. Then, in the aftermath of battle, discharging their duty by collecting, treating, and preparing for evacuating the wounded to the best of their ability, in preparation for the next phase of battle.

Often working independently, Medical Technicians are exposed to injuries and illness rarely seen during peace; even by highly trained medical practitioners in major hospital’s emergency departments (Gabriel & Metz, 1992b; Haller, 1992; Salazar, 2000; Johnston, 2014), and on scales unimaginable, all the while labouring to save these casualties of war, with only the equipment they carried into battle in their pack. The method by which these competency-based trained health professionals are employed supporting other Defence force elements, and the level of responsibility they are given in performing across a spectrum of health care, adds to the complexity of their training and how their skills, knowledge and attitudes are maintained.

Rationale for this research

This research came about following release in 2011 of the Australian Army policy that covered the clinical readiness of all Army Health Services personnel; Army Health Services Personnel Clinical Readiness Standards (DoD, 2016a). Since 2011, there have been four iterations of this policy, which since its initial release has caused much debate as to its efficacy in providing a sound framework in which clinical readiness can be measured. Originally released on 16 September 2011 as Director of Army Health Technical Instruction Number 05, this policy was reissued in 2012 with minor updates. In 2013, the policy underwent a complete rewrite and reissued as Army Health Instruction Number 05, and finally in 2016 as Army Standing Instruction (Personnel), Part 8, Chapter 9, with the current version of this policy issued late 2017.

This clinical readiness framework (all iterations) was developed with what can at best be described as “best guess” opinion, with little to no scientific method or evidence basis. Release of a low-fidelity clinical readiness framework in 2011 3 continued a history of organisational change of the RAAMC and the broader Army Health Services where health policy initiatives are introduced that not only seems ad hoc, but appears to be based on no more evidence than opinion (Butler 1938; Gurner 1970).

In tracing the history of the RAAMC, it becomes obvious that the drivers for change have often been based on the strength of the personality of key decision makers at the time, political or personal agendas, or an exercise in reducing costs in the pursuit of so called ‘reform’; but rarely driven by empirical evidence or “best practice” (Butler 1938; Gurner 1970; Tyquin 2003; McCullagh 2010). Unfortunately, reform based on the opinion; whether expert or not, with little supporting evidence does not usually result in positive outcomes to either the men and women of the Australian Army Health Services or to the Army as a whole (Butler 1938; Gurner 1970; Tyquin 2003).

3 As Staff Officer Grade 1, Health Capability and Plans in Army Headquarters, the researcher was the lead author of this policy in 2011 and the revised version released in 2012.

Hypothesis and Research Question

The purpose of this research is to better understand, and present a model for enhancing and maintaining health workforce readiness by examining the preparedness of the Australian Army’s Medical Technicians.

It is hypothesised that:

the current Australian Army clinical readiness model does not ensure preparedness of Medical Technicians.

Therefore, this research will address the central research question of:

how to develop and maintain a high readiness and adaptive health workforce?

It is important to note that this research will generate a conceptual model that can be utilised to develop and maintain a high readiness health workforce. Being largely conceptual instead of mathematical, the model that is developed will allow for greater utility across craft groups instead of just Medical Technicians.

To answer the central research question, this study will examine the following human capital elements of people capability:

training, education and development,

maintenance of skills, knowledge and attitudes, and

workforce retention.

Scope and limitations of this research

This research was limited to examining the preparedness domain of military capability, focusing on Personnel element of the Fundamental Inputs to Capability. While the initial intent of this research was to examine all Australian Army Health Services clinical craft groups, it was decided early (December 2014) during the scoping phase that study would be limited to RAAMC Medical Technicians; as the largest clinical craft group in the Australian Army. In addition, the Medical Technician’s military scope of practice is unique to Defence, and covers a range of skills found across a number of tertiary qualified clinical craft groups, which presents the greatest challenge for maintaining clinical readiness and currency.

The study did not investigate, or undertake a study into the specific range of tasks Medical Technicians require to be able to provide the range of clinical interventions within their scope of practice. Therefore, a task inventory was not undertaken as part of this research as it was beyond the scope of this study. In should be noted that the Australian Defence Force has undertaken a number of task inventories for Medical Technicians, including the two Occupational Analysis conducted in the 90’s (DoD, 1991; DoD, 1995).

Finally, this study only examined the clinical aspects of Medical Technician’s employment requirements. This study did not investigate the range military skills and competencies Medical Technicians require in order to carry out their duties. The range, depth and type of military tactical skills required by Medical Technicians vary, and change depending on the type of unit they are supporting, as well as the environment they are operating in. There are a broad range of military skills that everyone in the Australian Army is required to be trained in and to maintain, termed All Corps skills, which are delivered throughout an individual’s career. All Corps skills, knowledge and attitudes are delivered during the All Corps Soldier Training Continuum (ACSTC), that commences with a soldier’s recruit training. Similarly, Officers gain their All Corps skills, knowledge and attitudes by attending courses, which are part of the All Corps Officer Training Continuum (ACOTC).

Thesis structure

This thesis is structured to answer the central reform question, by progressively addressing the key elements of human capital by drawing out workforce, and educational and training themes that are then brought together at the end in a series of observation and recommendations. The following is a summary of each chapter:

Chapter 1 provides a brief introduction to the research by presenting the rationale for the research, the central research question and the structure of this thesis. It also situates military medicine, military operations and warfare, Australia’s military strategy and how it generates military capability.

Chapter 2 examines and summarises the current state of knowledge associated with the personnel element of capability by reviewing available literature in the areas of recruitment and retention of military health services personnel, the training, education and development of personnel and the maintenance of clinical skills.

Chapter 3 discusses the research methodology used, including a discussion on the ontological and epistemological foundations that underpins it. It justifies the selection of mixed methods, and outlines the administrative processes followed during the conduct of this research.

Chapter 4 presents the mixed methods findings collected in Section 1 of the survey to build the profile of the Medical Technician sample.

Chapter 5 presents the quantitative findings of this mixed methods research.

Chapter 6 presents the qualitative results of this mixed methods research.

Chapter 7 integrates the quantitative findings and qualitative results, discusses the findings and brings together information from the preceding chapters by drawing on the relevant themes and conclusions to develop a thematic framework for maintaining a high readiness and adaptive health workforce.

Part 2: Situating the Research

Overview

To understand how the Medical Technician contributes to the operational success of the Australian Army, and the broader Australian Defence Force, it is important to discuss the nature of military operations, the characteristics of war and conflict, and how military medicine contributes to military capability. This part briefly discusses the nature of military operations and warfare, Australia’s military strategy and how the Australian Defence Force generates military capability. Finally, it provides an outline of the evolution and development of military medicine, history of the Royal Australian Army Medical Corps and details the employment, training and development of Medical Technician.

Nature of Military Operations

“War is … an act of force to compel our enemy to do our will.”

von Clausewitz, 18304

According to Clausewitz, the purpose of war is to make an adversary comply with ones will (Howard and Paret, 1989); and while the fundamental nature of war remains an unchanging and enduring mix of violent contest between adversaries; its character and form will continue to change and evolve (DoD, 2017a). The unchanging nature of war represents the idea that war is a constant (Lindley-French & Boyer, 2012; DoD, 2017a), in that it is the use of force that resolves disputes between groups and reshapes the situation (Lindley-French & Boyer, 2012; DoD, 2014b; DoD, 2017a). The changing character of war is how it is conducted in an ever-changing world (DoD, 2014b; DoD, 2017a), influenced by society, generational values, emerging technology and other factors that change over time, in what is called the ‘spirit of the age’ (Howard and Paret, 1989; Lindley-French & Boyer, 2012; DoD, 2017a).

4 Howard & Paret, 1984.

In the Australian Defence Force, the term ‘war’ is used interchangeably with the word ‘armed conflict’, which represents a political act with the aim of achieving political objectives (DoD, 2012). Conflict represents a constant struggle to achieve understanding, opportunity, and control; ranging from peaceful interaction between states engaged in cooperation, commercial competition and assistance, through to total war, such as the First and Second World Wars. For ease of understanding, conflict is represented as a continuum of military operations, best illustrated as a spectrum of conflict. This spectrum places levels of engagement and violence on an ascending scale, as shown in Figure 1. This spectrum spans from stable peace to general war, with ascending levels of unstable peace, terrorism, and insurgency through to sectarian violence and civil war (DoD, 2012).

Figure 1: Spectrum of Conflict (adopted from: DoD, 2012)

The continuum of military operations superimposes a spectrum of conflict with operational themes that provide the framework for Australia’s strategic and operational thinking. Throughout the spectrum, the Australian Defence Force must be postured to respond to Government direction to support national security objectives and priorities.

Australia’s Strategic Context

The Australian Government’s overarching strategic defence strategy that guides Australia’s Defence efforts is detailed in the 2016 Defence White Paper (DoD, 2016b) and other strategic policy documents (DoD, 2017b). Australia’s strategic policy is not directed towards meeting any one specific threat, instead aims to address the enduring fundamentals of Australia’s current strategic situation. The Australian Government’s fundamental strategic interest is to prevent an armed attack or threat of attack or coercion against Australia and its national interests.

The Defence White Paper makes it clear that Australia’s defence strategy is founded on the principle of self-reliance and is based on Australia’s Strategic Defence which identifies three strategic interests:

a secure, resilient Australia, with secure northern approaches and sea line of communications

a secure nearer region encompassing the South Pacific, focusing on Papua New Guinea, Timor-Leste and Pacific Island Nations, and maritime South-East Asia

a stable Indo-Pacific region and a rules-based global order (DoD, 2016b).

While armed force of some description remains the greatest threat to Australia, Australia’s sovereignty and national interests are continuously being challenged by other global and regional factors: terrorism, regional state fragility, pandemic disease, cyber warfare, resource depletion and climate change, all of which impact Australia’s interests, both directly and indirectly (DoD, 2016b). The challenge for the Australian Government is how to manage the Australian Defence Force’s limited resources in order to remain capable of responding to these ever-changing and simultaneous threats, both regionally and globally. To implement Government policy, a number of classified documents provide detailed guidance to Defence. These classified documents expand policy direction of the current White Paper, and inform Australian Defence Force posture, force design and operational planning (DoD, 2017b).

The Australian Defence Force

The Australian Defence Force is the arm of government established to defend Australia (DoD, 2016b). The global security situation in 21st century means that the Australian Defence Force will no longer operate in a single environment or theatre of operations. Therefore, the Australian Defence Force must remain agile and adaptive in order to operate across a range of environments in concert with all of its partners (DoD, 2010a; DoD, 2016b; DoD, 2017b). To achieve its agility and adaptiveness, the Australian Defence Force generates its capability through a joint force strategy based on the Royal Australian Navy, the Australian Army and the Royal Australian Air Force (DoD, 2016b). The concept of joint operations is more than operating together in a theatre of operations; it is about maximising the collective warfighting capabilities of each Service (DoD, 2009; DoD, 2010a) and focusing it to achieve mission success.

Generation of Capability

To achieve its mission, the Australian Defence Force must develop and have ready a range of military capabilities that can provide Government viable options to achieve its national security priorities (DoD, 2013a). In Defence, capability is having the power to achieve a particular operational effect, within a specified time that is achieved by having a force element appropriately prepared for a range of potential operations (DoD, 2013a). Capability is the combination of Force Structure and Preparedness (see Figure 2). Therefore, in simple terms, capability is having the right people, equipment and systems (force structure), ready at short notice (preparedness) to undertake a range of tasks to achieve mission success.

Figure 2: Generation of Capability (adopted from: DoD, 2013a)

To ensure consistency in developing, maintaining and measuring capability, the Australian Defence Force developed a list of inputs that are fundamental in generating capability. These Fundamental Inputs to Capability (DoD, 2013a) consists of nine individual, and interconnected elements (see Table 1). As an interlocked and interdependent system of individual elements that generate capability, the performance of the system is dependent on the performance of some or all of the individual elements. This systems approach to developing capability ensures capability managers develop and maintain a holistic way of thinking, with the focus being on the capability system as a connected whole and not as a set of discrete elements. (Gaidow, et al., 2006).

Input Description

Personnel Personnel include recruiting, conducting individual training, and developing and retaining the necessary people with appropriate core skills to meet Defence needs.

Collective Training Collective training applies across combined, joint, single-service and unit levels, which requires elements to undertake a comprehensive and ongoing collective training regime validated against the preparedness requirements for a range of operations.

Organisation Organisation is the appropriate personnel establishment, balance of competencies and structure to accomplish Defence tasks and to ensure appropriate command and control.

Major Systems Major systems include significant platforms, fleets of equipment and operating systems designed to enhance Defence’s ability to engage military power.

Supplies Supplies must be available for units and force elements to conduct the necessary training activities and ongoing administrative tasks required for an operational level of capability.

Facilities Facilities include buildings, structures, property, plant, equipment, training areas, civil engineering works, base support areas and associated through-life maintenance and utilities necessary to support capabilities, both at the home base and at deployed locations.

Support Support includes infrastructure and services that are integral to the maintenance of the Defence effort in Australia and worldwide to support deployed Defence capability.

Command and Command and management includes the command and control Management mechanisms decision-making processes, procedures and management reporting avenues, doctrine, security, processes and procedures to enhance the military effectiveness of Defence.

Industry5 Industry takes into account the capabilities and capacity of Australian industry, and the contribution they can make to Defence.

Table 1: Fundamental Inputs to Capability (DoD, 2013a; DoD, 2016b)

5 The release of the Defence White Paper in 2016, saw the inclusion of Industry as a Fundamental Input Capability (DoD, 2016b).

Preparedness

According to Australian Defence Force doctrine, preparedness is a measure of the state of an organisation to undertake an activity to achieve the required effect, which is informed by strategic guidance from Government (DoD, 2013a). Preparedness is a key element by which the Australian Defence Force is able to achieve its mission, and it is the central concept by which Government articulates Defence’s performance (DoD, 2012; DoD, 2013a). It is through preparedness that the Chief of Defence Force articulates Australian Defence Force performance expectations, which is achieved through the release of the Chief of Defence Force Preparedness Directive (DoD, 2013a). The Chief of Defence Force Preparedness Directive describes military response options and places them in specific warning time bands (DoD, 2013a). This then provides direction and responsibility to the three services Chiefs for their specific output requirements to generate the required military capabilities.

To measure the state of an organisation; i.e. preparedness, Defence has developed the Preparedness Management System that provides an adaptive management framework with linkages between Government strategic guidance, operational planning and Defence outputs (DoD, 2013a). The Preparedness Management System attaches the preparedness of specified forces, especially their proficiency and equipment levels, down to unit level. Preparedness levels are determined with reference to a specific mission, or scenarios and the time at which they might be needed for such tasking. Finally, the preparedness of a force is driven by a sound appreciation of the period for which a force may need to be engaged and therefore sustained (DoD, 2012; DoD, 2013a). The preparedness levels of capability comprise measures of the force development processes, or specific stages reached during force generation cycles of each force element. These levels are benchmarks of capability and are standards that reflect objective or normative measures of preparedness (DoD, 2012).

In the Australian Defence Force, preparedness is the sum of two separate interrelated related elements: readiness and sustainability (DoD, 2013a). Readiness is the ability to commit a capability for operations within a designated time, and sustainability is the ability to maintain the capability on operations for a specific period of time, usually until mission success (DoD, 2013a). This division of the two elements of preparedness is designed to recognise the separate nature of the management processes underlying the achievement of military readiness, and the many factors influencing the length of time for which a military force may sustain operations on a particular mission.

Although readiness and sustainability are separate conditions, they are inseparable in terms of overall preparedness management and must be considered as an integrated planning framework. Readiness is the ability to prepare a capability for operations within a designated time. Therefore, readiness is a key determinant of how capability can be delivered by the Australian Defence Force, with how effectively it is achieved, significantly affecting Defence’s ability to undertake the defence of Australia and other government directions.

According to Australian Defence Force doctrine, “readiness is the physical application of the [Fundamental Inputs to Capability] to meet an operational requirement” (DoD, 2013a, p 1-13), (see Figure 3), though not all elements of the Fundamental Inputs to Capability impact a force’s readiness.

Figure 3: Relationship of Readiness to Capability (adopted from: DoD, 2013a)

The Australian Army

As a key component of Australia’s defence strategy, the Australian Army must be ready to respond at short notice to the range of likely tasks given to it by Government. The mission of the Australian Army is to prepare “…land forces for war in order to defend Australia and its national interests” (DoD, 2017a, p. 5). Therefore, the Australian Army must be capable of responding to the strategic tasks detailed in the Defence White Paper and be prepared to meet a range of other national tasks and responses, across a range of diverse environments (DoD, 2017a). While warfighting remains the Australian Army’s raison d'être, it must be capable and prepared to respond to a range of strategic tasks such as: shaping Australia’s strategic environment, denying and defeating threats to Australia and its interests, and protecting and supporting Australian and foreign civilian populations, which includes humanitarian and disaster assistance, and evacuation of Australian nationals from overseas (DoD, 2016b, DoD, 2017a, DoD, 2017b).

Grouping military tasks with common characteristics under operational themes allows the Australian Army to develop doctrine and plans for each theme, rather than for a multitude of likely tasks (DoD, 2016b, DoD, 2017a, DoD, 2017b). For example, the Australian Army’s contribution to humanitarian and disaster assistance is an example of a legitimate use of military forces, both domestically and internationally (Leahy, 2013), leveraging on the Army’s high level of readiness and its ability to act at short notice. Historically, the Australian Army’s contribution to humanitarian and disaster assistance has taken the form of logistics and engineering support, the provision of health care, the supply of readily available and fit workforce and the supply of relief supplies (Greet, 2008) as was highlighted in:

2016 with Australia’s humanitarian and disaster response assistance to Fiji following Cyclone Winston (DoD, 2017c)

2017 following the ADF’s response following Cyclone Debbie in Queensland (DoD, 2017d).

The Australian Army generates the physical components of capability through a series of functional Land Force Elements (see Table 2). While each Land Force Element has distinct roles and responsibilities, they operate interdependently, synchronising their effects in order to generate warfighting capability (DoD, 2017a).

Force Element Description

Combat Combat elements are those land force elements designed to engage the enemy with direct fire weapons, including armour, infantry, Special Forces and aviation.

Combat Support Combat support elements provide offensive support and operational assistance to combat elements; including offensive support, ground-based air defence, intelligence, surveillance and reconnaissance, electronic warfare elements, combat engineers and battlefield support aviation.

Combat Service Support Combat service support elements support the land force through the provision of sustainment, movement, distribution, health services, personnel services and equipment maintenance activities.

Command Support Command support elements enable commanders to execute their command responsibilities, exercise control and provide specialist advice.

Table 2: Physical Components of Fighting Power (DoD, 2017a)

As previously discussed, preparedness is a measure of the state of an organisation to undertake an activity to achieve the required effect, which is informed by strategic guidance from Government (DoD, 2013a). Maintaining all of the Australian Army’s Land Force Elements prepared to be capable of achieving its mission at the shortest possible notice, would not only be very expensive, but would take a significant toll on personnel and equipment (DoD, 2013a). To manage its preparedness, the Australian Army employs a Force Generation Cycle (DoD, 2017a). The Force Generation Cycle is based on rotating same Land Force Elements through three parallel, but offset phases of Reset, Readying and Ready (DoD, 2017e).

The first phase of the Force Generation Cycle is Reset. In Reset, units have returned from deployment, resetting and repairing/refurbishing equipment, receiving new personnel, and undertaking individual training preparing for the next mission. The second phase of the Force Generation Cycle is Readying. In Readying, units are focused on preparing for deployment and major exercises, focusing on collective training. The last phase of the Force Generation Cycle is Ready. In the Ready phase units are immediately available for deployment within their nominated readiness notice (DoD, 2017a; DoD, 2017e).

The Force Generation Cycle was designed to present significant opportunities to improve and tailor individual and collective training, but to also reduced operational tempo, to allow forces to implement improvements more effectively derived from learning in the readying and ready phases.

The Royal Australian Army Medical Corps

The RAAMC, as a component of Combat Service Support Land Force Element, is one of the key enablers of land power. The establishment and growth of RAAMC provides a rich and colourful sub-narrative in the history of the Australian Army. Created prior to Australian Federation in 1901, when each Colony had its own military medical service, RAAMC was established on 01 July 1902 as the Australian Army Medical Services (Butler, 1938; Gurner, 1970; Tyquin, 2003). Throughout its history, RAAMC personnel have made a major contribution to the defence of Australia, and to the success of Australia’s military operations. From Australia’s first military commitment to the Sudan6 in 1885 where the deployment of a ‘medical element’ is generally recognized as the birth of the Australian Army Medical Corps (Tyquin, 2003); through to the current 14 military operations around the globe (DoD, 2016c), the Army Health Services have, and continue to support the men and women in the Australian Defence Force.

The RAAMC, as well as the broader Australian health system, traces its origins to the 11 medical personnel who landed in Sydney Cove, with the arrival of First Fleet in 1788 (Gurner, 1970; Pearn, 1998). These 11 health personnel; five medical officers from the Colonial Medical Service, and six surgeon’s mates (Pearn, 1998; Cummins, 2003), were the genesis of the RAAMC, that over the past 230 years has undergo significant change and reform to become world class health service, with highly trained health professionals from 137 different clinical craft groups. The evolution of RAAMC has been aligned to the development of the science of military medicine; and intimately linked to the military history of the Australian Army (Butler, 1938; Gurner, 1970; Tyquin, 2003; Cummins, 2003). While the RAAMC grew out of the arrival of the First Fleet in 1788

6 While it is acknowledged that the military commitment to the Sudan in 1885 was from individual States pre-Federation, for the purpose of this paper, all military commitments by Australian forces will be recorded collectively as an Australian commitment and therefore will use Australia and the Australian Army when referring to individual States’ commitments or military forces. 7 RAAMC has the following Officer (LT-MAJGEN) and Other Ranks (PTE – WO1) craft groups: Officer, Environmental Health Officer, Physiotherapist, Scientific Officer, Radiographer, General Service Officer, Medical Technician, Technician Operating Theatre, Underwater Medical Clinician, Combat Paramedic, Physical Training Instructor, Combat Medical Attendant, Preventive Medicine Technician

(Gurner, 1970), the modern concept of military medicine, as practiced by the armies of the United Kingdom, Canada, Australia and New Zealand, can be traced back to 1660 with the formation of the Standing Regular Army (Garrison, 1922; Cantlie, 1974a; Cantlie, 1974b; Royal Army Medical Corps [RAMC], 2015).

The evolution of modern military medicine, and military medical services has been complex, with constant change and improvement since the primitive arrangements for the care of the wounded, injured and ill in the 17th century. From their inception through to today, some 358 years later, the military medical services have developed and changed into an efficient and effective health service. The creation of the standing army saw each regiment allocated a Regimental Surgeon and one or two Surgeon’s Assistants (Garrison, 1922, Cook, 1990; RAMC, 2015). However, the concept of military medicine was not formally organised until 1804 during the Peninsular Wars (Garrison, 1928; Cook, 1990, RAMC, 2015) between Britain against Napoleon’s Army. While Butler (1938) states that the evolution of the Australian Army medical services has been continuous since 1788, Cantlie (1974a) makes it clear that the development of the British medical services has, since 1660 been slow and painful, and often controversial.

Evolution of Military Medicine

“He who desires to practice surgery must go to war.”

Hippocrates, 400 BC8

“The theory and practices of military medicine are not the same as practicing medicine in the military.”

Smith, 1992

In his Treatise on Surgery, Hippocrates wrote, “…he who desires to practice surgery must go to war” (Davis, 1903, p 25), as true today, as it was over 2,400 years ago. Hippocrates must have foreseen the evolution of medicine, and great advances in medical and surgical treatments that would result from lessons learnt from treating casualties on battlefields around the world, and throughout history. The history of medicine runs in parallel with the history of warfare since the dawn of recorded history (Garrison, 1922; Rostker, 2013). While today there is some distinction between military medicine and medicine practiced in civilian society (Smith, 1992), the two were one and the same in the ancient world (Gabriel and Metz, 1992).

When examining human history, it is difficult to find a time when mankind did not devote a large portion of time and resources to fighting and killing one another (Mark, 2009). Throughout this continuous history of aggression, it is evident that for almost as long people have tried to repair some of this human carnage (Garrison, 1922; Salazar, 2000; Gabriel and Metz, 1992). There is no doubt that conflict between men existed before man’s ability to record history, therefore it is just as likely that men also tried to mend damage sustain from such conflict. Prehistoric skulls smashed from some sort of primitive weapon have been found with holes drilled alongside to provide some level of comfort, evidence of early surgery dating back over 15,000 years (Wright, 2011). While recorded history generally highlights the development of military medicine in treating combat related trauma, warfare has made significant contributions to the development of occupational medicine and public health (Garrison, 1922).

8 Hippocrates. & Adams, 1985.

As tribes, and then armies moved forth to attack their neighbouring tribes and cities, the spread of disease began killing more people (in both combatants and in non- combatants) than combat related injuries (Garrison, 1922; Gabriel and Metz, 1992; Wright, 2011; Salazar, 2000).

While not understanding the nature of disease or how it spread, the development of military medicine saw advances in field sanitation, nutrition and potable water (Garrison, 1922; Gabriel and Metz, 1992), all of which in time were embraced by cities and towns in between battles and wars (Salazar, 2000; Gabriel and Metz, 1992). Even with improvements in public health, the death of soldiers from disease would outnumber death from battle wounds, and remained the number one cause of death during war, until the late 20th century (Garrison, 1922; Salazar, 2000; Gabriel and Metz, 1992). Similarly advances in occupational medicine to prevent injury can be seen throughout history, such as Ancient Egyptian surgeons convincing soldiers to wear helmets as a means of reducing head injuries (Wright, 2011). As man discovered and developed better weapons and more efficient ways to kill, so too did medicine improve to better treat the resulting wounds and illness.

While today the distinction between ‘civilian’ medicine and military medicine, seems less obvious, there are still differences between military medicine and practicing medicine in the military (Smith, 1992). A most significant difference between practicing medicine and military medicine is the concept that operational imperatives override clinical imperatives (DoD, 2015a; DoD, 2015b). This results in what can be described as ‘best possible practice’ as opposed to ‘best practice’. The concept of operational imperatives overriding clinical imperatives is based on a simple concept of the ‘greater good’, exemplified by the notion that good medicine usually means bad tactics, while bad tactics can mean that others may die (Butler, 2017).

Since at least 1874, military medicine has been defined to include “…military hygiene and sanitation, military surgery, medico-military administration, medico-military transport, recruiting, sanitary formations and training” (Garrison, 1922, p. 1). Despite the similarities between ‘medicine’ and ‘military medicine’, the International

Committee of Military Medicine (2013) has defined military medicine as the spectrum of medical activities performed during war and peace, including:

all medical and surgical activities from all clinical specialties performed for military personnel

occupational medicine, preventive medicine, hygiene and industrial medicine practiced in a military environment

medical, psychological, physical enlistment assessments

military public health and health surveillance

all aspects of military dentistry

administrative and logistical, including pharmaceutical activities associated with military medicine

research undertaken to support military medicine.

In the Australian Army, military medicine activities as defined by the International Committee of Military Medicine are referred to as health support, which is a key enabler for operational success through the conservation of personnel to maintain operational capability (DoD, 2016d). Military medicine is delivered through four separate Army Health Corps, each with its own individual, but inter-related role (see Table 3), that together comprise, and are collectively referred to as the Army Health Services.

Corps Role

Royal Australian Army Medical Corps To contribute to the Army’s operational capability by promoting health and wellbeing, through the prevention (RAAMC) of disease and injury, and through the care, treatment and evacuation of wounded, injured and ill.

Royal Australian Army Dental Corps To contribute to the Army’s operational capability through the prevention and treatment of dental illness and injury. (RAADC)

Australian Army Psychology Corps To enhance and maintain the personnel component of the Army’s operational and support capabilities by delivering (AAPSYCH) effective and appropriate specialist psychology advice and practice.

Royal Australian Army Nursing Corps To contribute to the Army’s operational capability through the provision of advanced clinical nursing care, education (RAANC) and clinical practice management.

Table 3: Roles of the Army Health Services Corps (DoD, 2016d)

Military health support is a complex system weaving together a range of interdependent and interrelated health functions (DoD, 2016d) designed to deliver optimal health outcomes that include:

the promotion, sustainment, and enhancement of the health and wellbeing

the preparation of personnel to undertake the range of tasks expected of them throughout their military career

provision of deployable operational health care

supporting Army’s wounded, injured and ill members

the provision of occupational health9 support

the provision of advice to commanders on all health-related issues.

To achieve its mission, the Army Health Services must be prepared to provide a range of rapidly deployable and scalable health capabilities, tailored to meet the operational requirements of the overall mission (DoD, 2015a). This is achieved through the provision of health support as a continuum of health care, that commences from when an individual enlists, through to their transition from service, including the provision of health support during all phases of operations and deployments: including pre- deployment health screening and force protection activities, the provision of point of injury care and evacuation during deployments and the provision of post-deployment health support (DoD, 2015a).

The Army Health Services employ a philosophy of centralised command and control, and decentralised execution of the provision of medical support (DoD, 2015a; DoD, 2015b). By commanding medical assets at the highest operational level, it allows the best utility of relatively scarce but highly flexible assets. As a key enabler, this arrangement acknowledges the need for medical elements to integrate their operations closely with supported organisations. It also recognises that health assets can be rapidly reallocated or deployed to meet the changing situation (DoD, 2015a; DoD, 2015b).

The mechanism for delivering the range of health functions throughout the continuum of health care is through the Combat Health Operating System (DoD, 2015a; DoD, 2015b). The Combat Health Operating System (see Figure 4), comprises five inter-

9 As defined by the Joint World Health Organisation and International Labour Organisation Committee on Occupational Health, revised in 1995: “Occupational health should aim at the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities; and the adaptation of work to man and of each man to his job.”

25 related systems, integrated to produce a range of health effects. The Combat Health Operating System provides a continuum of care, that begins from enlistment, includes point of wounding, injury or illness, both in Australia and during deployment, through to return to work, and ultimately through to a member’s transition from service (DoD, 2015a; DoD, 2015b).

Figure 4: Combat Health Operating System (adopted from: DoD, 2015a; DoD, 2015b)

Each of the five Combat Health Operating System sub-systems deliver integrated health effects throughout the health care continuum (DoD, 2015b), with each sub- system comprising a number of health functions that provide a range of health effects that contribute to the health and wellbeing of individuals (see Table 4).

System Description

Force Health The Force Health Protection System is the occupational health element of the Combat Health Protection Operating System. It includes all the services designed to promote, improve, restore and conserve the psychological and physical wellbeing of members to enable a fit and healthy force; through the prevention or injury and illness, and is delivered through the following components:

• Primary Health Care System. The Primary Health Care System includes the provision of all primary health care services focused on health promotion and the early diagnosis and treatment of injury and illness. This is delivered through a range of health services, including: general medical and dental care; including health promotion and fitness advice, mental health care and rehabilitation.

• Occupational and Environmental Health System. The Occupational and Environment Health System is an integrated system of the three sub-systems of Occupational Medicine, Occupational Hygiene and Environmental Health. These three sub-systems are focused on the organisational causes of occupational related injury and illness that members may be exposed to during their service.

Land Based The Land Based Trauma System is the deployable health treatment system that covers the provision Trauma of point of injury emergency health care, the collection and evacuation of casualties, the provision of en-route care to casualties through to the provision of damage control surgery. It also includes the definitive medical and surgical treatment to patients in deployed health facilities.

The focus of the Land Based Trauma System is the provision of timely health care, as far forward as tactically possible to reduce the incidence of casualty morbidity and mortality. It includes all aspects of health care from point of injury/wounding through to the handover of the patient for the strategic evacuation to Australia. As an inherently adaptive system, the Land Based Trauma System is primarily focused on the Combat Health Principles of proximity, mobility and continuity.

Health The role of the Health Materiel System is to ensure that the Army Health Services have ready access Materiel to the range of health material: medical equipment, consumables and medications, required to provide the range of health care effects. The Health Materiel System includes the maintenance and replacement of health materiel to ensure the provision of best practice health care.

Health The Health Knowledge System includes the information and communications technologies and Knowledge systems required to provide an integrated e-health system from point of injury/wounding back to the corporate health records management system in Australia. It includes electronic health records management and telemedicine systems.

Health The Health Training Continuum underpins the Combat Health Operating sub-systems, for it ensure Training that all Army Health Services personnel have the appropriate skill, knowledge and attitudes Continuum required to deliver all aspects of the Combat Health Operating System when and where required. It includes initial individual and collective health training and education, ongoing professional development and continuing collective health training.

Table 4: Elements of the Combat Health Operating System (DoD, 2015a; DoD, 2015b)

As key enablers of land power, the Army Health Services have two separate, but clearly interconnected roles within the Force Generation Cycle; the requirement to provide the range of military medicine capabilities so other elements of the Army can train, while undertaking its own force generation activities, so health personnel are also ready to deploy. This provides a challenge as to how it can concurrently produce the health effect required, and maintain a health service that can provide best possible practice health care from a health workforce that does not work fulltime in clinical environments. This duality of purpose creates a significant challenge for the Army Health Services in achieving a balance between these competing requirements. It also means that the Army Health Services will forever be managing the competing priorities of providing health support so others may train; and in ensuring Army Health Services personnel are provided sufficient time to maintain individual clinical skills, professionally develop and improving the collective small team health synergies.

Medical Technicians

The Medical Technicians employment category is the largest clinical craft group of the Army Health Services. Medical Technicians are highly qualified RAAMC soldiers, whose primary role is the provision of health care from fully equipped medical facilities through to austere and remote environments, both in Australia and overseas (DoD, 2016e). As discussed, for all intents and purposes, the employment category of Medical Technician10 can be traced to the arrival of the six surgeon’s mates in 1788. Over the past 230 years, the Medical Technician has developed in skill and scope in parallel with the evolution of military medicine, from the rudimentary skills of a surgeon’s mate, through to the highly trained and qualified Medical Technician of today’s Army.

Medical Technicians provide health care from point of injury as independent health partitioners, providing en-route patient care in a variety of evacuation platforms, such as ambulances or helicopters, through to mobile or fixed medical facilities as part of multi-disciplinary health care teams (DoD, 2016e). Based on their training and tasks, Medical Technicians work in five broad health domains (DoD, 2016e; Defence, 2017f): professional practice, critical reasoning, clinical practice/patient care, health administration, and team work and leadership.

Army Medical Technicians; together with Navy and Air Force Medical Technicians, are trained to provide prehospital emergency care, advanced life support, primary health care and general inpatient care (DoD, 2016e) at the Army School of Health, on the ADF Medic Course (DoD, 2017f). The ADF Medic Course is a 76-week (376 days) competency-based training course, at the end of which trainees are awarded two Australian Qualification Framework (AQF) 5 level qualifications (DoD, 2016e; DoD,

10 For this research, the employment category nomenclature “Medical Technician” will be to describe all soldiers formally trained in the provision of medical care to wounded, injured and ill soldiers, and whose primary job is the provision of health care. Medical Technician is the current name of a trade that has undergone numerous name changes since 1788 through to 2017. From Surgeon’s Mate, Surgeon’s Assistant, to Medical Orderly and Medical Assistant to Medical Technician.

2017f); Diploma in Nursing (Enrolled/Division 2) and a Diploma in Paramedical Science (Ambulance) (DoD, 2015c; DoD, 2017f).

The ADF Medic course comprises seven modules (see Table 5) (DoD, 2015c), which equip Medical Technicians with the skills, knowledge and attitudes to undertake a range of clinical and non-clinical skills to competently perform their duties as military health care providers (see Table 6) (DoD, 2016d). Unless Medical Technicians undergo specialist training as either an Underwater Medical Clinician, or a Technician Operating Theatre, the 18-month ADF Medic course is the only formal clinical training Medical Technicians undertake throughout their career.

Course Module Days

Module 1 - Introduction to ADF Health 9

Module 2 - Diploma of Nursing (Enrolled/Division 2) 148

Module 3 - Military Medicine 37

Module 4 - Clinical Placement – Nursing 50

Module 5 - Diploma of Paramedical Science (Ambulance) 52

Module 6 - Clinical Placement – Paramedic 20

Module 7 - Provide Combat Health Support 7

Miscellaneous Administration, Assessments, Physical Training Periods 53

Total Training: 376

Table 5: ADF Medics Course Training Modules (DoD, 2015c)

Clinical and Non-Clinical Tasks

Protecting the rights of individuals and groups

Assisting in the provision of outpatient care as part of a health care team

Conduct training

Operating a heat stress monitor

Performing and contributing to health facility administration

Contributing to and coordinating health logistic support

Contributing to patient care as part of a health care team or when working as an independent health care provider

Providing emergency care as part of a team or as an independent health care provider

Contributing to the coordination of patient needs

Assisting with and promoting the health and wellbeing of personnel

Applying and coordinating the application of safe practices within the workplace

Contributing to and assisting with the coordination of the deployment of an operational health support facility

Providing medical support planning to activities

Assisting with and contributing to the professional development of self and others

Effectively communicating

Performing resuscitation bay duties

Providing humanitarian health support

Performing the duties of a Prohibited Substance Tester

Contribute to Care of the Battle Casualty (CBC)

Table 6: Medical Technician Clinical and Non-Clinical Tasks (DoD, 2016e)

In 2011, the SGADF directed that all Australian Defence Force health practitioners, including Medical Technicians, must comply with the Health Practitioner Regulation National Law Act 2009 (DoD, 2011a), and where applicable, comply with the Australian Health Practitioner Regulation Agency (AHPRA) professional requirements, standards, codes and policies. It is for this reason that Medical Technician health training is linked to Australian civilian health standards, which is delivered by under contract by Wodonga Institute of TAFE (DoD, 2015c).

Medical Technicians are registered with the Nursing and Midwifery Board of Australia as Enrolled Nurses through the AHPRA (DoD, 2016d). As registered health professionals, Medical Technician must meet mandated registration standards to practice, including specific minimum recency of practice and continuing professional development requirements (DoD, 2016d; Defence, 2017f). With their dual qualifications, Medical Technicians will be able to apply to AHPRA for registration as paramedics under the National Registration and Accreditation Scheme, which is planned to commence in 2018 (AHPRA, 2017).

Medical Technicians currently work within the framework of two11 scopes of practice:

Royal Australian Army Medical Corps Employment Specification: including Career Management Guidance – Medical Technician (ECN 031)

Nursing and Midwifery Board of Australia Standards for Practice: Enrolled Nurses

In addition to the professional requirements, standards, codes and policies associated with National registration, Medical Technicians must meet clinical practice readiness requirements detailed in the Clinical Readiness Standards for Army Health Services Personnel (DoD, 2016a).

11 Once Paramedics receive National registration in late 2018, Medical Technicians will be required to work within the framework of a third scope of practice framework set by Paramedics Australia.

As protocol guided health providers, Australian Army Medical Technicians work in accordance with a number of treatment protocols, including the Primary Clinical Care Manual published by Queensland Health. The Primary Clinical Care Manual is authorised by the SGADF “…for use by [Medical Technicians] across the Australian Defence Force for practice when deployed in the field, at sea and overseas…” (Queensland Health, 2016, p. xiii). The use of the Primary Clinical Care Manual by Medical Technicians is restricted for use within the framework of the Australian Army – Drug Therapy Protocol – Medical Technician which authorises Medical Technicians to supply, control, carry, issue and administer scheduled medications in accordance with the Health Management Protocols detailed in the Primary Clinical Care Manual (DoD, 2015f).

It should be noted that the requirement to register Australian Defence Force health practitioners is based purely on the direction of the SGADF. In accordance with Section 49 of Defence Regulations 2016, the Australian Defence Force is exempt from complying with any State or Territory law for the provision of treatment and supply of pharmaceuticals to Defence members (Defence Regulations, 2016).

Training, Education and Development in the Australian Army

In examining the readiness of Army Medical Technicians’, it is important to understand how training, education and professional development is undertaken in the Australian Army. The systematic practice of training individuals and teams by armies can be traced back to antiquity (Strauss, 2008; Campbell & Tritle, 2013; Halden & Jackson, 2016). However, while it was common for artisans and craftsmen to train one, or at most two apprentices, organised warfare on a massive scale required the common training of thousands of men in order to produce the synchronised effects required to defeat the enemy (Campbell & Tritle, 2013).

So, began the evolution of military training and education, which throughout history has, and continues to contribute to the discovery and advances in the theories and practices of learning and education. While philosophical debates on the efficacy of one training strategy or system over another have, and will continue to abound, what is known is that military training will continue to reflect the societal norms of each nation.

The focus of the Australian Defence Force training system is to “train individuals and force elements to develop the knowledge, skills and attitudes to enable…successful military operations” (DoD, 2011b, p. 1.1). Training in the Australian Defence Force is a blend of individual and collective training that progress an individual from foundation war fight training, through to collective training to develop cohesive force elements to be able to accomplish their mission (DoD, 2011b: DoD, 2015d).

Individual training imparts the skills, knowledge and attitudes that individuals need to perform their job role, while collective training focuses on the knowledge and skills that teams/units require to collectively perform directed tasks (DoD, 2015d). According to the Australian Army’ Land Warfare Doctrine 7-0 – Training and Education (DoD, 2015d), skills, knowledge and attitudes are defined as:

Skill – the ability to carry out a function

Knowledge – the awareness of, or cognisance with, information

Attitudes – the opinions that influence action. 34

Together, individual and collective training contribute to a single training continuum that contributes to the preparedness of the Australian Army, and its ability to perform a range of operational tasks (DoD, 2011b). In the Australian Army, all officers and soldiers undergo two forms of individual training (Luhrs, 2012, p. 33):

All Corps Training – this is foundation warfighting training that all members of the Australian Army undergo throughout their career. This training includes initial soldier and officer training and training required for career progression and promotion.

Corps Specific Training – is the specialist training officers and soldiers undergo as a prerequisite for their chosen employment category. Initial Corps Specific training is undertaken following an individuals’ initial All Corps training.

The majority of the Australian Army’s ‘in-house’ training is delivered under a vocational education and training framework, underpinned by the concept of competency-based training. The use of competency-based training, within a vocational education and training framework in the Australian Army can be traced to post-Second World War, which saw the establishment of the Army Apprentice scheme in 1948 (Johnstone, 2016).

According to Australian Defence Doctrine Publication 7.0 – Training, vocational education and training is defined as encompassing education and training “… which provides people with occupational or work-related knowledge and skills…’ (2011b, p 10). By embracing competency-based training that complemented the Army’s outcome-oriented nature of training, the Australian Army was able to better align itself with the national vocational education and training system, thereby allowing for national accreditation of its training (Johnstone, 2016).

Clinical Readiness Standards for Army Health Services Personnel

The purpose of the Clinical Readiness Standards for Army Health Services Personnel is to articulate the clinical readiness standards required by Army Health Services personnel in order to “…be prepared to deploy to deliver health support…” (DoD, 2016a, p.1). According to Clinical Readiness Standards for Army Health Services Personnel, clinical readiness is the sum of three inputs: Professional Good Standing, Professional Competence, and Clinical Currency, with the output being Clinical Readiness (see Figure 5).

Figure 5: Clinical Readiness Standards (adopted from: DoD, 2016a)

A shortcoming of the Australian Army’s clinical readiness policy is how it measures clinical readiness. The current clinical readiness model focuses on measuring inputs rather than on measuring clinical outputs. It uses a clinical readiness metric that focuses purely on three inputs with no metric designed to measure the capability output; i.e. delivery of health support (DoD, 2016a). The policy establishes three tiers of clinical readiness purely based on the three inputs (see Table 7).

The Australian Army’s clinical readiness standards is an example of what Harrison (2014) calls, the circular chain of logic, where readiness reporting is used to justify the inputs required, as opposed to measuring actual clinical outputs. The Australian Army’s clinical readiness policy makes the assumption that there is a proportional relationship between inputs and outputs. That is to say, in the current model if you increase inputs you get a proportional increase in outputs. Therefore, since the key variable of this

36 model is the amount of clinical practice as part of Clinical Currency, the underpinning premise of this readiness policy is that undertaking more clinical practice means an individual becomes a more capable military health practitioner, which is simply not supported by any research.

Tier Description

Tier 1 (T1) Clinically current for their assessed primary role and do not routinely require additional training or clinical placement prior to employment or deployment in the assessed role.

Tier 2 (T2) Clinically current to be employed and deployed in a clinical role under supervision. Requires additional training or clinical placements to be assessed as T1, or can be waived for operational imperatives.

Tier 3 (T3) May have the underpinning skills and knowledge but lack the clinical currency to be routinely employed in a clinical role without significant supervision. Requires significant additional training or clinical placements to be assessed as T1, or can be waived for operational imperatives.

Table 7: Tiers of Clinical Readiness (DoD, 2016a)

Summary

This chapter provided a brief overview on the background as to how this research came about and the rationale for its conduct. It situated the research by providing an overview of how Medical Technicians contribute to the operational success of the Australian Army and the broader Australian Defence Force, by describing Australia’s military strategy and how it generates military capability. To get to the current state of Australian military medicine and the effect Medical Technicians provide, this chapter outlined the evolution and development of military medicine and its history.

To prepare Medical Technicians to perform their duties during peace and during conflict, the Australian Army invests significant resources in initial medical training and education. Medical Technicians undergo their initial health training at the Army School of Health12, to prepare them to be competent as health care providers. Once qualified, Medical Technicians work in either garrison health facilities a providing primary health care, or in one of the Army health units training, and preparing for operations. The challenge now, in the 21st century as it was in the past three centuries, is how to maintain clinical readiness across the spectrum of skills required to saves lives during operations, when working in Australia during peacetime.

The Australian Army Health Services face a number of challenges in coping with the competing demands of maintaining clinical competence against the requirement to undertake non-clinical tasks. These competing demands creating an organisational challenge for the Army to ensure its health services personnel are adequately skilled to meet the demands of providing health care to deployed forces at short-notice.

12 For this research, the Army School of Health includes local health training facilities across Australia located in each Military District, the School of Army Health (1948 – 1998) and the current Army School of Health (1998-present).

Chapter 2: Literature Review

Introduction

The previous chapter outlined the scope and rationale for this research, including its central research question. It also provided an overview of military medicine, military operations and warfare, Australia’s military strategy and how it generates military capability. This chapter provides an overview of the available literature identified as relevant in answering the research question, how to develop and maintain a high readiness and adaptive health workforce. This literature review examined the human element of capability, focusing on the training and education, and on skills maintenance of a health worker who does not work in a clinical environment on a full- time basis. Finally, this review examined the literature on the recruiting and retaining of military medical personnel and impact of leadership on a workforces’ readiness.

The aim of this literature review was to identify where, when and how operational preparedness of health services personnel has been measured in military health services in order to identify the rationale, and research question for this study.

Search Methodology

According to Mertens (2015, p. 89), a “literature review… provides the reader with an overall framework for where this [research] fits in the big picture of what is known about [the] topic from previous research.” Since there is no right or wrong method for conducting a literature review (Mertens, 2015; Creswell, 2014), in undertaking mixed methods research, the researcher can use either a qualitative or a quantitative approach in conducting the literature review, as long as if the selected method best supports the study’s aim (Creswell, 2014).

For this research, the literature review was conducted using a qualitative approach where literature is used sparingly in an inductive approach (Creswell, 2014). By its very nature, an inductive approach is more exploratory and open-ended since it begins with broader observations and measures, allowing for the detection of patterns and

39 regularities; thereby allowing for the formulation of a hypothesis that can be explored by the researcher (Trochim, Donnelly and Arora, 2016).

The literature review process included the following key stages: identification of keywords and suitable databases, and searching of the databases; screening of literature, assessment of the suitability of literature for inclusion in the review, and the inclusion of relevant literature, see Figure 6.

Figure 6: Literature Review Process

The review included an initial horizon scan using Google® for potential keywords or phrases that could assist in the review. This proved fruitful during the early stages of the review, with key phrases such as “skills degradation”, “skills maintenance”, “skills decay” and “cognitive readiness”, etc, leading to further investigation, resulting in additional relevant literature being identified. 40

Literature Sources

The review included literature searched through the UNSW Library search engine, using the literature following databases: CINAHL, EBSCO, EMBASE, MEDLINE, ProQuest Central, PubMed, and SCOPUS. These databases were selected following research in order to identify suitable databases that would provide a wide range multidisciplinary literature within the area of military and civilian health workforce management, human capital, training and education and health workforce preparedness.

In addition to peer-reviewed literature, this review included grey literature including policy and doctrine documents, monographs, studies and reports and conference proceedings sourced from the governments and non-government organisations. Grey literature was sourced from the Australian Government; United States Government; United Nations (UN); Government of the United Kingdom; North Atlantic Treaty Organisation (NATO); Government of Canada and Rand Corporation. The selection of grey literature was based on:

the close relationship between the Australian Army and the US, UK, and Canada armies under the auspices of the American, British, Canadian, Australian, and New Zealand Armies Program, which is designed to optimise the cooperation and interoperability of the five-partnered Armies

the Australian Army having adopted and standardised much of its own doctrine to NATO doctrine for the purposes of interoperability

the extensive range of health workforce policy documents from UN, in particular, the World Health Organisation (WHO)

the range of military health specific topics, including military health leadership, and the delivery of health care in a range of monographs, studies and reports from the Rand Corporation.

Keywords and Phrases

The keywords and phrases used for the searching of relevant literature are detailed in Tables 8. The original literature review was conducted in 2014, and was updated in early 2017. A further literature review was undertaken in early 2018, which refined some of the original search words/phrases and included a number of new search words/phrases, resulting in a total of 46 words/phrases being used for this study.

Word/Phrase Boolean Word/Phrase Boolean Word/Phrase Army AND Medic OR Medical Technician Army AND Nurse OR Nursing Army AND Doctor OR Medical Officer Clinical AND Leadership AND Preparedness Clinical AND Leadership AND Readiness Clinical AND Preparedness OR Readiness Clinical AND Human Capital Clinical AND Skills AND Maintenance Clinical AND Skills AND Retention Clinical Competence AND Decay OR Fade Clinical Competence AND Retention Clinical Knowledge AND Maintenance Clinical Knowledge AND Military Clinical Practice AND Military Clinical Preparedness Clinical Readiness Clinical Skills AND Retention OR Maintenance Clinical Workforce AND Adaptive Clinical Workforce AND Skills AND Retention Combat Medic Combat Medical Technician First Aider AND Preparedness OR Readiness First Aider AND Skills OR Training Health Leadership AND Workforce AND Retention Health Leadership AND Workforce AND Satisfaction Health Workforce AND Satisfaction Medic AND Army Medic AND Military Military AND Clinical AND Training Military AND Health Personnel AND Preparedness Military AND Health Personnel AND Readiness Military AND Health Personnel AND Recruitment Military AND Health Personnel AND Retention Military AND Health Personnel AND Satisfaction Military AND Health Personnel AND Training Military Medicine AND Preparedness Military Medicine AND Readiness Military Medicine AND Training Paramedic AND Retention OR Satisfaction Paramedic AND Skill AND Retention Paramedic AND Preparedness OR Readiness Paramedic AND Training Simulation AND Clinical Simulation AND Medical AND Military Simulation AND Military AND Medic Skills AND Decay OR Fade Table 8: Search Keywords/Phrases

Search Results

The search produced over 600,000 records. An initial scan of the results confirmed that the majority of these records had limited relevance to the preparedness of army or military health personnel, or more specifically Medical Technicians/Medics. The records returned were either clinical in nature, or of a general military nature. The results confirm that there is limited relevant literature in the area of military health services readiness; particularly on health workforce preparedness.

The searches were refined by both resource type and topic and with the date range of 1900 through to 2014, and included non-military articles, documents, reports and studies that may have some application to the context of a military health workforce. This non-military literature related to a range of workforce issues common to both a civilian and military workforce, such as: human capital; skills decay; education and training; unlearning; recruitment and retention; vocational training; competency- based training; health development; learning, lifelong learning, on the job training, on the job experience and fatigue. Furthermore, the strong correlation between military medicine and disaster medicine (Brismar, Totten & Persson, 1996, Sariego, 2006 & Weeks, 2007), this review included literature from civilian public health and emergency/disaster medicine fields of research. Search results were further refined by limiting the date range from 1980 to 2018. Following the scanning of relevant paper’s key words and their abstracts, a total of 793 articles, reports, and policy documents were identified as potentially having some value to the research, see Figure 7.

Figure 7: Literature Search Results: First and Second Round

Military Health Workforce Preparedness

The challenge of health workforce preparedness is not unique to the Australian Army. Clinical readiness is a universal challenge faced by the health services personnel of our coalition partner armies, as well as health workers in the civilian sector both here in Australia and abroad. While there is a paucity of literature available on preparedness or readiness of military medical/health workers, the majority of this limited literature comes from the US and UK Armies. From an employment category perspective, the closest equivalent to the Australian Army’s Medical Technician is the US Army Military Occupational Speciality 68W10 (68Whiskey) Combat Medic (D'Aoust, Rossiter and Clochesy, 2016), with the UK Army equivalent being the Combat Medical Technician (DGAMS, 2015).

The U.S. Army’s Combat Medic is the second largest Military Occupational within the US Army, second in total numbers only to the Infantry (Chapman et al., 2014; D'Aoust, Rossiter and Clochesy, 2016). Combat Medics are an integral part of the US Army’s combat mission, serving in manoeuvring or sustainment units, military treatment facilities and clinics. Combat Medics undergo 16 weeks of medical training in emergency care, limited primary care and tactical medicine based on TCCC (Chapman et al., 2012). In the British Army, Combat Medical Technicians undergo 50 weeks of medical training that includes emergency medicine, primary care, en-route care and limited in-patient care (DGAMS, 2015).

While there is literature available (<250 peer reviewed articles) on Combat Medics or Combat Medical Technicians, none of the literature examines the preparedness of these craft groups through the lens of people capability or human capital. However, some papers do examine individual elements of preparedness that may be of some relevance. Of the available literature, the majority focused on specific clinical interventions or, more common, the mental health effects of numerous deployments on this cohort of military health care providers.

Of the papers identified as maybe having some relevance to this research, they examine: initial and continuation training (Bolton, 1994; McCarthy, 2003; Hemman, 2005; Riddle et al., 2006; Fowlkes, Dickinson and Lazarus, 2010; Randall-Carrick, 2012; Parsons, Rawden and Wheatley, 2013; Mahan, 2014; Schauer, Mabry, Varney and Howard, 2015; D'Aoust, Rossiter and Clochesy, 2016); the use of simulation for learning and maintaining specific clinical interventions (Hart et al., 2016; Siu et al., 2016; DeForest et al., 2018; Gendron, Cronin, Monti and Brigg, 2018; Planchon et al., 2018); skills maintenance (Linde, Caridha and Kunkler, 2017); pre-deployment training (Sohn et al., 2007; Chapman et al., 2012; Parsons, Rawden and Wheatley, 2013); and lessons learnt from deployment (Eldred, 2016).

The porosity of relevant military literature required expanding the search to include similar civilian clinical craft groups, such as paramedics and nursing. While there are some similarities between civilian health care workers and Army Medical Technicians, the differences are more apparent than their similarities. As posited by Smith (1992) there is a significant difference in the practice of medicine within the military and the practice of military medicine. The difference between civilian and military clinical health care workers as suggested by Smith (1992) is supported the works of Stanton- Bandiero (1998), Biedermann, Usher, Williams, & Hayes (2001) and Linblad & Sjostrom (2005). According to Stanton-Bandiero (1998); which confirms the work of Stanton, Dittmar, Jezewski and Dickerson (1996), the key differences between clinical practice in the military and in a civilian clinical environment are: greater autonomy and responsibility, the complexity of casualties, extended clinical roles, and need for adaptability. As found by Andersson, et al. (2017), “it is not possible to transfer civilian guidelines to the military environment without the necessary adjustments” (p. 71).

Despite the obvious difference between military and civilian clinical practice, literature that examines skills maintenance and readiness may be of relevance to this research. Finally, the key difference between Army Medical Technicians and civilian health care workers is that Medical Technicians do not work in full time clinical employment, which is the genesis of this study to ensure clinical competence, thereby ensuring Medical Technicians are clinically ready to deploy at short notice.

Human Capital – An Investment is Workforce Learning

The concept of human capital can be traced to Adam Smith in the 18th century, and his seminal works “An Inquiry into the Nature and Causes of the Wealth of Nations” (1904), books 1 to 5. The key premise of Smith’s work is that a nation’s main source of wealth is its labour (Becker, 1993). He found the concept that there is a distinction in wages between skilled labour, men educated and trained to carry out work that requires ‘extraordinary dexterity and skill’, and common labour, i.e. unskilled workers (Smith, 1904).

While Smith may be credited with planting the seeds for the concept of human capital (Becker, 1993), human capital theory did not gain widespread recognition for at least another 190 years. The publication of Theodore Schultz’s, “Investment in Human Capital” in 1961, followed by Gary Becker’s 1964 book “Human Capital: A Theoretical and Empirical Analysis with Special Reference to Education” did human capital gain widespread recognition and became a mainstay in economic literature when discussing issues such as workforce education, training and experience.

According to Schultz (1961), Becker (1993), Mincer (1975), Keeley (2007) and Judge et al. (2010), human capital comes from general and specific education, training and work experience. While the concept and an exact definition of human capital varies within contemporary literature (Almeida and Carnerio, 2009; Kambourov and Manovskii, 2009; Judge et al., 2010), it is generally agreed that human capital includes a return on the investment made on workforce experience, education and training. Therefore, for the purpose of this research, human capital will be described using the Organisation for Economic Cooperation and Development (OECD) definition, of “the knowledge, skills, competencies and attitudes embodied in individuals that facilitate the creation of personal, social and economic well-being.” (Keeley, 2007, p. 29).

While traditionally the literature looks at human capital from an economy position; both from an individual and/or organisational perspective (Almeida and Carnerio, 2009; Kambourov and Manovskii, 2009), in the end human capital represents the capability of the organisation which is resident in its workforce. It incorporates the

48 capacity to act or react; both individually and collectively, to a wide range of situations in order to achieve organisational outcomes (Schultz, 1961; Becker, 1964; Mincer, 1975; Lawler, 2009; Almeida and Carnerio, 2009; Kambourov and Manovskii, 2009; Judge, et al., 2010; Crook, et al., 2011;).

Taking away the organisational profit motive, examining human capital from a military perspective does not dilute the value or importance of a strategic approach to human capital management and development. After all an Army is but its soldiers’ (Halter, 2012), therefore effective human capital management is fundamental for the delivery of military capability (Nagra, 2011; Glasser, 2011; Halter, 2012; Eynde, 2015; Pecht & Tisghler, 2015; Spain, Mohundro & Banks., 2015). The Australian Army, just like organisations the world over, has had its Chief on numerous occasion stand up and proudly proclaim that people are the Army’s greatest asset, and indeed the notion of “…enabling the right people [in] their endeavours…” (Campbell, 2016) to achieve operational success supports this notion.

When discussing human capital, and before discussing how to develop and maintain a high readiness and adaptive workforce, it is important to briefly examine how knowledge is gained, and just as importantly how people unlearn or forget. While there are countless theories surround learning, the learning theories discussed in this research aligned to how the Australian Army imparts skills and knowledge, and also resonated most with me based on my epistemological view of knowledge.

Learning

While the foundations of experiential learning and knowledge can be traced back to Aristotle, Plato, and Socrates (Smith & Knapp, 2011), it is the seminal work of scholars such as William James; John Dewey, Kurt Lewin, Jean Piaget, Jack Mezirow and David Kolb (Kolb, 2014) in the 20th century that give us the experiential learning theories of today. According to Kolb (2014), people learn best through experience or by doing, in what he calls ‘experiential learning’. Unlike behavioural theories of learning that do not fully explain the contribution of the lived experience to the learning process effectively, experiential learning is the process by which knowledge is created through the transformation of experience (Kolb, 2014). Experiential learning describes the holistic integrative perspective on learning that combines experience, perceptions, cognition and behaviour (Kolb, 2014).

In Kolb’s model, trainees have the opportunity to learn through an experience (Concrete Experience); allowing them to reflect on what is working and what is not (Reflective Observation); think about how to improve on what they experienced (Abstract Conceptualisation); then use this knowledge to change or improve what they experienced, thereby creating a new experience (Active Experimentation) see Figure 8 (Kolb, 2014). Since experiential learning cycle is a continuous process with the creation of new experiences, the cycle is, according to T.S. Elliot a continuous recursive spiral of learning (Kolb, 2014).

The underlying premise of Kold’s model is that a number of factors impact learning and therefore must be taken into consideration when looking at how people learn. Similarly, Mezirow (1990) posits that experience is a catalyst to learning, since learning is about making an interpretation of an experience, which results in an individual’s subsequent understanding, appreciation and finally action. The learning theories such Kolb’s and Mezirow’s, align well to the Australian Army concept of learning, where learning occurs when an individual experiences an activity which leads to them acquire new or modifying existing knowledge that leads them to modifying their actions or behaviours (DoD, 2015d).

Figure 8: Kolb's Experiential Learning Cycle (adopted from: Kolb, 2014)

Kolb’s experiential learning cycle highlights and reinforces the relationship between the critical linkages between education, work and personal development (Kolb, 2014), see Figure 9. It provides a solid learning framework which formalises the link between the classroom and the workplace, validating competencies, highlighting the workplace as a learning environment, and developing a habit of lifelong learning in individual (Kolb, 2014). It is for this reason that there is a growing body of literature in the use of experiential learning in medicine, nursing and other health related fields, (Cole, 2000; Braddock, Eckstrom & Haidet, 2004; Wolf & Mehl, 2011; D'Amore, et al., 2011; Taylor & Hamdy, 2013; McCallum, Duffy & McGuinness, 2016).

Figure 9: Experiential Learning Framework (adopted from: Kolb, 2014)

Having examined how people learn, and the benefits of experiential learning, the next phase is to consider how long it takes for people to actually learn new skills, and to improve their overall competence. According to Ritter & Schooler (2001), having learnt how to perform a task, the time for completing that task will become faster and faster with practice. This learning performance can be represented graphically (see Figure 10), where the x-axis is the level of skill (competence), and the y-axis represents experience (time) (Ritter & Schooler, 2001). The learning curve follows what Ritter & Schooler (2001) call the “power law of practice”, which is the relationship between performance and practice. The power law of practice tracks learning whereby performance improves early, then plateaus over time, as Logan (1988) describes, skill acquisition follows a regular function, whereby substantial gains are made early with practice, but diminish with further experience.

Figure 10: Typical Learning Curve (adopted from: Logan, 1988; Ritter & Schooler, 2001)

Finally, since team work is essential in a healthcare setting, especially in a military environment where health care is usually delivered by capability bricks, comprising of a multi-disciplinary clinical team; it is important to look at the concept team based learning. Working as part of a team, reinforces the experiential learning experience of all members, since practitioners able to observe the practice carried out by more experienced team members. Team based experiential learning “improves student performance, team communication skills, leadership skills, problem solving skills, and cognitive conceptual structures and increases student engagement and satisfaction” (Hur, Cho and Kim, 2013 p. 271). Another advantage of Team based experiential learning, is that team members with less ability are able to leverage of higher performing members, thereby enhance overall team mastery (Koles et al., 2010).

In addition to the learning of knowledge, an important aspect of Medical Technician training is the acquisition of psychomotor skills. Psychomotor skills are actions that are neuromuscular in nature and demand certain levels of physical dexterity (Seidel, Perencevich and Kett, 2007). The acquisition of psychomotor skills is best described by Fitts and Posner (1967) three phase theory: cognitive phase – when the skill is learned when the trainee commits a set of facts to memory by rehearsal; associative phase – when performance is becoming skilled through links made between facts; autonomous 53 phase – when the skill has become entirely automatic, when the links become smooth and continuous, and can be performed without much thought regarding the task (see Figure 11).

Figure 11: Phases of Psychomotor Skills Acquisition (adopted from: Fitts & Posner, 1967)

The phases of psychomotor skills acquisition can be graphically represented by overlaying the three phases on top of the learning curve (see Figure 12).

Figure 12: Psychomotor skills acquisition (adopted from: Fitts & Posner, 1967; Logan, 1988; Ritter & Schooler, 2001)

The theoretical models of learning and skills acquisitions, leads to the concept of expertise. Expertise can be characterised, in part, as representing the highest level of technical skill acquisition, which through prolonged experience and practice leads to a gradual improvement in performance (Sadideen and Kneebone, 2012). This level of performance improvement stabilises and plateaus over time meaning most experts reach a stable, average level of performance and maintain this for the rest of their careers (Ericsson, 2006; Sadideen and Kneebone, 2012). Ericsson (2006) describes the progression to expert performance as remaining within the cognitive and associative phases of performance. By remaining in the cognitive and associative phases of performance, experts can draw upon all or part of an existing skill and apply this to a new problem allowing for a more effective solution (Ericsson, 2006; Sadideen and Kneebone, 2012). Since experts have a broader and deeper understanding of a particular domain than the beginner, they can recognise solutions, and know how best to apply these solutions in any given circumstances (Ericsson, 2006).

Maintaining Clinical Readiness

Clinical competence that comes from maintaining clinical currency and recency of practice contribute to the public’s trust in health professionals (AHPRA, 2015). To ensure clinical competence, the Health Practitioner Regulation National Law Act 2009 legislated that each National Board must develop ‘requirements in relation to the nature, extent, period and recency of any previous practice of the profession by applicants for registration in the profession’. To meet this legislative requirement, the Australian Health Ministers Council approved revised recency of practice standards required by the 1413 National Boards covered under National Law (AHPRA, 2015).

The revised recency of practice of 450 hours over three years14 (AHPRA, 2015), was developed based on limited literature available on the subject of skills decay, and the expert opinion of each National Board. The National Boards claim that 450 hours of practice over three years provides an appropriate balance between ensuring that practitioners have undertaken sufficient recent practice to maintain the knowledge and skills to safely practice, though “it is not restricted to the provision of direct clinical care” (AHPRA, 2015).

As mentioned, Medical Technicians must be registered with the Nursing and Midwifery Board of Australia as Enrolled Nurses (DoD, 2016e), and therefore, must comply with the professional requirements, standards, codes and policies (DoD, 2011a). This includes recency of practice requirements and the requirement to undertake continuing professional development. In addition to their legislated registration and professional requirements, Army Health Services personnel must also meet clinical readiness standards as defined by the Director General Army Health Services in Clinical Readiness Standards for Army Health Services Personnel (DoD, 2016a). These clinical readiness standards were developed to ensure Army Health Service personnel are

13 In 2018, Paramedics Australian will be covered under National Law as the 15th National Board. 14 Based on a 38-hour working, i.e. 7.6 hour working day, this averages to ~60 days over the three years.

56 prepared to deploy at short notice to deliver the health effects required across the spectrum of military operations (DoD, 2016a).

Unlike civilian health professionals, the majority of Australian Army health professionals do not work in clinical roles on a daily basis. Health support in the Australian Army is provided along a health care continuum that begins from when a soldier joins the Army, sustained throughout a member’s career, both in Australia and while on deployment, and ends only when a member is transitioned back to civilian life (DoD, 2015a; DoD, 2015e).

The challenge therefore, is how to balance the requirement of providing health care in a garrison health facility, against the requirement to provide combat health, both during training and on deployment. This challenge is further complicated by the constant friction between providing health support so that other Army force elements can train, and the requirement for Army Health Services personnel to undertake clinical practice in order to prevent degradation of clinical skills. Therefore, it is important to maximise training opportunities by focusing on those skills that are critical for the provision of health care and that require regular practice.

As outlined in Chapter 1, the challenge for the Australian Army is how to measure the level of clinical readiness. While the Australian Army’s clinical readiness policy articulates a standard (DoD, 2016a), it does not measure the level of efficacy of the clinical outcome being provided by either the individual health care provider or collectively from a health care team. Despite the fact that Army’s clinical readiness policy details the amount of clinical practice, and what courses and training is required (DoD, 2016a), it fails to detail the actual minimum clinical skill standards required and which must be maintained. To truly measure the clinical readiness of the health services, the Army must first determine the range and level of skills required to provide the spectrum of effects it requires from its workforce (Kaplan and Norton, 2004).

The intent of the Australian Army’s clinical readiness standards is to avoid skills decay, which according to Arthur et al., (1998), Perez, et al. (2013) and Kluge & Frank (2014) increases through prolonged periods of non-use. Unfortunately, there is little to no

57 research that quantifies how much practice a health practitioner needs to maintain their skills and knowledge, nor at what speed skills actually deteriorate after a period of non/under use (Arthur et al., 1998; Perez, et al., 2013; Kluge & Frank, 2014; AHPRA, 2015). Performance decay can occur due to several factors, including lack of training, reduced retention of skills, a lapse in performance, extended breaks in practice, and natural forgetting.

Just like Australian Army Medical Technicians, Mahan (2014) identifies the challenges Army Combat Medical Technicians’ face in their ability to apply their clinical skills while posted to locations in the United Kingdom. He suggests that this ‘friction’ in the Combat Medical Technician’s ability to practice requires a ‘metric’ to measure currency. While Broom (2008) suggested collaboration with local ambulances services, as a way to maintain clinical skills in pre-hospital care, provides education and training from both the Combat Medical Technicians and the local ambulance service, it does not provide primary care practice opportunities. Since the majority of clinical interventions performed by Combat Medical Technicians on operations is primary care (Parsons, Rawden and Wheatley, 2013), a primary care training simulation model is required. To address this, Parsons, Rawden and Wheatley (2013) undertook a training needs analysis to identify the range and type of primary care conditions seen in Afghanistan in order to develop a pre-deployment primary care training package (Parsons, Rawden and Wheatley, 2013). The primary care curriculum established by Parson, et al. was validated by 72 Combat Medical Technicians on operations in Afghanistan, 90% of who reported that they saw patients who presented with conditions covered during their training (Parsons, Rawden and Wheatley, 2013).

While US Army Combat Medics do not provide the range and breadth of primary care as do Combat Medical Technicians, the US military face similar challenges in ensuring their Combat Medics maintain clinical currency (Linde, Caridha and Kunkler, 2017). In 2012, the US Army allocated USD $12 million to research skills decay (Linde, Caridha and Kunkler, 2017). According to Linde, et al. (2017), the focus of this research on skills decay is to determine ‘when and why’ skills decay occurs, and to create tools to predict likely skills decay. Another goal of this research project is to “[determine] optimal and

58 minimal refreshment intervals” and to identify suitable training models to “conduct realistic combat trauma training” (Linde, Caridha and Kunkler, 2017, pp. e42 - e43). While this investigation into skills decay is still ongoing, other research into specific skills maintenance suggest that initial over training, with regular refresher training decreases the incidence of skills decay (Hart et al., 2016; Siu et al., 2016; Linde, Caridha and Kunkler, 2017; DeForest et al., 2018; Gendron, Cronin, Monti and Brigg, 2018; Planchon et al., 2018)

DeForest et al., (2018) undertook a prospective observational study to evaluate the performance of en-route care providers undertaking a range of critical and secondary actions during an immersive, high-fidelity, patient transport simulation scenario focused on the care during an inter-facility transfer. Participants of this study were assessed in order to test their ability to perform critical actions such as “patient handoff communication (initial patient history, current assessment, medications administered, and interventions performed) and life-saving interventions: tourniquet application, [etc]” (DeForest et al., 2018, p. 3). While the study design had some limitations regarding the efficacy of the simulated environment, and the fact that treatment guidelines had been amended during the 12-month study, which required some additional refresher training (DeForest et al., 2018, p. 7), it’s unlikely the results were significantly impacted. The results of this study found only one of the 84 participants completed all critical actions required, with 98% failing to properly perform all actions that could result in a preventable death.

Clinical Skills Decay

Skill decay refers to the loss or attenuation of skills/knowledge in individuals after having receive skills/knowledge training that they may not be required to use, or may not have the opportunity to perform for extended periods of time (Wagner, 1994; Arthur, et al. 1998; Anderson, Finchum, and Douglas, 1999; Wang, 2011; Arthur, et al. 2013; Perez, et al., 2013). While research into skills decay has been undertaken by numerous researchers that identify a set of factors that influence skills retention, and while much of the research does not clearly articulate the rate of decay (McGeoch, 1932; Semb, Ellis and Araujo, 1993; Arthur, et al. 1998; Wang, 2011; Arthur, et al. 2013; Perez, et al., 2013; Kluge & Frank, 2014), no studies were found that refute the hypothesis that skills decay after a period of non-use.

Furthermore, while it’s a commonly held perception that physical skills, such as riding a bicycle, may need very little in the way of refresher training to achieve the same level of performance, the majority of the evidence posit that this is not so for cognitive skills (Semb, Ellis and Araujo, 1993; Wagner, 1994; Arthur, et al. 1998; Anderson, Finchum, and Douglas, 1999; Wang, 2011; Arthur, et al. 2013; Perez, et al., 2013). Moreover, there seems a general lack of literature in the area of skills decay relating to psychomotor skills.

This is supported by findings from the literature review into skills decay, undertaken in 2014 on behalf of the UK General Medical Council. The literature review observed that there is a lack of empirical evidence on the area of clinical skills decay, which found that research into skills decay in health professionals has not been extensively researched (UK General Medical Council, 2014). The UK General Medical Council’s research examined 24015 papers on the subject of skills decay, published over a 15- year period (1999-2014). Following this extensive literature review, the UK General Medical Council concluded that there is limited evidence to determine exactly how non or under use affects a health professionals’ skills (2014). Though a consistent theme in

15 This literature included papers on skills decay in medical practitioners, dentist, nurses, opticians, occupational therapists and physiotherapists.

60 skills decay literature is on the importance of initial skills acquisition, which is identified a vital prerequisite for knowledge and skills retention (Farr, 1987; Arthur et al., 1998).

The issue of skills acquisition and skills decay is particularly salient and problematic in situations where an individual receives initial training on skills and knowledge that they may not be required to use, or have the opportunity to use for extended periods of time. In examining the literature, it was found that skills decay occurs at a rate that is best represented by the power curve shown in Figure 13 (Logan, 1988; Semb, Ellis and Araujo, 1993; Arthur, et al. 1998; Ritter & Schooler 2001; Wang, 2011; Arthur, et al. 2013; Perez, et al., 2013; Kluge & Frank, 2014).

Figure 13: Typical Forgetting Curve (adopted from :Logan, 1988; Semb, Ellis and Araujo, 1993; Arthur, et al. 1998; Ritter & Schooler 2001; Wang, 2011; Arthur, et al. 2013; Perez, et al., 2013; Kluge & Frank, 2014).

In essence, learning is characterised by an initial period of steep learning, which then plateaus, as shown in Figure 10 (Semb, Ellis and Araujo, 1993; Arthur, et al., 1998; Ritter & Schooler 2001; Wang, 2011; Arthur, et al., 2013; Perez, et al., 2013; Kluge & Frank, 2014). Forgetting of skills decay, is the inverse of the learning curve, which is characterised by an initial steep drop in skills/proficiency, and then plateauing, with slower decreases in skills as time goes on (Logan, 1988; Semb, Ellis and Araujo, 1993;

Arthur, et al., 1998; Ritter & Schooler 2001; Wang, 2011; Arthur, et al., 2013; Perez, et al., 2013; Kluge & Frank, 2014). It is important to note, that it was identified that a major gap in the literature exists in the area of refresher training or relearning. Almost all of the literature examined learning from a single, one off event flowed by a period of non-use. No studies were identified that examined a single learning event, followed by regular retraining or learning, and the impact on unlearning or forgetting.

What is obvious from the literature is the factors that lead to skills decay. According to Arthur, et al. (1998), supported by other research (Ritter & Schooler 2001; Wang, 2011; Arthur, et al. 2013; Perez, et al., 2013; Kluge & Frank, 2014), factors that contribute to silks decay include: length of the period of non-use; closed looped vs open looped tasks; degree of over learning, original training method, and individual differences. Over learning was identified by Driskell, Willis, and Copper (1992), Arthur et al., (1993) and Lance, et al., (1998) as a most significant factor that can delay or reduce skill decay. Though in a study with 130 university students, Rohrer, et al. (2004) found that mere process of overlearning alone is an inefficient strategy for learning over long periods of time. Rohrer, et al. (2004) suggest that overlearning sessions must be undertaken over multiple sessions rather than concentrating practice into one session, which increases long-term retention.

Recruitment and Retention of Army Health Services Personnel

Recruitment of suitably qualified and trained health professionals has been a challenge for the Army Health Services since before Federation (Tyquin, 2003). A challenge of the Australian Army is attracting sufficient numbers of quality recruits, capable of undergoing rigorous military and specialist training and ongoing development, while maintaining the workforce to achieve the required level of capability (Thomas & Bell, 2007; DoD, 2016b).

To secure its future workforce needs, the Australian Defence Force has developed its 10-year Strategic Workforce Plan, that details how it will attract, develop and retain its people (DoD, 2016b). An effective workforce strategy involves aligning Army’s current workforce with its future objectives, while taking into account Australia’s ever changing strategic priorities. The Australian Army’s workforce strategy is a key element of its continuous modernisation plan, which is more than restructuring units, changes in technologies or the procurement of new equipment (DoD, 2013b; DoD, 2014b).

This concept of recruiting, training and maintain a force is commonly referred to as Raise, Train and Sustain; and which has been used by armies around the world for over 2,000 years (Dennis & Grey, 2010) as a means to addressing the challenges of maintaining a standing army. The principle of Raise, Train and Sustain allows the Australian Defence Force to generate its workforce by recruiting young Australians, then preparing them for military service by investing in their education and future long- term development.

While the concept of training a workforce from scratch provides a larger pool from which to select potential recruits, it also presents other workforce challenges (Australian National Audit Office [ANAO], 2014). By providing a comprehensive education and training, with extensive experience across a range of specialist and generalist skill sets, retention of qualified and experienced health professionals becomes a major challenge, since these individuals are now highly employable in the competitive Australian workforce market (ANAO, 2014).

One reason for the difficulty in retaining suitably qualified health professionals is that the Australian Army is competing for the same scarce human resource of health professionals as other civilian health workplaces. Since the World Health Organisation (WHO) having identified the current shortage of 7.2 million health workers around the globe; a figure likely to increase to 12.9 million by 2035 (WHO, 2014), the health sector is growing and therefore offering a range of recruitment incentives. The reasons for this shortage include the maldistribution for the workforce, underproductions of health professionals, an aging workforce, etc (WHO, 2014). For military health services, retention becomes a more challenging endeavour, especially for certain clinical craft- groups for a number of reasons, which according to Holmes, et al., (2009) includes:

the inability for the Army to compete with the better resourced civilian healthcare sector with regards to remuneration and conditions of employment

the inability to undertake further specialisation/education while serving in the Army

the competing challenges between general military service and the inability to practice medicine.

Retention of health professionals in the Army Health Services remains a complex challenge (Holmes et al., 2009) and one that directly impacts on preparedness. Even though some of the retention challenges are similar to the challenges facing recruiting health professionals, some are not easily defined. According to Schedlich (2008) the dilemma to remain in the Army changes over an individual’s career. While the reasons to leave are many and varied, a common factor for separation from service was the inability to undertake continuing training and education (Schedlich, 2008).

When a Medical Technician separates from the Army, it is not only costly in purely monetary terms, but potentially threatens an organisation’s whole workforce management system (Mueller and Price, 1989; Hoglin, 2012). There are two major types of turnover; the process of recruiting and retention, each with its organisational effects; involuntary and voluntary turnover (Lee and Mitchell, 1994; Hoglin, 2012). To 64 target the problems associated with excessive turnover, there must be an understanding of each, in order to develop a targeted approach (Kacmar et al., 2006; Hoglin, 2012). The first type of turnover is involuntary turnover, occurring when an employer terminates the working relationship with an employee (i.e., the employee is not leaving voluntarily). The second is voluntary turnover, occurring when an employee chooses to leave an organization.

Despite the complexity of the challenges associated with the retention of health professionals in the Australian Army, the strategies to address this problem do not seem to be working (Clements, 2008). Both Schedlich (2008) and Clements (2008) suggest that the retention strategies employed by the Australian Defence Force may not be comprehensive enough and are often limited to addressing one or a limited number of separation factors, usually remuneration. Due to the complex nature of the factors that influence and impact retention, there is a strong argument that retention strategies need to be multi-focal in approach (Schedlich, 2008), which means that the solution may need to include initiatives that are not only evolutionary but revolutionary.

The challenges faced by the Australian Army in recruiting and especially retaining health services personnel is similar to the United States Army, where shortages in some craft groups have become critical (Gahol, 2005). While Gahol’s research focuses on nurses, it applies equally to all health craft groups, especially Medical Technicians; since the consequence that the shortage of a health workforce may ‘lead to negative [clinical] outcomes’ (Gahol, 2005, p. 70). The bigger challenge in addressing the retention problems faced by the Army Health Services is the lack of organisational understanding. According to House (2007, p. 3), while the civilian health sector has “long-since recognised the need to expand an understanding of, and improve the strategies for retention of nursing staff… there is virtually no published work concerning the retention of military [health care providers].”

As key enablers, retaining Medical Technicians at a healthy level remains a challenge for the Australian Army. In the long run, as the Australian Army adapts to the changing character of war (Smith and Palazzo, 2016), the supply of, and the demand for Medical

Technicians will continue to be problematic; more so, since the Army Health Services have shown time and again since Federation their inability to adapt to meet emerging challenges in supporting the Army (Butler 1938; Gurner 1970; Tyquin 2003; McCullagh 2010).

Leadership

Leadership is a major factor in shaping an organisational culture of clinical readiness, clinical safety and, continuing lifelong learning (West, et al., 2014). While there are numerous publications on the topic of leadership in healthcare, there is a dearth of literature on the role of leaders on maintaining workforce clinical readiness (Kim and Newby-Bennett, 2012; West, et al., 2014; West et al., 2015). Therefore, examining the literature on the role of leadership in developing an adaptive organisational culture will be examined.

To develop the adaptive workforce required to respond in an environment of rapid change, increasing complexity and greater uncertainty, the Australian Army has itself become an adaptive organic organisation (DoD, 2009; Gillespie, 2009). Success in the conduct of contemporary and future operations required the Australian Army to learn and adapt (Gillespie, 2009), and to develop a “culture of adaption across all levels of the Army” (Ryan, 2009, p. 21). The word adaptive implies that an organisation is capable of studying and analysing the operating environment, and taking appropriate actions that adjust itself to the external forces in that environment to attain success (Bennet and Bennet, 2003; Grisogono and Spaans, 2008; DoD, 2009). The Australian Army’s Adaptive Army initiative has been developed on the concept of adaption based on the study of ‘complex adaptive systems’ (DoD, 2009; Ryan, 2009).

The major difference between an adaptive system; be it an individual or an organisation, and a non-adaptive system is learning (Lichtenstein, et al., 2006; Schneider and Somers, 2006; Liang, 2007; DoD, 2009; Hunt, Osborn and Boal, 2009; Uhl-Bien and Marion, 2009; Liang, 2010; Mendes et al., 2016; Rayan, 2016). Though in a complex, or knowledge intensive organisations or environments; like the Army or the complex environments that the Army will find itself operating in, just learning is simply

66 not enough, learning must be continuous, relevant and fast (Liang, 2007; DoD, 2009; Hunt, Osborn and Boal, 2009; Uhl-Bien and Marion, 2009).

However, to be truly adaptive, and to instil adaptiveness in its workforce, organisations must develop an adaptive and learning culture. Since an organisation’s culture is inextricably linked to its leadership, then the organisation’s leaders must adopt the behaviours and attitudes that promote adaptability at every level of the organisation. It is the values, beliefs, and assumptions of the organisation’s leadership that are displayed, and thereby communicated to individuals that encourages adaptiveness throughout the organisation. Therefore, adaptive leadership is critical to the development and maintenance of a ready and adaptive workforce, though simply being adaptable is not enough for effective leaders.

According to Yukl (2013), leadership has a direct impact on organizational performance, and he provides a number of ‘determinants of team performance’ that show how leaders impact team performance, with skills and knowledge being a key determinant of a team’s performance. While Morgenson, Reider and Campion, (2005) (cited in Yukl, 2013, p. 247), posit “group performance will be higher when members have the knowledge and skills necessary to do the work, and they understand what to do, how to do it, and when it must be done”. Critically, leaders play a central role in assessing the currency of team members skills, and in providing “constructive feedback and coaching, and [arranging]…necessary [training]” (Yukl, 2013, p. 247). Adaptive leaders must therefore develop adaptability in their teams by encouraging and rewarding adaptive behaviour. Furthermore, they must also develop adaptive teamwork, where the team’s efforts are synchronised, and everyone in the team works together in a coordinated interdependent fashion. This coordinated interdependence is the orchestrating of a response, through either an existing range of tried and proven actions, or by inventing new and novel responses (Kozlowski, et al., 1999). Therefore, this requires leaders to be both creative and adaptable (Burke, et al., 2006; Uhl-Bien & Marion, 2009).

Since the probable future operating environment that Medical Technicians will find themselves providing tactical healthcare will be non-linear, complex and dynamic

(Kilcullen, 2014; DoD, 2017a), they will require high levels of individual adaptability to deal with situational ambiguity. Ambiguity challenges sound decision-making in unclear circumstances, and since Medical Technicians must sift through personal bias, time constraints, and rushes to conclusions, developing Medical Technicians who are adaptable and capable of critically thinking is curial. While there are many definitions surrounding critical thinking, the literature agrees that it includes the skills for analysing arguments, making inferences using inductive or deductive reasoning, judging and/or evaluating, making decisions and solving complex problems (Halpern, 1998; Bailin et al., 1999; Facione, 2000; Lai, 2011). Importantly, the literature describes improvement in critical thinking as a process which is slow in development, and the average individual struggles to think critically (Halpern, 1998; Lai, 2011).

Leadership also plays a major role in workplace satisfaction and workforce retention, with effective leadership playing a role in increasing organisational effectiveness and efficiency (Schmalenberg & Kramer, 2007; Erkutlu, 2008). In a cross-sectional descriptive study conducted by Schmalenberg & Kramer (2007) identified several key hospital attributes that encourage the retention of staff. Using a sample of 698 staff nurses across eight magnet hospitals16, it was found that the hospitals included in the study had lower workforce turnover rates and promoted healthy working environments, and supported professional nursing (Schmalenberg & Kramer, 2007). Building on their research from 2001, Schmalenberg & Kramer (2007) found eight attributes that common in magnet hospitals: working with clinically competent peers; collegial/collaborative relationships; clinical autonomy; manager support; control over nursing practice; adequate staffing levels; support for education and development; and patient centred culture. According to Schmalenberg & Kramer (2007), to retain staff managers must establish and maintain supportive work environments.

16 Magnet hospitals are hospitals that are able to attract and retain staff without difficulty due to their work environment.

Discussion

Over the past 10 years, RAAMC has undergone the most significant structural and cultural change since the creation of the Australian Army Medical Services in 1902. The pursuit of best practice and compliance with the legislative requirements for the delivery of health care, have created significant challenges for the Australian Army’s health workforce, the majority of which does not work in a clinical environment on a daily basis.

A key challenge for the Australian Army is how to ensure Army Health Services personnel; who do not clinically practice full-time, are capable of providing safe and clinical care when required? There is a constant friction between the requirement to work in non-clinical roles against the need for maintaining clinical competence, continuing development and education.

As capability enablers, Medical Technicians struggle with the competing priorities of providing health support so others may train, while trying to find the opportunities to ensure they have sufficient time to maintain individual professionally mastery, ongoing development and improving the collective small health team synergies. This duality of purpose creates a challenge for the Army in ensuring the efficacy of its initial and ongoing individual training requirements, the effectiveness of collective health training and relevance of continued professional development.

The Australian Army faces further health workforce challenges, specifically in retaining clinicians, deteriorating clinical skills, declining morale in clinical craft groups due to limited clinical and career opportunities. Furthermore, there are growing concerns amongst clinicians that continued service in the Australian Army will adversely impact their future employability as health professionals once they decide to leave the Army.

To address these challenges requires capable health leaders, not only with highly developed command, leadership and management skills, but the technical understanding of how to deliver health outcomes and effects. According to Health Workforce Australia (2012, p. 9) ‘the quality…health leadership directly and indirectly affects the quality of patient care and is an important factor supporting best practice.’ 69

Therefore, to address Medical Technician workforce challenges requires significant changes in how the Army health workforce is structured, trained, developed and employed.

Health workforce reform must be evidence based to ensure that initial and ongoing training, ongoing development and clinical readiness requirements are appropriate for the range of tasks the Army expects the Health Services to deliver in support of Australia’s national security priorities. To support the Adaptive Army, the Army Health Services must themselves become adaptive. To achieve this, the following key research questions must be answered before health services workforce can be reformed:

How to develop and maintain a high readiness and adaptive health workforce?

To answer this question, an examining is required of three supporting areas of human capital: training, education and development, maintenance of skills, knowledge and attitudes, and workforce retention.

This research will address this problem by examining the largest clinical craft group in the Australian Army, Medical Technicians, and developing a model or workforce reform.

Summary

There is a gap in the available literature with no specific reference to the preparedness of Army or Military health services personnel. The preparedness of the Army Health Services is a complex problem, and having a workforce ready and capable of responding across a spectrum of likely tasks is challenging. The shortage of relevant literature examining and measuring the preparedness of military health services is a significant gap in evidence-based literature on human capital aspect of generating health capability.

While available literature discusses individual challenges that affect the health workforce in the health services, there is an obvious gap in the literature that draws the correlation between the health capital and preparedness. There is a research gap in why people join the Army Health Services and when does this motivation to join wane or becomes less relevant over time. There is also an opportunity to examine whether there is a correlation between the military and disaster medicine can be used to attract people to the military health services that do not normally consider a career in the Army Health Services.

A major deficiency in available literature surrounds the area of military clinical readiness. While there are some articles available on education and training of health professionals, there is no literature that quantifies how much clinical practice health professionals; who do not work fulltime in clinical environments, must undertake to remain current, competent and clinically safe? All professional governing bodies nominate minimum practice requirements to maintain professional registration; though these do not equate to clinical mastery or necessarily to best practice standards. Currency, competency and safety are critical elements of ensuring the health workforce is ready and prepared.

It is anticipated that this research will provide a foundation for future research, aimed at improving the preparedness of health services personnel. Similarly, this research can be used to assess and measure the preparedness of health services’ ability to respond to a range of disaster response.

Chapter 3: Methodology and Methods

Introduction

This chapter outlines and explains the methodology selected for this research. It outlines the research design and methods selected for the study, and explains why these methods were considered as appropriate to gather the information needed to address the question posed by the research problem:

How to develop and maintain a high readiness and adaptive health workforce?

The aim of this chapter is to present the justification as to why the use of a mixed methods approach was considered most appropriate to address the research question, by discussing:

the ontological and epistemological foundations that underpin this research

the justification for the chosen methodology

the research processes and procedures used for this research.

Reflection on the Nature of Higher Level Research

Before undertaking this journey of discovery, I thought I understood the concept of research. After all I, like all people undertake some type of research all the time, from researching which car to buy, where to go on holidays, or which suburb is the best location to buy a house. Unfortunately, research is, as Tomossy (2008) suggests a highly contentious and confusing concept to define, let alone fully understand. While the word ‘research’ is used every day by people to describe any number of activities, from “…collecting masses of information, delving into esoteric theories, and producing new products” (Walliman, 2011, p. 6), its definition remains elusive. Although the National Health and Medical Research Council (NHMRC) and Australian Research Council (ARC) define research as “…original investigation undertaken to gain knowledge, understanding and insight.”; it is clearly stated that “…there is no simple, single way to define research...’ (NHMRC, 2007, p. 1).

Notwithstanding the exact wording used to defining research, such as learning, enquiry, education, etc, what is apparent is that research is, as the NHMRC (2007) states, about the gaining of knowledge. Therefore, research can be defined as the process of “systematically collecting and analysing valid and reliable information” (Kayrooz & Trevitt, 2005, p 4) to “gain knowledge and understanding” (NHMRC, 2007). Even though “research is conducted for a variety of reasons” (Mertens, 2015, p. 26), the act of higher level research is different to other learning activities. For unlike other learning activities, knowledge gained through higher level research must be acquired through empirical evidence based on fact that is collected, observed or gathered by the researcher, and not through faith or speculation (Sarantakos, 2013). Or, as Lee (2009) suggests, undertaking higher level research is a challenging and exciting journey of intellectual and personal development, that must stimulate and create knowledge.

Therefore, undertaking higher level research is not a simple or straightforward endeavour. Research must be appropriately designed, conducted in a suitable and ethical manner, and effectively documented to achieve academic rigour. Furthermore, as Crotty (1998) suggests, the researcher must decide what research methodology and methods will be employed during the research. In addition, methodological decisions must be justified (Crotty, 1998) and assumptions need to be clear to explain why particular themes were pursued and certain choices were made, while others were rejected to enable the replication of the research.

Furthermore, empirical research is differentiated from other learning activities, in that the “exact nature of the definition of [higher level] research is influenced by the researcher’s theoretical framework and by the importance the researcher places on distinguishing research from other activities (Mertens, 2015, p. 26). Put simply, it is the reason for and how the researcher seeks, observes and records knowledge gained during their endeavour that distinguishes research from other learning activities. Therefore, before undertaking any research, the researcher must, as Mertens’ (2015) suggests, have a clear understanding of the theoretical framework within which their research will be undertaken, for it is this philosophical framework that will guide their research (Creswell, 1998).

Applied Research

“People demand evidence to change what they are doing, without any good evidence at all for what they are doing at present.”

Captain F.K. Butler Jr. USN (Rtd), 2017b

To address the challenge of how to maintain a high readiness and adaptive health workforce, multiple lines of inquiry across numerous disciplines were required. Therefore, to address this specific workplace problem, this higher-level research was perfectly aligned to the nature of applied research undertaken as a Professional Doctorate.

In Australia, higher level research is undertaken within the Australian Qualification Framework (AQF), which specifies two doctoral level (AQF Level 10) degrees; Research Doctoral (PhD) and Professional Doctoral (DrXX) degrees (AQF, 2013). The purpose of both AQF level 10 degrees is to qualify individuals who apply a substantial body of knowledge to research, investigation and developing new knowledge, in one or more fields of investigation, scholarship or professional practice (AQF, 2013). While research is the defining and qualifying characteristic of both doctorates, the Professional Doctoral degree makes a significant and original contribution to knowledge through applied research in the context of professional practice (AQF, 2013).

A Question of Philosophy

A philosophical framework, worldview or paradigm underpins and affects every aspect of the researcher’s activities, and shapes how the researcher sees and acts in the world (Denzin and Lincoln, 2005). Paradigms are composed of philosophical assumptions that guide and direct the researcher’s thinking and action (Creswell, 1998). Since paradigms describe perceptions, beliefs, assumptions and the nature of reality and truth (Morgan, 2007), they can; either consciously or unconsciously, influence the way in which the research is undertaken, from design, to data collection and through to its conclusion. It was therefore critical that I clearly understood the key aspects of each paradigm to ensure that the approach I selected remained consistent to the nature and aims of the philosophy I adopted, and to ensure that any biases I may have had were understood, 74 exposed, and minimised (Creswell & Plano Clark, 2011). I was very conscious that any failure to clearly define and understand the philosophical framework could have undermined and adversely affected the quality of this study (Easterby-Smith, et al., 2002, p. 27).

Each paradigm has several philosophical assumptions or beliefs that underpin or guide each paradigm’s research activities. While commentators (Guba & Lincoln, 1994; Crotty, 1998; Creswell, 1998; Durant-Law, 2012) agree with the concept of philosophical assumptions, the number of assumptions and what constitutes an assumption varies. Guba & Lincoln (1994) proposed three assumptions: ontological, epistemological and methodological. Crotty (1998) on the other hand proposed four assumptions; epistemological, theoretical perspective, methodology and methods. Durant-Law (2012) proposes the ‘philosophical trinity’ of ontology, epistemology and axiology. Alternatively, Creswell (1998) proposes five philosophical assumptions that guide each paradigm’s line of inquiry; ontological, epistemological, axiological, rhetorical and methodological.

While there is some variation in the exact combination of assumptions for undertaking research, most authors agree with the following as key philosophical assumptions that guide the researcher’s line of inquiry:

Ontological. Ontological assumptions are concerned with what constitutes reality (Creswell, 1998), a study of the nature of being if you like. Therefore, the researcher must take an ontological position based on their own perceptions of how they perceive things really are and how things really work. According to Guba & Lincoln (1994), “if a ‘real’ world is assumed’, ontology ask the questions, “how things really are?” and “how things really work?”. In essence, it is the researcher’s individual belief system that determines what constitutes fact. Since everyone has their own world view of reality, multiple realities exist, constructed by individuals; including the researcher, involved a particular situation (Creswell, 1998). Crotty (1998) on the other hand, does not see ontology as a separate, standalone assumption. According to Crotty (1998) ontological and epistemological assumptions are intertwined and

75 emerge together, therefore Crotty does not include ontology as a separate assumption.

Epistemological. Epistemological assumptions are concerned with the nature and forms of knowledge, and with how knowledge is created, acquired and communicated, in other words with “know-what, know-why and know-how knowledge” (Durant-Law, 2012). Therefore, epistemology is, as explained by Maynard, is “concerned with providing a philosophical grounding for deciding what kinds of knowledge are possible and how we can ensure that they are both adequate and legitimate” (as cited in Crotty, 1998, p. 8). Epistemology also questions, “the nature of the relationship between the would-be knower and what can be known?” (Guba and Lincoln, 1994, p. 108). Therefore, as a belief system, epistemology defines what constitutes fact, which will shape the researcher down either a subjective or an objective path of enquiry (Crotty, 1998). The question of objectivism or subjectivism of enquiry will ultimately lead the research to a particular paradigm, built upon the researcher’s own ontological and epistemological position.

Methodological. Methodological assumptions are concerned with how the researcher conceptualises the research process (Creswell, 1998), based on the researcher’s ontological and epistemological position (Crotty, 1998; Durant- Law, 2012). Crotty (1998) explains that methodology is the strategy, or plan of action that lies behind the choice and use of particular methods; or as Guba and Lincoln (1994, p. 108) explain “it is how the researcher will go about finding out whatever they believe can be known, or should be known.”

Axiological. Axiological assumptions are concerned with the researcher’s own values and biases; whether conscious or unconscious, and ethical issues that may shape the conduct of the research (Creswell, 1998; Durant-Law, 2012). Therefore, it is incumbent on the researcher to acknowledge and openly discusses biases that may be present and that certain issues may in fact effect findings.

Research Paradigms

Having examined and reflected on my philosophical position, I then had to identify the research paradigm that would both shape and guide me in the course of my enquiry. According to Crotty (1998), it is the researcher’s belief system that shapes them down a particular paradigm; a subjective or an objective path of enquiry. Each paradigm has its own inherently different ontological and epistemological views; therefore, each has differing assumptions of reality and knowledge (Guba and Lincoln, 1994; Crotty, 1998), which underpin their particular approach to research. This is then reflected in each paradigm’s differing methodology and methods. In the late 20th Century, philosophical commenters, such as Crotty (1998), Guba and Lincoln (1994), Tashakkori and Teddlie (1998) and others contended that scientific research must be conducted within the framework of key paradigms. While the exact number and nomenclature used varies, the common paradigms include: Positivism, Post-positivism, Critical Theory, Constructivism, Advocacy/Participatory, and Pragmatic.

Research Methodology

Research methodologies are broadly classified as either quantitative, qualitative or mixed methods (Denzin and Lincoln, 2005; Johnson and Onwuegbuzie, 2004; Creswell and Plano Clarke, 2011). The selection of the correct research methodology is critical during the design stage of research. According to Creswell and Plano Clarke (2011), research designs are the processes and procedures used when collecting, analysing and interpreting data during a line of inquiry. Selection of a particular research methodology shapes how the research is planned, conducted, data collection undertaken and how the results will be analysed (Creswell, 2014). Selection of an appropriate research methodology is based on the nature of the research problem.

Justification Worldview and Methodology Selected for this Research

Having developed an understanding of the common paradigms and their philosophical assumptions, I was able to identify the worldview that best aligns with my beliefs, and which would guide my thinking and actions throughout this research. (Creswell, 1998). Of the accepted research paradigms, the one that resonated with me the most (probably due to my military background), was the pragmatic worldview.

Pragmatists argue against the notion that social science research can find the truth about the real world solely by using a single scientific method (Mertens, 2015). Since their underlying philosophical framework focuses on the research problem, the researcher is free to use all research approaches available to understanding the problem (Creswell, 2013). Therefore, pragmatists are not committed to any single philosophy and/or reality. This provides the researcher the freedom to choose the methods, techniques and procedures of research that best meet their needs and purposes (Creswell, 2013). Pragmatists decide whether the methods selected are appropriate for their research, which is determined whether those methods achieve the outcome (Mertens, 2015).

As a pragmatist, I was able to use the most effective methodologies that worked best, while maintaining the highest ethical and methodological standards of undertaking research. Effectiveness counts as the criteria for judging the value of research, rather than checking whether the findings correspond to some preconceived condition of truth in the real world. Furthermore, effectiveness aims at establishing that the results are in accordance to the problem the researcher seeks to solve (Mertens, 2010).

Since pragmatists seek any and many approaches to collect and analyse data instead of sticking to one methodology, it was decided early during the research design phase that neither a quantitative nor qualitative method alone would not have been sufficient to answer the research question. Therefore, the use of a mixed methods approach provided me with a greater understanding of the study and improved results (Denzin and Lincoln 2005).

Having identified that a mixed methods approach was best suited for me to undertake this study, I was able to draw from both quantitative and qualitative assumptions, methods and procedures for conducting this research to provide the best understanding of the problem (Creswell, 2013). So, the strength of one method was used to offset the limitations of the other method, providing a deeper understanding of the research problem than either approach could by itself or in isolation (Cameron & Malina-Azorin 2010; Creswell & Plano, 2011). While some commentators believe in the incompatibility of different research methods (Johnson and Onwuegbuzie, 2004), some take the position that it is unimportant “whether numbers (quantitative) or words (qualitative) [are used in] research…” (Gummesson, 2003, p. 485). This is why Gummesson (2003) suggests that mixed methods debate is a distraction from the “real issue” at hand, the issue of research methodology that supports research validity (p. 486).

In addition, the mixed methods approach provided me with the freedom of action to choose all methods possible for addressing the problem. This made the research process practical, as it attempted to solve the problem by using deductive and inductive thinking.

The quantitative approach was best placed to provide me with a general understanding of demographics of the population, an understanding of the amount of time spent undertaking a variety of tasks. While it allowed me to situate research, it could not clearly quantify the intangibles with meaning. Similarly, the qualitative approach was best placed to provide me with an in-depth understanding of the intangible aspects of the problem by ensuring the data collected was qualified through the collection of data seeking each participant’s position or view to key questions directly related to the research question. Put simply, quantitative provided the mean, while qualitative provided the meaning (Saldana, 2013).

The mixed methods approach selected for this research was triangulation, which according to Denzin (1989; cited in Denzin and Lincoln 2005), provides a greater insight into the subject and a more comprehensive response to the research question through analysis of quantitative data and the review of the qualitative data. In 1978, Norman

Denzin (cited in Tashakkori and Teddlie, 1998) identified four basic types of triangulation: data, investigator, theory and methodological triangulation, which for this study I selected methodological triangulation.

The core strength of methods triangulation is its potential to expose unique differences of meaningful information that may have remained undiscovered with the use of only one approach or data collection technique used for the study (Jick, 1979). Integrating quantitative and qualitative methods enhances my ability to rule out rival explanations of change and improve the validity and reliability of any change-related findings (Morse, 1991). For example, qualitative findings may help explain the success of an intervention when the quantitative data does not provide any corollary information. Many experts believe that a cross-method and within-method triangulation provide far richer findings than reliance on a single method (Jick, 1979).

The use of methods triangulation for this study, allowed me to achieve, what Greene, Caracelli and Graham (1989) argue is the convergence, corroboration, and correspondence of the results. However, since mixed methods research requires extensive data collection, there are at least twice as many opportunities to make mistakes (Greene & Caracelli, 1997). Furthermore, Bryman & Bell (2011) argue that since mixed methods requires significant data collection and data analysis, it can become resource intensive and therefore dilate the research effort due to spreading of limited research resources.

So, as Creswell (1998) argues, what holds true is what works at the time of inquiry, thereby allowing the researcher to focus on the what and how of research based on where the researcher wants to go with it (Creswell & Plano, 2011; Creswell, 2013), instead of the process of research. Similarly, Morgan (2007) emphasizes that the researcher must make a choice about what is important and what is appropriate, based on what works best for answering the research questions. Therefore, as a pragmatist’s I was not obsessed with the pursuit of knowledge, but rather pursued knowledge in the pursuit of desired ends (Morgan, 2007). Table 9 highlights how this study is representative of a pragmatic worldview, by meeting the elements as described by Creswell and Plano Clarke (2011).

Pragmatic World View Application in this Research

Ontology: What is the nature of Reality? The use of both qualitative and quantitative questions to elicit responses that embrace the concept of multiple Singular and multiple realities (e.g. realities by capturing and discussing the different researchers test hypothesise and provide perspectives of each individual participant. multiple perspectives)

Epistemology: What is the relationship The use of various tools to collect data from individual between the researcher and that being participants is based on their subjective views of the researched? research problem by relying on each participant’s response.

Practicality (e.g. researchers collect data by “what works” to address research questions)

Axiology: What is the role of values? Acknowledging the researcher's interpretation of data in conjunction with that of the participants’ personal views, Multiple stances (e.g. researchers include reveals the role of values based on both the biased and both biased and unbiased perspectives) unbiased views of the research.

Methodology: What is the process of The uses both quantitative and qualitative methods to collect research? multiple sources of information; such as questionnaires and focus group discussion embraces the concept of mixed Combining (e.g. researchers collect both methods. quantitative and qualitative data and mix them)

Rhetoric: What is the language of research? The framing of, and the independent and dependant nature of supporting questions and collection tools are designed Formal and informal (e.g. researchers may with the intent of answering the research question in employ both formal and informal styles of different ways that are that deem appropriate and utilising writing) the results in ways that bring about positive outcomes from this research.

Table 9: Worldview of this Research (Creswell and Plano Clark, 2011)

Research Design

Research design can be thought of as the strategic plan that details how the research will be conducted from its inception to its conclusion in a manner that helps achieve the research aims (Mouton, 1996; Sekaran, 2003). Like all plans, research design provides a framework within which the researcher can return to when they have strayed off the path during their research journey. Sekaran (2003) suggests that when developing a research design, the researcher undertakes a series of rational decisions:

identifying the purpose of the study

deciding on the data analysis methods

the type of investigation

deciding data collection methods

deciding on the extent of the researcher’s intervention

deciding on the sampling design

identifying the setting of the study

identifying the unit of analysis.

deciding the measurement and measures.

During the initial planning phase, I scoped the problem and formulated an initial version of the research question. The research question was further refined through the researcher’s engagement of subject matter experts and through examining the literature and existing research, which allowed me to focus on the question:

How to develop and maintain a high readiness and adaptive health workforce?

Furthermore, as I travelled down this road of discovery, I was able to generate ideas that informed the scope of the research and shaped its design, which as an iterative process assisted me in:

formulating and developing the supporting human capital questions

identifying key stakeholders and sample population

deciding to gather data through the use of questionnaires, the conduct of open forum and focus group discussion.

Concurrently, I undertook a literature review, which Burns and Groves (1993) described its purpose as being ‘…the generation of a written report that summarises what is known and not known about a phenomenon’. As previously stated, the objective of this literature review was to identify where, when and how operational preparedness of health services personnel had been measured in military health services personnel to locate the rationale and research questions for this study, by examining the human capital elements required to generate health capability.

Having decided that on a mixed methods approach, I decided upon a convergent parallel mixed method (Creswell, 2014) where both qualitative and quantitative data was collected concurrently, then analysed separately with equal weight. The results of the analysis were then brought together (converged), with the resulting findings integrated into one overall research interpretation (see Figure 14). Qualitative data collected during focus group discussions was integrated into the qualitative data collected through the survey instrument and analysed together. Data collection activities throughout the study, were conducted in accordance with the data collection strategies recommended by Cohen, Manion & Morrison (2011).

Figure 14: Convergent Parallel Mixed Methods (adopted from: Creswell, 2014)

Reflecting on the Research Journey

Reflecting on my research journey that began almost four years ago, the first question that came to mind was; why would a mature person, with a family and in full-time employment decide to undertake doctoral level research? Especially since the urban myth is that less than 20% of all doctorate candidates actually complete their research. My decision to undertake this research can be traced back to 2011 when I authored the first version of the Army policy on the clinical readiness of Army Health Services personnel. The lack of empirical evidence on how much clinical time is needed for clinicians to remain current and safe was surprising. It was not until 2013 as Command Health Officer, I was able to observe the impact this policy had on units’ capability and for no observable or measurable benefit in improved clinical effect. This motivated me to question the rationale of not only the amount of time stated that clinicians must undertake, but whether it was actually possible to quantify clinical readiness by simply measuring inputs.

The decision to undertake this research was not taken lightly, as was my decision to undertake this research on a full-time basis. Over the course of this research, I dedicated between 25 – 35 hours per week to conducting this research after-hours and on weekends. Furthermore, I was fortunate that I was able to take a total of seven weeks of study leave, in addition to using the majority of my annual year each year towards this research project. The time used for planning this study is detailed in Figure 15.

Figure 15: Research Timeline 86

The Researcher

During this study, I approached the study as objectively as possible, having acknowledged that my role during qualitative and quantitative research is different (Creswell, 2014). I also understood that during the conduct of qualitative studies, researcher bias may be introduced (Moustakas, 1994, Gillis & Jackson, 2002; Denzin & Lincoln, 2005, Creswell, 2014). Since the researcher is a data collection instrument during qualitative data collection (Denzin & Lincoln 2005; Creswell, 2014), it is vitally important to clearly identify any personal values, experiences, expectations or assumptions that may influence the interpretation of the data to be collected.

Therefore, I am a 53-year-old first generation Australian born male of Greek heritage, and am currently a commissioned officer in the Australian Army, with over 36 years of service in the RAAMC. At 17 years of age in 1982, I enlisted and was allocated to RAAMC, in which I severed as an Other Rank from 1982 to 1999, undertaking a variety of appointments, originally as a Medical Assistant, then in a range of regimental, advisory and training roles; reaching the rank of Warrant Officer Class Two. In 1999, I was commissioned into the RAAMC as a General Service Officer, and for the past 19 years have held a variety of command and staff appointments in both health and non- health roles. As Trade Manager and Training Development Officer of RAAMC Trades, I was responsible for the Medical Technician trade from 2002 to 2004.

In 2001 I deployed on operations with the United Nations Military Hospital in East Timor, and in 2010 as commander of Defence Supplementation Staff during the Australian humanitarian response to Pakistan. While at Army Headquarters, I authored a number of health policies, including the original Army clinical readiness policy, and introduced the current Medical Technician protocols, the Primary Clinical Care Manual. My academic qualifications include Master of Science, Master of Management and a Master of Logistics Management, in addition to undergraduate qualifications in training, health leadership and management.

My professional memberships include: Fellow of the Royal Society of Public Health, Associate Fellow of the Australasian College of Health Service Management, Member of the Australasian Military Medicine Association, Member of American College of Health Executives, Member of Special Operations Medical Association, and Member of the Australian Tactical Medical Association.

While I approached the research objectively, it is acknowledged that my background and experience may have some influence in the interpretation of the data; though as Gummesson (2003) posits, all research is in fact interpretive. In fact, interpretation occurs throughout all research from start to end (Gummesson, 2003). Therefore, while bias cannot be completely removed (Gillis & Jackson, 2002), measures can be undertaken to reduce it.

As a researcher, I was very conscious of the risk of introducing unconscious bias due to a perceived power relationship between me, as a Lieutenant Colonel, and the study participants, soldiers between the ranks of Private to Warrant Officer. To address this issue, I did not use my rank or military title in any correspondence, and I made use non- Defence email address where possible. In addition, during all interaction with participants, I remained in civilian attire and only used my first name, thereby eliminating, or at least reducing any perceived power relationship between myself and the participants.

However, since the qualitative element of a study’s data collection and analysis depends heavily on the researcher’s interpretation of events based on the researcher’ background (Yin, 2003); the researcher’s background is less likely to distort the data but more likely contribute to its validity. Furthermore, a researcher with sound and extensive knowledge of the organisation or context being researched enhances validity when collecting data (Gray, 2014).

Finally, since I decided to undertake the qualitative aspect of this research in the phenomenological tradition, I was in a better position to explore and describe the lived experience and perceptions of Medical Technicians. My background allowed me to find the meaning and reason for phenomena (Moustakas, 1994) by exploring the meaning

88 of participants lived experiences by analysing their words, instead of trying to learn to better understand the context of the phenomenon (Creswell, 2013).

Therefore, I implemented a number of validity procedures throughout the conduct of the study, including:

Triangulation. Since the qualitative data (from all sources) was converged and integrated with the quantitative data collect concurrently, this triangulation of data only strengthened the research by allowing the study to be examined holistically, which as Jick (1979) and Yin (2003) both agree, enhances the validity and reliability of the results to gain a more complete picture.

Reflection. Through self-reflection, I identified and then disclosed in this thesis my beliefs, values and any biases that may have shaped my research (Creswell & Miller, 2000). By bracketing (Moustakas, 1994; Creswell & Miller, 2000; Creswell, 2013) my personal biases, I was able to effectively set aside bias by focusing on the information collected from participants, ensuring that the participants lived experiences were recorded, and not my interpretation of their experiences (Moustakas, 1994). I also undertook personal reflection at the end of each data collection session and throughout the study to capture my thoughts on the day’s events.

Participant Checking. According to Lincoln & Guba (1985), participant engagement for confirmation of the interpretation of data is considered crucial for establishing the creditability of the study (Creswell & Miller, 2000). To achieve this, I engaged a random selection of 19 participants; who had provided an expression of interest in participating, to review the themes developed based on the coding of data to determine both their relevance and their accuracy.

Population and Sample Selection

As the largest clinical craft group of the Army Health Services, RAAMC Medical Technicians were selected as the target population for this research. Medical Technicians are highly qualified soldiers, whose primary role is the provision of health care to wounded, injured and ill members of the Australian Defence Force. Medical Technicians provide health care from point of injury as independent health partitioners, in the back of Australian Defence Force ambulances, in helicopters or on- board vessels providing casualty evacuation, through to mobile or fixed medical facilities as part of multi-disciplinary health care teams.

Army Medical Technicians are trained to provide pre-hospital emergency care, advanced life support, primary health care and general inpatient care. Their training is provided by the Army School of Health (ASH), which in addition to training Army Medical Technicians, is responsible for training Medical Technician from the Royal Australian Navy and the Royal Australian Air Force on the ADF Medic Course (ADFMC). The ADFMC is an 18-month competency-based training course, at the end of which trainees are awarded two AQF5 level qualifications; Diploma in Nursing (Enrolled/Division 2) and a Diploma in Paramedical Science (Ambulance). Medical Technicians are registered with the Nursing and Midwifery Board of Australia (NMBA) as Enrolled Nurses through the Australian Health Practitioner Regulation Agency (AHPRA). As registered health professionals, Medical Technician must meet mandated registration standards to practice, including specific minimum recency of practice and continuing professional development requirements (AHPRA, 2015).

Inclusion / Exclusion Criteria

It was determined that for this research, the target Medical Technician population should be restricted to Medical Technicians who are not engaged in the provision of direct patient care on a full-time basis, but who can be called upon to provide a range of clinical interventions at short notice17. Therefore, the population sample selected and invited to participate in this research were Medical Technicians posted to the Australian Army’s two Regular Army deployable health units; 1st Close Health Battalion (1 CHB) and 2nd General Health Battalion (2 GHB), tasked with the delivery of health support to deployed Australian Defence Force force-elements within a specified readiness notice (DoD, 2016f; DoD, 2016g). Due to the short-notice requirements, participation in this research was also limited to Medical Technician in the Australian Regular Army or Army Reservists undertaking Continuous Full-Time Service.

In addition to trained Medical Technicians, this research included 18 Army Medical Technician trainees in the final weeks of their training at ASH. This focus group discussion was restricted on questions regarding their motivation for joining the Army as Medical Technician, any prior military service, their current training and their expectations for their pending graduation and posting to medical units as qualified Medical Technicians.

Exclusion criteria for this research included Medical Technicians posted to Special Forces units, ASH, Joint Health Command, non-clinical roles, Army Reserve Medical Technicians or Medical Technicians deployed on operations at the time of data collection.

17 This includes short-notice operational deployments overseas, response to domestic and international disaster response. The requirement to provide short-notice care also includes provision of health care to ADF members undertaking training both in Australia and overseas.

Ethics

Having identified the research question, the sample population and the research methodology, I sought ethical approval through the Australian Defence Human Ethics Committee. The role of the Australian Defence Human Research Ethics Committee is to oversee all human research undertaken in Defence and by Defence members. It is registered with the National Health and Medical Research Council (NHMRC) and constituted in accordance with the National Statement on Ethical Conduct in Human Research. The ethics application for this study was assessed as ‘low risk’ and processed through the Defence People Group Low Risk Panel, in accordance with the National Health and Medical Research Council National Statement (2007), which states low risk research is research in which the only foreseeable risk is one of discomfort (NHMRC, 2007).

Ethics approval was originally provided on 31 August 2015; later updated on 13 October 2016, with ethics approval for this study being valid from 31 August 2015 until 30 January 2018. A copy of the Ethics Approval, Protocol Number: DRP-LREP 060-15, is attached in Appendix 1. A copy of the Informed Consent Form and the Expression of Interest to participate in future research are included in Appendix 2 and 3 respectively. The Information Sheet to participants was included on the cover sheet to the survey instrument (Appendix 4), which participants took with them at the end of each survey.

Issues of Confidentiality

To ensure participants were open, honest and candid in their responses, it was important that all data collected was anonymous. To ensure anonymity, no identifying data were collected during the survey, such as name, age, unit or rank. The only time participants provided their name was when providing informed consent. Once signed these forms were collected before the survey instrument was distributed to ensure no consent forms were mistakenly included with survey forms. All completed survey forms were checked by me at the end of each session to ensure, participants did not include any information that could be used as identifiers. Any such information, such as names, units, etc were redacted during transcription.

Total anonymity is not usually possible with focus group discussion, due to the nature of having several people in the room. To assist with anonymity, participants were briefed again that information collected during the focus group would not be shared with anyone, or used in a way that could identify who made a particular comment. Furthermore, participants were asked not to use individuals’ names during the discussion.

Finally, to ensure confidentiality, I gave an assurance to all participants, that all data associated with this research would only be accessed by myself, including the transcribing, reading, scanning and storage, which is in accordance with my ethics approval. All documents; i.e. signed consent forms, completed survey instruments, expressions of interest, transcribed audio data from focus groups, my research journal and notes were scanned and saved as protected Portable Document Format® (pdf®) documents, electronically signed by me. All pdf® and raw audio files were then saved in a secure folder that is accessible only by me on the Defence Record Management System that uses the Objective Corporation’s, Enterprise Content Management system, Objective ECM®. All records and data will be retained on file for a minimum of five years from the date of collection. The handling of all data collected during this study is in accordance with Section 2 – Management of Research Data and Primary Materials of the joint NHMRC and ARC Australian Code for Responsible Conduct of Research (NHMRC, 2007).

Survey Instrument

Following from the analysis of human capital research collected from the literature review, a 42-question mixed methods survey instrument was developed (see Appendix 4). This questionnaire was designed to elicit responses to the following topics:

workforce profile

level of individual clinical readiness

reasons for joining the Army, level of workplace satisfaction, intention and motivation for continued service or separation

opinions on training, education and professional development

deployment history

opinion on the Army Health Services.

The mixed methods survey tool comprised of 27 Quantitative and 26 Qualitative questions18 grouped into seven sections. Table 10 details the purpose of each section and the data category for each question. To increase participants’ motivation to take part in the survey, and to increase both the level and quality of responses, the instrument was purposefully designed and formatted based strategies detailed by Cohen, Manion & Morrison (2011).

18 While the questionnaire included 42, 11 questions included both qualitative and quantitative questions, thus the questionnaires 53 questions.

Quantitative Qualitative Instrument Section Questions Questions

1 – Workforce Profile. This section was designed to build a Q_1, Q_2, Q_3, Q_4, Q_3_A, Q_4_A, workforce profile by collecting data such as type and length Q_5, Q_6, Q_7 Q_5_A of service, employment prior to joining the Army, details of prior military service and primary role.

2 – Recruiting and Retention. This section was designed to Q_8, Q_10, Q_11, Q_9, Q_10_A, capture the reasons why people joined the Army as Medical Q_12 Q_13, Q_14, Q_15 Technicians, their level of workplace satisfaction and the reasons for leaving the Army and their motivation for staying.

3 – Education, Training and Professional Development. Q_16, Q_18, Q_19, Q_17, Q_18_A, This section captures data on health training, education and Q_20 Q_18_B, Q_19_A, professional development. Q_21, Q_22

4 – Military Training and Education. This section looked at Q_23, Q_24 Q_24_A, Q_25 the military training undertaken by Medical Technicians.

5 – Skills Maintenance and Clinical Readiness. This section Q_26, Q_27, Q_30, Q_28, Q_29, Q_32, examined the level of individual clinical readiness and the Q_31, Q_33, Q_34 Q_35 type and range of skills maintenance activities undertaken by Medical Technicians.

6 – Deployment. This section looked at the type and Q_36, Q_37, Q_38, Q_37_A, Q_38_A, number of deployments undertaken my Medical Q_39 Q_39_A, Q_40 Technicians and whether their training prepared them for their deployment.

7 – Final Say. This section provided Medical Technicians the Q_41, Q_42 opportunity to raise any issues they felt impacted, either positively or negatively their trade, their employment of the Army Health Services as a whole.

Table 10: Survey Instrument Description

To ensure the survey instrument was sound; in that the questions were unambiguous, not leading or biased, the questionnaire was piloted in mid-2015. The purpose of questionnaire piloting is, as Cohen, Manion & Morrison (2011) state, “to increase reliability, validity and practicability”. Piloting of the questionnaire was undertaken by seven Army Health Services personnel from five craft-groups. Feedback from the pilot study was of constructive and valuable in allowing me to re-visit formatting of the questionnaire to improve sequencing of a few questions, and the re-wording of two questions to better clarify their purpose.

The original data collection concept for this study was through an online survey sent to each Medical Technician, followed up with focus group discussion in each data collection location. Following an analysis of the challenges associated with administering an online survey over the Defence restricted network, I decided that a facilitated19 self-administered paper based instrument would be more effective. The questionnaire was finally printed in booklet form by the Defence Publishing Service, Canberra and readied for distribution. Data collection took place over the period 28 September to 26 November 2015.

The decision for a facilitated self-administered questionnaire was based on a number of facts, such as:

It made it easier to explain the reason behind the research, allowing me to detail the benefits I hoped this research would result for them. Therefore, since I was able to convey a perceived benefit from participating, respondents were more likely to provide, what I hoped would be more detailed and richer answers. This was based on the concept of Social Exchange Theory, where the costs of participating are outweighed by the perceived value gained from answering the questionnaire (Dillman, et al., 2014).

19 A facilitated self-administered paper based instrument is what Cohen, Manion and Morrison (2011) call a self-administered questionnaire in the presence of the researcher.

It allowed me to answer questions participant had regarding a question or to clarify and points of confusion.

I was able to collect all questionnaires at the end of each session.

By travelling to each location to administer the survey, I was also able to seek expressions of interest for participation in focus group discussions, which were conducted in the afternoon in each location following completing of the questionnaire.

Each section was structured to address one or more of the three key areas of human capital element of capability to answer the central research question ‘how to develop and maintain a high readiness and adaptive health workforce?’ (see table 11).

Instrument Section Questions

Workforce retention Q_8, Q_9, Q_10, Q_11, Q_12, Q_13, Q_14, Q_15, Q_41, Q_42

Training, education and development Q_16, Q_17, Q_18, Q_19, Q_20, Q_21, Q_22, Q_23, Q_24, Q_25, Q_37, Q_40, Q_41, Q_42, FG_Q_7, FG_Q_8, FG_Q_9, FG_Q_10, FG_Q_11, FG_Q_12, FG_Q_13

Maintenance of skills, knowledge and attitudes Q_26, Q_27, Q_28, Q_29, Q_30, Q_31, Q_32, Q_33, Q_34, Q_35, Q_38, Q_40, Q_41, Q_42, FG_Q_7, FG_Q_8, FG_Q_9, FG_Q_10, FG_Q_11, FG_Q_12, FG_Q_13

Table 11: Alignment of Survey Questions to People Capability Themes

Focus groups discussed the 13 questions detailed below, Table 12. Six of these questions come from the survey instrument, and seven additional questions with ethics approval specifically for these focus groups.

Focus Group Questions

FG_Q_1. In your opinion, have the military courses you have attended over your career prepared you to perform your duties? (Q_24)

FG_Q_2. In your opinion, how can the training continuum for Army Health Services personnel be improved? (Q_25)

FG_Q_3. In your opinion, how can we change or improve Army Health Instruction 05 Clinical Readiness of Army Health Services Personnel? (Q_29)

FG_Q_4. In your opinion, what are the critical skills you require to carry out your mission as a health professional on deployment? (Q_40)

FG_Q_5. What do you see as the biggest challenges for your Employment Category and RAAMC in general? (Q_41)

FG_Q_6. How do you see these challenges being addressed? (Q_42)

FG_Q_7. Is the current Medical Technicians employment model sound and/or relevant?

FG_Q_8. Is the current Medical Technician training model too long and still relevant?

FG_Q_9. What clinical, general health and military training is Medical Technician require at the ranks of PTE, CPL, SGT and WO2?

FG_Q_10. What type, amount and frequency of continuing professional development is required for Medical Technicians?

FG_Q_11. Is registration required for Army Medical Technicians?

FG_Q_12. How to improve, practice and maintain clinical team dynamics?

FG_Q_13. Is an annual certification assessment/test required to assure and maintain the proficiency to practice?

Table 12: Survey Instrument Questions used for Focus Group Discussion

Data Collection

Following ethics approval, I approached the Commanding Officers of 1st Close Health Battalion and 2nd General Health Battalion through their Brigade Commander seeking their support with my study. Both were supportive and through their chain of command arranged for data collection for this study.

Due to Defence IT restrictions, I decided to use a paper based mixed-methods instrument to collect data. Instead of mailing out the survey to all Medical Technicians, I decided it was important that participants had the opportunity to meet me and to discuss any issues or concerns they had about the research. I also believed that by administering the survey in person allowed me to ensure no unauthorised access to the data collected and to ensure all present were in fact volunteers. The decision to administer the survey in person resulted in me traveling to Sydney, Brisbane, Darwin Townsville and Wodonga to conduct the face to face surveys and to conduct the focus group discussions. The process of each session was the same at each location:

all available Medical Technicians were asked by their chain of command whether they were willing to participate in a survey about their trade

Medical Technicians who volunteered were then assembled and addressed by me to:

confirm all present were volunteers

provide an overview and the purpose of the research

seek participant informed consent

outline how the survey was to be administered

seek volunteers for the focus groups through Expressions of Interest.

At the end of each survey session, participants were given the opportunity to provide any additional comments for any of the survey questions in an open forum. These open forms lasted around 60 minutes and were recorded by the researcher. These forums provided a rich narrative by providing additional information to the data collected during the survey.

I then randomly selected focus group participants from the Medical Technicians who had provided an Expression of Interest to participate further in this study. It was fortunate that all 179 participants were keen to participate in future research. A total of eight focus groups were conducted with a total of 66 participants from across all rank levels. To ensure open discussion during these sessions, focus groups were rank based, with three sessions for PTE and LCPL/CPL and two sessions for SGT/WO2. Focus group discussions lasted between 90 – 150 minutes which was driven by the participant’s level of engagement and the availability of time.

Transcribing data captured during both the open forum group discussion and the eight focus groups, was a much more challenging and time-consuming process. All discussions were recorded in .wav file format using a Zoom H2n® Handy Recorder connected to my laptop. Audio files were transcribed as soon as possible at the end of each data collection session, while the discussions were fresh in my mind.

In addition to the survey instrument, qualitative data was collected during the conduct of eight focus groups with 66 respondents randomly selected at the end of each survey session. These focus groups discussed in further detail six questions from the survey instrument, see Table 13.

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Focus Group Questions

Q 24 – In your opinion, have the military courses you have attended over your career prepared you to perform your duties?

Q 25 – In your opinion, how can the training continuum for Army Health Services personnel be improved?

Q 29 – In your opinion, how can we change or improve Army Health Instruction 05 Clinical Readiness of Army Health Services Personnel?

Q 40 – In your opinion, what are the critical skills you require to carry out your mission as a health professional on deployment?

Q 41 – What do you see as the biggest challenges for your Employment Category and RAAMC in general?

Q 42 – How do you see these challenges being addressed?

Table 13: Survey Instrument Questions used for Focus Group Discussion

To ensure equitable participation during focus group discussion, participants were divided by rank, PTE (n=20), LCPL/CPL (n=34) and SGT/WO2 (n=12). Each focus group discussion varied from 120 – 140 minutes, and focused on only expanding on information collected from the following the survey instrument questions:

To reinforce to participants of their confidentiality, no typical demographical information: i.e. age, date of birth, gender, race, etc, was collected. During instrument development, it was decided that such demographical information would not value add or contribute to this specific research. Excluding such data also reinforced to participants that it would be extremely difficult to identify them form their responses. This decision ensured participants were open and honest in their responses.

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Data Analysis

Following completion of data collection activities, qualitative and quantitative data were separated for analysis; managed in a manner best suited to convergent parallel mixed method design. For the quantitative data collected, I decided that descriptive statistical analysis was most suitable for this study, while thematic analysis was considered most suitable for analysing the qualitative data.

All data collected from the mixed methods survey were prepared for preliminary analysis, which involved reviewing each completed questionnaire and checking for completeness. Data captured during both the open forum group discussion and the eight focus groups, was a much more challenging and time-consuming process. All audio files were transcribed verbatim to Microsoft Word® for Mac as soon as possible at the end of each data collection session, while the discussions were fresh in my mind.

Following data collection, both quantitative and qualitative data were transcribed to Microsoft Excel® for Mac, separating quantitative and qualitative data into individual spreadsheets. Once all data was transcribed, data were checked for accuracy by reviewing questionnaires and audio transcripts against data entered on the spreadsheets. Analysis and interpretation of data collected in this study generally followed the processes outlined by Creswell & Plano-Clark (2011), Cohen, Manion & Morrison (2011) and Saldana (2013).

Quantitative Data. Three different types of quantitative data measurements were collected by the questionnaire: nominal (e.g. type of service) interval (e.g. year of enlistment) and ordinal (e.g. level of satisfaction). Having transcribed the data from the instrument to Microsoft Excel® for Mac, the spreadsheet was imported in IBM SPSS Statistics® Ver 24 to enable analysis.

Qualitative Data. According to Elo & Kyngas (2008), there is no single right way of undertaking qualitative content analysis, so they advise that the researcher must select the variation of the method that is most suitable for their study. Since, as previously mentioned, the researcher is a data collection instrument (Denzin & Lincoln 2003; Creswell, 2014), data analysis is dependent on the researcher’s ability to analyse,

102 interpret and connect data so that a theory can be developed. I therefore decided that thematic analysis was the best methods to explore the data’s concealed and latent content by identifying and analysing patterns of meaning (Braun & Clarke, 2006). Transcribed data were imported into QSR International NVivo® for Mac.

Analysis and interpretation of data collected in this study followed the general processes outlined by Creswell (2013) and Creswell & Plano-Clark (2011), however, my data analysis approaches and procedures were heavily influenced by Cohen, Manion & Morrison (2011) and especially Saldana (2013) see Figure 16.

The qualitative data was analysed in accordance with the theoretical coding procedure (i.e., using techniques such as open coding, axial coding, and selective coding), and this provided proper explanations about how the theory was built. The data analysis procedures began once the interview data was converted from audiotapes to transcribed text. Data reduction began with reading and re-reading the transcribed data. The themes began to emerge with the initial reading of each transcript. Next, an open coding procedure was utilized for the identification of emergent themes. With respect to open-ended questions, a thematic analysis was used, with all responses initially scanned to identify key themes and any commonality between them.

Figure 16: Model for codifying qualitative data (adopted from: Saldana, 2013)

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Summary

In this chapter I began by reflecting on my journey of discovery and what led me to undertake this mixed methods research. I disused and justified why I considered a mixed method approach as the most appropriate research approach to gather the information needed to address the question posed by the research problem. Finally, this chapter details how I undertook the study, outlined the research design and methods selected.

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Chapter 4: Participant Profile

Overview

This chapter presents the mixed methods findings collected in Section 1 of the survey, to build the profile of the Medical Technician sample. This section of the survey contained seven questions with four of the questions requiring an addition open ended response.

Survey Sample. A total of 179 (n=179) ARA Medical Technicians, from across five ranks levels20, participated in the survey, representing 67% of the target Medical Technician population (N=267).

Years of Army Service. Table 14 details the descriptive statistics for the year of enlistment for the sample. The length of Army service of participants ranged from 2 to 30 years21 (Table 15), with 90 Medical Technician (~50%) having less than five years of service in the Army.

Descriptive Statistics

n 179

Mean 2007

Median 2010

Mode 2013

Std. Deviation 5.82

Range 28

Minimum 1985

Maximum 2013

Table 14: Descriptive Statistics for Year of Enlistment

20 A total of 179 Medical Technician participated in this research from five ranks, Private (PTE), Corporal (CPL), Sergeant (SGT) and Warrant Officer Class II (WO2). 21 Years of Army service is calculated as at 2015.

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Year of Enlistment Years of Service Frequency Percentage Cumulative Percentage

<1994 22 - 30 6 3.4% 3.4%

1994 - 1999 16 - 21 13 7.3% 10.6%

2000-2001 14 - 15 8 4.5% 15.1%

2002-2003 12 - 13 9 5.0% 20.1%

2004-2005 10 - 11 17 9.5% 29.6%

2006-2007 8 - 9 24 13.4% 43.0%

2008-2009 6 - 7 12 6.7% 49.7%

2010-2011 4 - 5 41 22.9% 72.6%

2012-2013 2 - 3 49 27.4% 100.0%

Table 15: Frequency Distribution of Year of Enlistment and Years of Service

Prior Health Sector Employment. Out of the 179 respondents, n=16 (~9%) worked in the civilian health sector prior to enlistment, with 6 (~3%) working as Nursing Assistants prior to their enlistment, see Table 16.

Previous Occupation Frequency Percentage Cumulative Percentage

Nursing Assistant 6 3.4 3.4

First Aid Officer 3 1.7 5.0

Age Care Worker 2 1.1 6.2

Disability Health Care Worker 2 1.1 7.3

Medical Receptionist 2 1.1 8.4

Radiographer 1 0.6 8.9

No Prior Health Sector Employment 163 91.1 100.0

Table 16: Civilian Health Sector Occupations

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Prior Military Service. A total of n=29 (~16%) Medical Technicians had prior military service (75% prior ARA service and 25% prior Army Reserve service). Riflemen from the Royal Australian Infantry (RAInf) represented the highest number of in-Service transfers (n=14), followed by Royal Australian Army Ordnance Corps (RAAOC) Clerks (n=6), then Gun Numbers (n=4) from the Royal Australian Artillery (RAA). In-Service transfers included soldiers from Combat Engineers (n=2) from the Royal Australian Engineers (RAE), Royal Australian Armoured Corps (RAAC) Troopers (n=2) and Royal Australian Corps of Signals (RASig) Signallers (n=1). The length of prior military service ranges from three to 14 years. See Tables 17 and 18.

Previous Military Employment Frequency Percentage Cumulative Percentage

Rifleman 14 48.3 7.8

Clerk 6 20.7 11.2

Gun Number 4 13.8 13.4

Trooper 2 6.9 14.5

Combat Engineer 2 6.9 15.6

Signaller 1 3.4 16.2

No Previous Military Employment 150 83.8 100.0

Table 17: Previous Military Employment Categories

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Descriptive Statistics

n 29

Mean 5.9

Median 5

Mode 4

Std. Deviation 2.70

Range 10

Minimum 4

Maximum 14

Table 18: Length of Previous Military Service Descriptive Statistics

Current Role. Of the 179 Medical Technician surveyed 159 were employed in Clinical roles (89%), with the remaining 11% of respondents employed in Instructor (n=9), Operations Planning Staff (n=3), Development (n=4) and Command (n=4) roles.

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Chapter 5: Quantitative Results

This chapter presents the results from the 27 quantitative questions (see Table 10, p 95) from the mixed methods instrument.

Motivation Factors for Joining the Australian Army. To measure motivation factors for joining the Australian Army, a five option (one question offered a sixth option of Not Applicable) Likert scale was employed, ranging from 1 for Strongly Agree to 5 for Strongly Disagree, with 3 for Neutral responses. The results of these questions are shown in Table 19 and Figure 17.

When asked to identify the factors that motivated participants into joining the Australian Army, “to serve Australia” and “career/life change” were the two most common reasons identified, with 150 (84%) respondents each providing a positive response. Over 55% (n=98) respondents identified ‘to travel the world’ as a key motivating factor, while a “free education” was selected by 89 (50%) Medical Technicians.

Seventy-seven (43%) respondents provided a positive response to ‘family history serving in the Army’ as a key motivator for joining the Australian Army. While 28% selected the ‘Not Applicable’ option in answering this question. The remaining 29% of respondents selected either a neutral (n=26) or negative (n=25) response.

Conditions of service returned the highest neutral response from 85 (47%) participants, with “needed a job” recording the highest negative result with 35% (n=62) responses.

Make new friends recorded the second lowest negative result with 17 (12%) of the responses, with 88% of respondents recording a positive (48%) or neutral (40%) response.

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S/Agree Agree Disagree S/Disagree Motivation Factors Neutral N/A (Positive) (Negative)

84 66 25 4 0 To serve Australia (84%) (14%) (2%)

Family history serving in the 28 49 26 13 12 51

Army (43%) (15%) (14%) (28%)

31 67 59 20 2 To travel the world (55%) (31%) (14%)

4 52 85 28 10 Conditions of service (31%) (47%) (21%)

54 96 27 2 0 Career/Life change (84%) (15%) (1%)

21 68 73 12 5 Make new friends (48%) (40%) (12%)

12 35 70 48 14 Needed a job (26%) (39%) (35%)

23 66 50 30 10 Free education (50%) (28%) (22%)

Table 19: Motivation Factors Results

Figure 17: Motivation Factors for Joining the Australian Army

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Descriptive statistics for motivation factors are shown in Table 20. While most items measured a relatively neutral mean score, from 2.46 to 3.47, two factors; ‘to serve Australia’ and ‘career/life change’ measured relatively positive with 1.72 and 1.87 respectively. Cronbach’s alpha for this question was 0.41.

Mean Mode Std. Variance Skewness Deviation

To serve Australia 1.72 1 0.788 0.621 0.832

Family history serving in the Army 3.47 6 1.897 3.599 0.234

To travel the world 2.46 2 1.045 1.093 0.709

Conditions of service 2.93 3 0.872 0.760 0.440

Career/Life change 1.87 2 0.695 0.483 0.381

Make new friends 2.54 3 0.961 0.924 0.724

Needed a job 3.09 3 1.021 1.041 -0.128

Free education 2.65 2 1.077 1.160 0.373

Table 20: Descriptive Statistics – Motivation Factors

Member Expectations. In response to the question regarding whether their service in the Army Health Services has met their expectation, 103 (58%) respondents provided a negative result.

Levels of satisfaction and importance. Respondents were asked to rate their level of satisfaction against a series of statements on a five option Likert scale, with 1 for Very Satisfied; 2 for Satisfied; 3 for Neutral, 4 for Dissatisfied and 5 for Very Dissatisfied. Respondents were then asked to rate how important these statements were to them, again using a five option Likert scale with 1 for Very Important; 2 for Important, 3 for Neutral, 4 for Unimportant and 5 for Very Unimportant.

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Level of satisfaction. Table 21 and Figure 18 detail respondents’ satisfaction levels with their service in the Army as Medical Technicians. For all 13 workplace issues, the overall response rate was either Neutral or Negative, with the highest Positive response, with 45% (n=81) of respondents were either Very Satisfied (n=44) or Satisfied (n=37) with their ‘current posting’.

How participants ‘career is being managed’ returned a 34% (n=60) positive response, with 44% (n=70) providing a negative response, while 40 (22%) provided a neutral response. Similarly, 54 (30%) participants responded positively to their ‘long term career prospects’, with 45% (n=81) providing a negative response.

The amount of ‘clinical placement…undertaken in over the past 12 months’ attracted the third most negatives responses, with 93 (52%), though it did attract the largest number of Very Dissatisfied (n=62) response. On the question of ‘opportunities…to maintain [their] clinical skills’ 101 (56%) participants provided a negative response, with the remaining 41 (23%) participants providing a neutral response.

The level of participant’s satisfaction with their own ‘level of clinical competence’ returned a positive response from 71 (40%) respondents, while only 32% (n=57) respondents provided a positive response regarding the ‘clinical competence of other health craft groups’. Similarly, the neutral response for own competence was 34% (n=61), while for other craft groups it was 47% (n=84). Participants recorded a 21% (n=38) negative for other craft group clinical competence, with 47 (26%) providing a negative response when it came to their own clinical competence.

When it came to the question of participants’ satisfaction level in their ‘freedom to exercise [their own] clinical judgement, only 58 (32%) provided a positive response, while 121 participants provided a neutral (n=69) or negative (n=52) response. Similarly, 32% (n=57) respondents provided a positive result on the question of the ‘level of clinical supervision’ they are being provided in the workplace. The remaining participants provided with a neutral (30%) or negative (38%) response.

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Satisfaction levels regarding participants’ ongoing development produced similar results for the three questions; ‘amount of professional development’ undertake, ‘how [they] have been mentored’ and their ongoing ‘education opportunities’. While 35% (n=63) were positive in how they have been mentored, only 30% (n=54) were positive with the amount of professional development activities that have undertaken, and 51 (28%) participant’s being positive with education opportunities. Negative satisfaction for these questions were again very similar, with 44% (n=78) for the amount of professional development undertaken, with 39% (n=70) for how respondents have been mentored and 42% (n=75) for education opportunities.

The least level of satisfaction was recorded for the directions RAAMC is taking on a range of issues, with only 13% (n=24) respondents providing a positive response. One hundred and five (59%) participants responded negatively, while 50 (28%) providing a neutral response.

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Very Very Satisfied Dissatisfied Satisfied Neutral Dissatisfied (Positive) (Negative) 14 46 40 40 39 How my career is being managed (34%) (22%) (44%) The amount of clinical placement I have 22 15 49 31 62 been able to undertake over the past 12 (21%) (27%) (52%) months 44 37 46 28 24 My current posting (45%) (26%) (29%) 17 54 61 39 8 My level of clinical competence (40%) (34%) (26%) 17 41 69 30 22 Freedom to exercise my clinical judgment (32%) (39%) (29%) The level of clinical supervision I’m being 22 35 54 33 35 provided (32%) (30%) (38%) The amount of professional development I 21 33 47 40 38 have been able to undertake over the past (30%) (26%) (44%) 12 months The clinical competence of the other health 9 48 84 25 13 craft groups I work with (32%) (47%) (21%) 24 39 46 43 27 How I have been mentored (35%) (26%) (39%) The education opportunities I have been 20 31 53 34 41 given (28%) (30%) (42%) 12 42 44 34 47 My long-term career prospects (30%) (25%) (45%) The opportunities I have to maintain my 8 29 41 59 42 clinical skills (21%) (23%) (56%) Direction my Corps is taking on a range of 5 19 50 44 61 issues (13%) (28%) (59%)

Table 21: Level of Satisfaction of Workplace Issues

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Figure 18: Level of Satisfaction of Workplace Issues

The descriptive statistics for the satisfaction levels of workplace issues are shown in Table 22. Mean for satisfaction levels ranged from a relative positive 2.73 for current posting location to a relative negative 3.77 for the direction RAAMC is heading on a range of issues. Cronbach’s alpha for this satisfaction level was 0.82.

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Std. Workplace Issues Mean Mode Variance Skewness Deviation

How my career is being managed 3.25 2 1.27 1.61 -0.06

The amount of clinical placement I have been able to undertake over the past 12 3.54 5 1.36 1.86 -0.50 months

My current posting 2.73 3 1.35 1.82 0.23

My level of clinical competence 2.82 3 1.02 1.05 0.09

Freedom to exercise my clinical judgment 2.99 3 1.13 1.28 0.13

The level of clinical supervision I’m being 3.13 3 1.28 1.64 -0.04 provided

The amount of professional development I have been able to undertake over the past 3.23 3 1.30 1.68 -0.17 12 months

The clinical competence of the other health 2.92 3 0.95 0.90 0.33 craft groups I work with

How I have been mentored 3.06 3 1.27 1.60 -0.06

The education opportunities I have been 3.25 3 1.29 1.67 -0.15 given

My long-term career prospects 3.35 5 1.28 1.63 -0.10

The opportunities I have to maintain my 3.55 4 1.15 1.32 -0.42 clinical skills

Direction my Corps is taking on a range of 3.77 5 1.12 1.25 -0.48 issues

Table 22: Descriptive Statistics – Satisfaction Levels of Workplace Issues

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Level of importance. The level of importance to for the 13 workplace issues are detailed in Table 23 and Figure 19. Across all issues, the majority participants’, i.e. ≥ 58%, recorded positive response as either Very Important or Important. The negative response to these issues was between 2% – 17%, while neutral responses ranged between 4% and 30%.

The most important work place issue identified by participants was their level of clinical competence, with 158 (88%) identifying this as either Very Important (132) or Important (26). Only 7% (n=13) provided a negative response. Similarly, the ability to maintain clinical competence was the second most important workplace issue with 155 (87%) of respondents providing a positive response. While only 21 participants provided a neutral (8%) or negative (6%) response. Along a similar vein, 78% (n=139) of participants responded positively to the amount of clinical placement as being Very Important (n=94) or Important (n=45). While a similar number of participants provided either a neutral (n=20) or negative (n=20) response.

Career management returned a relatively high positive result, with 84% (n=151) respondents, with only 2% (n=4) providing a negative response.

Again, ongoing development produced similar results for the three questions; ‘amount of professional development’ undertake, ‘how [they] have been mentored’ and their ongoing ‘education opportunities’. The opportunity to undertake professional development was considered either Very Important (n=83) or Important (n=55) by 77% of respondents. The importance of mentoring highlighted by 73% (n=130) participants providing a positive response, with 49 neutral (15%) and negative (12%) responses. One hundred and forty-six participants (82%) considered opportunities for ongoing education as Very Important (n=84) or Important (n=62), with only 6% considering ongoing education negatively as either Unimportant (n=6) or Very Unimportant (n=5).

Current posting was considered Very Important (n=85) or Important (n=37) by 68% of respondents. While 15% (n-26) of participants provided a neutral response, 31 (17%) respondents though their current posting as either Unimportant (n=19) or Very Unimportant (n=12).

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Participants considered their ability to exercise their clinical judgement as either Very Important (49%) or Important (29%), with 139 positive responses. On the other hand, only 8% (n=13) provided a negative response.

The highest neutral response was provided for their level of clinical supervision, with 53 (30%) respondents. Only 58% of respondents considered the level of clinical supervision being provided as either Very Important (n=43) or Important (n=61), while 22 (12%) participants provided a negative response. On the question regarding the direction of RAAMC, 74% or respondents consider it Very Important (n=80) or Important (n=60), with only 15 (8%) providing a negative response.

Descriptive statistics for level of importance regarding a range of workplace issues are detailed in Table 24. This question also returned a very high level of reliability with a Cronbach’s alpha of 0.93.

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Very Very Important Unimportant Workplace Issues Important Neutral Unimportant (Positive) (Negative) 105 46 24 4 How my career is being managed (84%) (13%) (2%) The amount of clinical placement I 94 45 20 12 8 have been able to undertake over the past 12 months (78%) (11%) (11%) 85 37 26 19 12 My current posting (68%) (15%) (17%) 132 26 8 4 9 My level of clinical competence (88%) (4%) (7%) Freedom to exercise my clinical 87 52 26 6 8 judgment (78%) (15%) (8%) The level of clinical supervision I’m 43 61 53 14 8 being provided (58%) (30%) (12%) The amount of professional 83 55 28 8 5 development I have been able to undertake over the past 12 months (77%) (16%) (7%) The clinical competence of the other 65 57 40 11 6 health craft groups I work with (68%) (22%) (9%) 73 57 27 13 9 How I have been mentored (73%) (15%) (12%) The education opportunities I have 84 62 22 6 5 been given (82%) (12%) (6%) 93 31 32 16 7 My long-term career prospects (69%) (18%) (13%) The opportunities I have to maintain 109 46 14 3 7 my clinical skills (87%) (8%) (6%) Direction my Corps is taking on a 80 60 24 5 10 range of issues (78%) (13%) (8%)

Table 23: Level of Importance of Workplace Issues

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Figure 19: Level of Importance of Workplace Issues

Std. Workplace Issues Mean Mode Variance Skewness Deviation How my career is being managed 1.59 1 0.80 0.65 1.14 The amount of clinical placement I have been 1.85 1 1.14 1.29 1.31 able to undertake over the past 12 months My current posting 2.08 1 1.28 1.65 0.92 My level of clinical competence 1.50 1 1.04 1.08 2.32 Freedom to exercise my clinical judgment 1.86 1 1.07 1.15 1.33 The level of clinical supervision I’m being 2.35 2 1.07 1.14 0.56 provided The amount of professional development I have been able to undertake over the past 12 1.87 1 1.02 1.04 1.18 months The clinical competence of the other health 2.08 1 1.06 1.13 0.82 craft groups I work with How I have been mentored 2.04 1 1.14 1.31 1.04 The education opportunities I have been 1.80 1 0.97 0.94 1.37 given My long-term career prospects 1.96 1 1.19 1.41 0.98 The opportunities I have to maintain my 1.62 1 0.98 0.97 1.94 clinical skills Direction my Corps is taking on a range of 1.91 1 1.09 1.19 1.35 issues

Table 24: Descriptive Statistics – Importance of Workplace Issues

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Career Intentions. Twenty-five (14%) respondents indicated that they had submitted their request for discharge, with 16% (n=29) indicating they intend on submitting their discharge within the following 12 months. While 32% (n=58) of respondents indicated they have no intention of leaving the Army in the short-term, only 21 (12%) responded that they intend on staying in the Army until they retire. A total of 46 (26%) participants responded that they are undecided regarding their continued service with the Army. See tables 25 and 26.

Cumulative Career Intentions Frequency Percentage Percentage

I have already submitted my discharge 25 14.0 14.0

I plan on leaving within the next 12 months 29 16.2 30.2

I plan on staying in until my retirement 21 11.7 41.9

I have no intention of leaving in the short term 58 32.4 74.3

I am undecided 46 25.7 100.0

Table 25: Frequency Distribution of Medical Technician Career Intentions

Descriptive Statistics

n 179

Mean 3.40

Median 4

Mode 4

Std. Deviation 1.39

Range 4

Minimum 4

Maximum 5

Table 26: Descriptive Statistics: Career Intentions

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Level of Education. Most respondents (n=158) had AQF 1 to 6 level qualifications. Eighteen (10%) respondents had AQF 7 level qualifications, while 2% (n=3) had AQF level 8 education, see Table 27.

Previous Military Employment Frequency Percentage Cumulative Percentage

AQF 1 to 4 – Certificate I to IV 61 34.1 34.1

AQF 5 to 6 – Diploma, Advanced Diploma 97 54.2 88.3

AQF 7 – Bachelor Degree 18 10.1 98.4

AQF 8 – Honours, Graduate Certificate/Diploma 3 1.6 100.0

Table 27: Frequency Distribution of Medical Technician Education Levels

Continuing Education. Less than 30% (n=53) of respondents are currently undertaking any vocational or tertiary level education.

Professional Membership. Only 19 (11%) Medical Technicians are members of any professional/industry association.

Continuing Professional Development. Regarding the question as to whether participants had met their minimum Continuing Professional Development requirements for the past 12 months, 113 (63%) responded Yes, with 34% (n=66) of participants advising they have not met their mandated Continuing Professional Development22 requirements.

22 The NMBA mandates that all Registered and Enrolled Nurses must undertake a minimum of 20 hours of Continuing Professional Development each year.

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Military Training. Eighty-five (47%) participants had completed at least one promotion course, the All-Corps Junior Leaders Course, with 42 (23%) of the 85 respondents, having also completed the Subject 2 for Sergeant Health Services course. Thirty-five (20%) had completed the Subject 1 for Sergeant course while 17 (9%) participants had also completed their Subject 2 Warrant Officer Combat Service Support course. Out of the 85 respondents, 14 (8%) indicated that they had completed Subject 1 for Warrant Officer, or the Army Regimental Sergeant Major course. See Table 28.

Promotion Course Frequency

Junior Leaders Course 85

Subject 2 Sergeant Health Services Course 42

Subject 1 Sergeant Course 35

Subject 2 Warrant Officer Combat Service Support Course 17

Subject 1 Warrant Officers Course/Regimental Sergeant Course 14

Table 28: Frequency Distribution of Military Courses

Of the 179 participants, 37% (n=67) responded that their military courses had prepared them to perform their duties, with 112 (63%) responding that military courses did not prepare them to perform their duties.

Clinical Readiness. On the question of readiness, 28 (16%) of respondents achieved Tier 1 Clinical Readiness, with 22% (n=40) achieving Tier 2. The majority (n=111) of respondents only achieved Tier 3 Clinical Readiness (see Table 29).

n=179 Frequency Percentage

Tier 1 28 15.6

Tier 2 40 22.3

Tier 3 111 62.0

Table 29: Distribution of Medical Technician Readiness

Of the 179 respondents, 123 (69%) (Table 30) had never met the clinical readiness requirements to achieve Tier 1. Forty-four (25%) responded that they have met Tier 1

123 at least once since 2012, with 7 (4%) respondent having achieved Tier 1 twice since 2012. Only 5 (3%) of all respondents had achieved Tier 1 every year since 2012.

n=179 Frequency Percentage

Never 123 68.7

Once 44 24.6

Twice 7 3.9

Every Year 5 2.8

Table 30: Frequency of Medical Technician’s Achieving Clinical Readiness

Clinical Placement. Sixty-one (34%) of Medical Technicians did not undertake any clinical placement over the previous 12 months. Of the 118 (66%) that had undertaken some form of clinical placement, the number of days ranged from 5 to 74. The mean of clinical placement days was 29.83 with the mode for the number of days of clinical placement undertaken by Medical Technicians being 10 days (see Table 31).

Descriptive Statistics

n 118

Mean 29.83

Median 30

Mode 10

Std. Deviation 16.64

Range 69

Minimum 5

Maximum 74

Table 31: Descriptive Statistics: Clinical Placement

The Clinical Placement Setting distribution of clinical placement is shown in Table 32. The most common clinical placement was in an Acute setting, which accounted for 41% of all clinical placement days. This was followed by 16% of clinical placement spent in a Primary Care and Community Health setting. Clinical placement in Professional Practice, Outpatients and Sub-Acute settings accounted for 10%, 10% and 9%

124 respectively. Placements in the remaining clinical placements setting accounted for only 14%.

Percentage of Total Clinical Placement Setting Placement Days

Acute - hospital placements in wards, theatres and other specialty programs 40.8 excluding sub-acute, mental health and ambulatory/ outpatients.

Sub-Acute – placements in rehabilitation, palliative care, geriatric evaluation, and 9.0 management units

Outpatients – hospital placements involving outpatient and non- admitted patient 9.5 care and home delivered services provided by hospital staff.

Primary Care and Community Health – placements involving community health 16.1 centres or government managed health services that involve direct patient care, excluding General Practice.

Diagnostic Services – placements in diagnostic laboratories and medical imaging 3.8 organisations.

General Practice – includes general practice whether in a private clinic, community 4.3 health centre, super clinics or other setting.

Professional Practice – placements in non-hospital based professional practices such 10.4 as ambulance, casualty/patient retrieval service, allied health, public health, environmental health, excluding general practice.

Mental Health/Alcohol/Drugs – includes all placements in mental health programs, 3.3 including alcohol and other drugs services.

Dental and Oral Health – includes placements in school dental clinics, private or 0 public clinics or laboratories.

Other – any placement does not correspond to any of the listed settings listed above. 2.8

Table 32: Distribution of Clinical Placement Settings

Simulation. Over the previous 12 months, 92 (51%) of research participants had undertaken some form of High Fidelity simulation. The number of hours of simulation undertake ranged from 1 to 25 hours, with a mean of 9.35 hours, see Table 33.

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Descriptive Statistics n 92 Mean 9.35 Median 10 Mode 10 Std. Deviation 5.35 Variance 28.63 Skewness 0.93 Kurtosis 1.11 Range 24 Minimum 1 Maximum 25

Table 33: Descriptive Statistics: Hours of High Fidelity Simulation

The use of mannequin models was the most common (55%) simulation model, followed by simulated patients (34%). The remain simulations models; computer based virtual reality (6%), live animal models (2%) and cadavers (4%) accounted for less than 12% of simulations models used by Medical Technicians. See Table 34.

Simulation Model Percentage Mannequin models 55% Computer based virtual reality 6% Live animal models 2% Cadavers (human or animal) 4% Simulated patients (role players) 34% Combination or hybrid models 0%

Table 34: Distribution of Simulation Models

To assess the efficacy of simulation, respondents were asked to rate their level of agreement or disagreement against a series of statements on a five option Likert scale, with 1 for Strongly Agree, through to 5 for Strongly Disagree, with 3 for Neutral response. Overall reliability for this question was high, with a Cronbach’s alpha of 0.92.

Forty (44%) respondents provided a positive response when asked whether simulation is structured and planned, while 39% (n=36) provided a negative response. Fifty-one (55%) participants responded positively to the question as to whether simulation sessions involve both announced and unannounced emergency scenarios, with 19

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(21%) participant providing a negative response. On the question of pre-briefs and debriefs, 41 (45%) respondents either Strongly Agreed (n=3) or Agreed (n=38). Compared to 30% (n=28) who either Disagreed (n=25) or Strongly Disagreed (n=5), with 23 (25%) providing a neutral response. Similarly, when asked whether team simulation activities were followed by peer feedback and group debriefing, 45% (n=41) provided a positive response, with 26 (28%) providing a negative response.

The use of simulation as a key component of unit training returned an equal number of positive (n=34) and negative (n=34) responses, with 24 participants providing a neutral response. The highest negative response rate (64%) was regarding the question whether simulation sessions were videoed to help with debriefing. Only 13% (n=12) provided a positive response to this question.

Regarding the question of trained facilitators, 47 (51%) participants provided a positive response, while 27% either Disagreed (n=12) or Strongly Disagreed (n=13). When it came to the question whether simulation prepared Medical Technicians for clinical placement, 44% (n=40) provided a positive response, with 30 (33%) providing a negative response, with 24% (n=22) providing a neutral response.

The second largest negative (51%) response was provided to the question whether simulation is part of a structured unit training program. Forty-seven respondents either Disagreed (n=25) or Strongly Disagreed (n=22). Only 25 (27%) provided a positive response, with 22% (n=20) providing a neutral answer.

When it came to the difficulty and complexity of the scenarios, participants provided an equal positive and negative response rate of 37% (n=34) respectively. While 24 (26%) provided a neutral response. The question regarding the use of reflective practice returned the second lowest positive response (21%), with only 3 participants Strongly Agreeing and 16 respondents Agreeing. Conversely, 45% (n=41) provided a negative response, with 32 (35%) participants providing a Neutral response.

Enhancing the learning experience during simulation activities returned the most neutral response rates for the questions of ‘facilitator innovation’, ‘use of multiple simulation models’, and the use of ‘various locations’. Facilitator innovation resulted in

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32 (35%) of participants providing a negative response, while positive and neutral responses were equal with a 33% (n=30) response rate. Similarly, the use of multiple simulation models produced a negative response rate of 36% (n= 33), with 29 (31%) providing a positive response. The conduct of simulation activities in multiple locations produced a 33% (n=30) positive response, with 43 (47%) of participants responding negatively. See Tables 35 and 36.

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S/Agree Agree Neutral Disagree S/Disagree Conduct of Simulation (Positive) (Negative) Medical simulation is structured and 4 36 16 24 12 planned (43.5%) (17.4%) (39.1%) All simulation includes structured pre- 3 38 23 23 5 briefs and debriefs (44.6%) (25.0%) (30.4%) Sessions usually involved announced or 4 47 22 14 5 unannounced emergency scenarios (55.4%) (23.9%) (20.7%) The use of simulation is a key competent 9 25 24 28 6 of unit training (37.0%) (26.1%) (37.0%) Simulation sessions are video recorded to 2 10 21 42 17 aid in debriefing (13.0%) (22.8%) (64.1%) Simulation is conducted by 11 36 20 12 13 trained facilitators (51.1%) (21.7%) (27.2%) Simulation prepares me for clinical 11 29 22 16 14 placement (43.5%) (23.9%) (32.6%) The use of simulation is part of a 3 22 20 25 22 structured unit training program (27.2%) (21.7%) (51.1%) Each session involves a series of scenarios 1 33 24 23 11 increasing in difficulty and complexity (37.0%) (26.1%) (37.0%) Reflective practice is a key element of 3 16 32 30 11 simulation training (20.7%) (34.8%) (44.6%) Simulation facilitators are innovative 5 25 30 19 13 making training challenging to enhance (32.6%) (32.6%) (34.8%) the learning experience The use of multiple simulation models are 4 25 30 17 16 synchronised to maximise each models’ (31.5%) (32.6%) (35.9%) strengths Team activities are followed by peer 13 28 25 18 8 feedback and group debriefing (44.6%) (27.2%) (28.3%) Simulation is used in various locations to 2 28 19 24 19 maximise the learning experience (32.6%) (20.7%) (46.7%)

Table 35: Conduct of Simulation

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Mean Mode Std. Variance Skewness Kurtosis Conduct of Simulation Deviation Medical simulation is structured and 3.04 2 1.167 1.361 0.254 -1.147 planned

All simulation includes structured pre- 2.88 2 1.004 1.008 0.378 -0.819 briefs and debriefs

Sessions usually involved announced or 2.66 2 0.975 0.951 0.799 -0.068 unannounced emergency scenarios

The use of simulation is a key competent 2.97 4 1.114 1.241 -0.081 -0.883 of unit training

Simulation sessions are video recorded 3.67 4 0.973 0.947 -0.615 0.012 to aid in debriefing

Simulation is conducted by 2.78 2 1.239 1.535 0.496 -0.783 trained facilitators

Simulation prepares me for clinical 2.92 2 1.260 1.588 0.247 -0.990 placement

The use of simulation is part of a 3.45 4 1.189 1.415 -0.169 -1.137 structured unit training program

Each session involves a series 3.11 2 1.063 1.131 0.339 -1.037 of scenarios increasing in difficulty and complexity

Reflective practice is a key element of 3.33 3 1.007 1.013 -0.170 -0.470 simulation training

Simulation facilitators are innovative 3.11 3 1.124 1.263 0.162 -0.783 making training challenging to enhance the learning experience

The use of multiple simulation models 3.17 3 1.145 1.310 0.190 -0.895 are synchronised to maximise each models’ strengths

Team activities are followed by peer 2.78 2 1.175 1.381 0.228 -0.794 feedback and group debriefing

Simulation is used in various locations to 3.33 2 1.178 1.387 0.037 -1.274 maximise the learning experience

Table 36: Descriptive Statistics: Conduct of Simulation

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Deployment. Seventy respondents had deployed on operations on one or more occasions, Table 37. Thirty-seven (21%) Medical Technicians had deployed at least once, with 18 (10%) having had two deployments, with 5% (n=9) having deployed three times. The remaining 6 respondents had deployed either four times (n=3), with the remaining 3 Medical Technicians having deployed between five and seven times.

Number of Deployments Frequency Percentage Cumulative Percentage One 37 20.7 20.7 Two 18 10.1 30.7 Three 9 5.0 35.8 Four or More 6 3.4 39.1 Never Deployed 109 60.9 100.0

Table 37: Distribution of Number of Deployments

Of the 70 Medical Technicians who had deployed, n=59 (84%) deployed in a health- related role. Twenty-five (~42%) of the 59 respondents deployed in a health-related role indicated that their training had prepared them for their deployment. Finally, n=37 (~53%) respondents indicated that their pre-deployment, mission rehearsal, or certification exercise was relevant and tailored to their mission, with ~47% (n=33) stating such exercises were not relevant.

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Chapter 6: Qualitative Findings

This chapter presents the findings from the qualitative data collected for the study. The methodology used for codifying of the qualitative questions is detail in Chapter 3 – Methodology and Methods. Findings from the mixed methods questionnaire, open forum discussions and focus group discussions were merged and analysed together. Initial open coding of the data generated 187 codes (see Appendix 5). In accordance with the codification model shown in Figure 16 (p. 103), these codes were synthesised into the 13 themes, linked to the relevant elements of human capital, as shown in Table 38 below.

Supporting Research Questions Themes

Training, education and development Initial Employment Training

Ongoing/Advanced Medical Training

Relevance of Training

Civilian Qualifications

Maintenance of skills, knowledge and attitudes Continuing Professional Development

Skills Maintenance

Operational Tempo

Professional Education

Leadership, Supervision and Mentoring

Workforce retention Career Management

Expectation Management

Family History

Leadership, Supervision and Mentoring

Operational Tempo

Segue to other Health Professions

Table 38: Themes identified from Thematic Analysis

Response rates for the various qualitative questions (see Table 39) of the mixed- methods survey varied, with no discernible pattern or identifiable reason. It should be noted that participants provided responses to qualitative questions, even when not

132 required. For instance, some questions only required a response if participants provide a specific response to a quantitative question; i.e. “if No, please provide details”. A possible explanation for this phenomenon is that many participants provided a positive-negative response, such as “… great training that give the basics to build upon (Positive)…but it did not prepare us to do our job as medics (Negative) …”.

Qualitative Question Number of Responses Percentage of Responses

Q_9 179 100.0%

Q_10_A 108 60.3%

Q_13 29 16.2%

Q_14 27 15.1%

Q_15 27 15.1%

Q_17 179 100.0%

Q_18_A 31 17.3%

Q_18_B 71 39.7%

Q_19_A 13 7.3%

Q_21 153 85.5%

Q_22 167 93.3%

Q_24_A 167 93.3%

Q_25 167 93.3%

Q_28 152 84.9%

Q_29 150 83.8%

Q_32 162 90.5%

Q_35 128 71.5%

Q_37_A 59 33.0%

Q_38_A 64 35.8%

Q_39_A 64 35.8%

Q_40 147 82.1%

Q_41 179 100.0%

Q_42 179 100.0%

Table 39: Response Rates to Qualitative Questions

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Initial Employment Training

While the majority of participants’ responses regarding their Initial Employment Training, was generally positive (~71%), most Medical Technicians believed that their Initial Employment Training did not prepare them for their work or type of medical support they are expected to practice once posted to their units (~78%). The most common complaint made by almost all Medical Technicians is that their Initial Employment Training did not provide them with the skills, knowledge or attitudes to preform primary health care, either in a fixed health facility or as independent health practitioners (~89%).

S_69. “The ADFMC medic course prepared me adequately for dealing with nursing and trauma, but not for dealing with 95% of what presents to us, PHC.”

S_101. “The ADFMC is a great course that give the basics to build on. The focus of ADFMC is on nursing and emergency paramedic training. The problem is that when we get to our units we don't do nursing and paramedics, we do primary health care. We get very little on the job primary health care training so we have to learn on the job, alone and usually with little to no supervision.”

FG2_A. “Being part of the new ADFMC initiative I believe that the 18 months is fine, I also think that more time is needed for knowledge retention. Professional follow up training is a must!”

S_85. “PHC training on ADFMC and less nursing. Only need nursing at 2 GHB, but then you need to teach more advanced nursing such as HDU/ICU.”

S_78. “Soldiers coming off the ADFMC are so much better trained than when we were, but they only have good theoretical knowledge. They graduate and come to the unit and we throw them in the deep end with either limited or no consolidation.”

S_151. “Best course I’ve even done. It has given me all the skills I need to do my job. But I have only been in the unit for 4 months.”

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S_53. “All our training should be about what we will do when we get to our company. The focus on nursing is a waste. We need more PHC and more advance [advanced] skills. If I was king for a day I would get rid of the nursing on ADFMC and spend more time training in PHC.”

S_68. “I marched in J3123 so for the first 9 months I was doing placements in the HC [Health Centre] so I was able to really consolidate my training. What I did notice was that I wasn’t prepared for my job. Those 9 months made me a better med tech.”

FG7_C. “When I did my med assists [Medical Assistant] course we all went on to do on the job training. I went to 7 Camp Hospital where I was taught all the basics about from running sick parade, triage and all the medical conditions that soldiers suffer on a daily basis. While I can say we were not as well trained as our medics today straight off our course, but after 12 months we became much better medics.”

23 The ADF Medical Employment Classification (MEC) system is the mechanism by which the ADF determines medical fitness and employment of ADF personnel. The primary focus of the MEC system is employability, deployability and rehabilitation of ADF members. Medical fitness will impact on decisions involving employment, postings, training, occupational rehabilitation, transfers between employment categories, payment of specialist allowances and retention in the ADF. MEC is determined according to each member's primary military occupation. The assessment takes into account the environment in which the person is expected to perform when deployed, as well as any additional tasks which a member could be expected to perform as part of their general military duties. The MEC is reviewed on an ongoing basis to ensure that it is appropriate for the person's current circumstances. There are five broad MEC categories: MEC 1 – Fully Employable and Deployable; MEC 2 – Employable and Deployable with Restrictions; MEC 3 – Rehabilitation; MEC 4 – Employment Transition; MEC 5 – Separation. Each MEC category has a number of sub-categories beginning with J (Joint), L (Land), or M (Maritime). Members who are MEC 3 or below are unable to deploy, go out field or undertake certain training activities without a waiver (DoD, 2011d)

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FG3_A. “The ADFMC is a great course but it needs more Army instructors. The TAFE instructors were ok, but the Army instructors all had deployed and some of them were from SASR and 2 CDO so every time we discussed something they showed us the relevance by telling us how it applied on op or in real world situations.”

S_84. “Having done an IET before, the ADFMC is a really good course but it’s also the longest courses I’ve done in 8 years. When you look at what’s covered and the amount of down time we had, you can tell it’s as long as it is because of the civvi quals [civilian qualifications] we get.”

S_97. “My mate started his VM [Vehicle Mechanic] course that’s longer than the ADFMC but when they finish at Latchford [Latchford Barracks] they get posted to a unit to complete their training. We do ½ as much and then get thrown in the deep end. It’s not right.”

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Ongoing/Advanced Clinical Training

There was universal (~88%) concern identified by all Medical Technicians that the ADFMC is the only military medical/clinical course in the Medical Technician training continuum from the rank of Private to Warrant Officer Class One, “I’m fully qualified for WO1 for trade (Ha Ha)”. Advanced clinical skills training with a focus on independent, or isolated practice was a common theme.

S_53. “…develop more courses for CPL and SGT which are more advanced clinical skills...”

FG7_B. “We should also have more advance [advanced] medic training to give us the skills and confidence to work alone. We don’t get any primary health training and even when we work in garrison, we don’t do much and never get the opportunity to triage or treat patients, even under direct supervision.”

FG5_G. “While we get used as independent medics working remotely, I feel we are not trained enough to do so. We need more skills and training to make sure we’re safe and to handle a range of emergencies that may happen, even primary health care emergencies when we’re alone and miles from any other health support.”

S_152 “We’re always being told to keep learning and studying, even at the school house we were told we were beginning our lifelong learning journey but we don’t get any other training. And if we ask for support to do it ourselves they say no.”

S_126. “There must be additional training for MT to do for promotion to Cpl and Sgt. The only option we have is to go to SOCOMD and do our UM [Underwater Medical] course, which gives us all those advance [advanced] clinical skills we need.”

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S_46. “Heaps of other Corps have Sub 4s [Subject Four24] before you can get promoted to CPL or SGT why don’t we. This would give us the skills we’re lacking to be able to work as a CPL medic.”

FG5_B. “I did the BMAC [Basic Medical Assistant Course] and then did the first trial AMAC [Advanced Medical Assistant Course]. By then I was in the Army for about three and half years. I then did my Sub 1 [Subject One] and was promoted. We were then waiting for the SMA [Specialist Medical Assistant] course that never came. Even now we keep talking about it but it never runs. What I’m trying to say is that by Corporal I was fully qualified. I then when to the West and did my UMs [Underwater Medical course] where I realised how much more I need to learn. Looking back now I was being set up for failure by the system. Lucky for me, I had great MOs [Medical Officers] and seniors [Warrant Officers and Senior Non-Commissioned Officers] who took the time to train and mentor us.”

FG1_A. “As a retread [in service Corps transfer] the ADFMC is the best course in the Army. Not only is it challenging and so you have pay attention, you learn so much from great lecturers, though it would be better if all the instructors were Army or at least ADF. I’ve probably done over 15 Army or ADF courses before my ADFMC, but I have never been on one so good. The only problem now is that I realised it’s a great course but not designed to produce Med Techs that are employed in combat health roles. The ADFMC gives us great underpinning knowledge, good nursing and paramedic skills but we are so not ready to

24 Subject Four (Sub 4) are trade specific Army run courses that soldiers undertake for promotion. These courses provide advance trade skills training that are required to undertake greater scopes of employment. Not all Army trades have Sub 4 courses, though most technical or complex trades have these courses for promotion to CPL, SGT and WO2. Sub 4 courses are part of a continuum of promotion courses that include Subject One (Sub 1) which provides All Corps training which every solder undertakes for promotion. Subject Two (Sub 2) are Corps specific courses which soldiers undertake which is of general nature but specific to that Corps. All soldiers of RAAMC and RAADC undertake the same Sub 2 for SGT and all AHS SGT attend a Sub 2 for WO call the Logistics Warrant Officer course. Up until recently, promotion to the rank of SGT and WO2 required solider without Year 12 education to undertake a Subject Three (Sub 3) course designed to improve soldier literacy and numeracy.

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provide primary health care. As a grunt [Rifleman] after my IET [Initial Employment Training] all I did was more training both on courses and on the job. We were constantly learning and then practicing our skills. We don’t do this as Med Techs.”

Participants identified a range of ongoing training/courses that they believed would enhance their ability to provide health care. The most common training/courses identified by participants (>70%) are detailed in Table 40.

Training/Course Percentage of Responses

Advanced Primary Health Care ~ 92%

Tactical Combat Casualty Care ~ 88%

Prehospital Trauma Life Support ~ 80%

Australian Resuscitation Council Advanced Life Support Level 2 ~ 78%

Burns Management ~ 75%

Advanced Wound Management ~ 75%

Managing Chemical, Biological, Radiological and Nuclear casualties ~ 72%

Table 40: Training/Courses Identified by >70% of Respondents

S_6. “Advanced life support. Paediatric courses. Strapping/Massage Course for augmentation at physio.”

S_9. “I would like to undertake more CPD in primary health care, advance [advanced] life support, MIMMS, wound care. I think we should also make everyone do CBC every year and look at online education courses.”

S_19. “Primary health care is our bread and butter as medics so we should include more training as we progress. More exchanges with civilian ambulance services, more placement in rural/indigenous health centres.”

S_170. “Wound management, palliative care, mental health first aid and burns management.”

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S_67. “Look at increasing our training in primary health care. We're pretty good at emergency medicine but struggle on primary health care.”

S_122. “Should include more primary health care training. We also should have more training on wounded management and occupational medicine.”

S_94. “TCCC and primary health care. We should also learn how to manage a patient in a complex environment.”

S_54. “ALS2, Primary Health Care, Burns Management, Wound Management.”

S_60. “Should do more advance [advanced] skills training for our junior medics, such as Primary Health Care and CBC, for our senior medics they should attend more conferences and training courses.”

S_44. “Underwater medicine, especially in the primary health care area so we can do dive medicals. AME training and refresher training. More PHC upskilling.”

S_31. “MIMMS, PHC training, CBC/ALS2 and PHTLS.”

S_132. “Managing a casualty in a CBRN environment is very important.

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Continuing Education

Responses surrounding Continuing Professional Education were generally negative (~91%). Respondents, who indicated that they were not undertaking any continuing education, identified that unit ‘op tempo’ as the main cause, followed by the lack of funding and support from the chain of command.

S_89. “I enrolled for my Bachelor of Nursing at QUT in 2014 but have had to defer after one semester because I was always out field.”

S_105. “There is just not enough time to undertake any studies at the moment.”

S_121. “Between work and family I can’t start any uni. Maybe next year.”

S_153. “Every time I ask for DASS [Defence Assisted Study Scheme25] I get told that there's no money so maybe next year. But somehow officers seem to get DASS to study.”

S_137. “I started my nursing degree this year but haven’t been able to get any time off for my clinical placement. Not sure what I'm going to do but I think the only way I’ll be able to finish it is by getting out.”

FG4_B. “The unit is not supportive for us to undertake any tertiary study, because they just want to smash us with support tasks. I know there are a couple of people who have been able to get DASS, the rest of us who are studying are doing it off our own back. For clinical placements, we usually have to take leave or leave with pay. We have two Med Techs that have applied for sponsorship to become Nursing Officers and their applications weren't supported.”

25 Defence Assisted Study Scheme (DASS) allows ADF members to undertake ongoing education for any course that has some relevance to the member’s Army employment. While the policy states members may receive reimbursement for up to 75% of their compulsory fees, funding for DASS is limited and the amount of reimbursement depends on the number of ADF members seeking DASS support.

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FG7_A. “Most of us have a choice, we can either study or have a family. Because the work will not reduce the amount of time we spend away from home on most unnecessary tasks. I’ve done around 160 days out field.”

S_26. “I was lucky this year because I’m 31 [J31] so I’ve been able to get time off to do my uni, but not sure what will happen next year because I’m due for upgrade later this year.”

S_43. “I'm about to complete my second year of my paramedicine degree but it’s been hard. My boss is very supportive but her hands are tied because I’m MEC 1 so I have to go out field. It’s been hard because when I’m home I have no life. I’m thinking of deferring next year.”

S_60. “I'm one of the lucky ones. I got DASS last year and this year and have been able to get time off to do my placements. I know others can’t get supported but I applied for 3 years before I was supported. I think it’s fair that people who have been in the unit longer get supported before the young ones straight out of the school house.”

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Continuing Professional Development

Discussion surrounding the issue of Continuing Professional Development was generally negative (~92%). The main Continuing Professional Development issues identified during coding was a lack of time due to unit tempo, but also included: not being released to undertake Continuing Professional Development, having no unit funding to pay for Continuing Professional Development, unit run Continuing Professional Development activities were ad hoc, not well delivered or not very relevant for their primary roles.

S_175. “When we find things that we can do as part of our CPD requirements we are shut down with the same stories, no funding, we can run our own unit CPD or we’re too busy.”

S_47. “I think the unit has run three or four activities to we can earn our CPD points, but most of us are out field, so the broken medics who never go our field attend so they get rewarded for being broken.”

S_63. A number of time we have found some really interesting and relevant CPD activities and when we push it up the chain the get back to us and say no money or time. We then go out field and then find out some of the NO [Nursing Officer] went on the conference of training. We need to meet our CPD requirements as much as the NO.

S_143. “I’m MEC 31 so I get to do all the CPD training because I’m always in barracks.”

S_79. “We must meet our registration CPD requirements Army decided that but they don’t give us any money to do CPD. Most unit of Defence CPD activities are useless or we do the same activities every year. Most of the time CPD means we so some simulation with the simman [SimMan®]. We have also been told that we should use clinical placement as CPD for registration purposes if we can make up our points.”

S_95. “How can we meet our CPD if we’re always out field.”

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S_112. “If all the MEC 1 and 2 folks are not out field, then they’re too busy in the sheds unpacking, rechecking and repacking stores.”

S_127. “CPD has become a reward for our NO and broken medics who never go field.”

S_159. “We have been told that meeting CPD registration requirements is our responsibility and that we can use it as a tax deduction.”

S_3. “I don’t know why they want us to be registered when they make it so hard to meet our registration requirements. There is just no time or money avail to do any CPD. The unit trys [tries] to run some CPD activities but their very basic and I don't think we get much out of them since we seem to repeat these activities every year.”

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Relevance of Training

Relevance of Medical Technician training was highlighted by the majority (~ 85%) of participants as an area of concern.

FG1_B. “ADFMC trains us to be EN and work in a team. We have good knowledge but little confidence in doing anything more than working on a ward or in the back of an ambulance as part of a team. We need more skills in primary health care and knowledge to be able to work remotely.”

S_87. “Our courses don't give us the confidence to do our job by ourselves. I don't know if that’s what we're supposed to do, but we don't work as part of a team or under supervision for long in the unit before we're sent out field to work alone or remotely.”

S_139. “I am only new, but so far I have been required to learn as I go. The School focuses on nursing rather than pre-hospital and field work. I believe it would be of greater benefit if the course was more military focused rather than civilian.”

FG2_D. “All Army training prepares us for our job but under supervision. Once we get more experience and confidence we should do more training. Our courses do not prepare us for our jobs at all ranks.”

S_150. “The school really prepares us for our ongoing care. Unlike our civilian counterparts we don't have a lifelong learning attitude. We are trained as nurses but don't do nursing. We need more primary health care. Our emergency skills are pretty good, but like my mates I don't have much confidence providing primary health care.”

S116. “I am really good EEN, but have little knowledge for my job as a medic which is providing primary health care. My emergency skills are ok, but I worry I might miss something when treat someone who doesn't feel well when outfield.”

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FG5_F. “Our promotion courses, especially our Subj 2 don't give us any skills that we can use. When you combine our experience with our Subj 1, we have all the skills we need to do our job that ALTC can't teach us. Most of the courses I've been on are outdated and teach us things we no longer do in the Army.”

FG3_E. “The ADFMC is a great course that give the basics to build on. The focus if ADFMC is on nursing and emergency paramedic training. The problem is that when we get to our units we don't do nursing and paramedics, we do primary health care. We get very little on the job primary health care training so we have to learn on the job, alone and usually with little to no supervision.”

S_114. “Medics are coming out with lots of knowledge, but need time to consolidate and to apply in the military workplace. Very low military skills. They don't understand how other units works or what other people do. Skill sets are still low and have little idea of paper work.”

S_133. “All our training should be about what we will do when we get to our company. The focus on nursing is a waste. We need more PHC and more advance [advanced] skills. If I was king for a day I would get rid of the nursing on ADFMC and spend more time training in PHC. Then develop more courses for CPL and SGT which are more advanced clinical skills. Finally if you want medics to do nursing, give to them when they post in to 2 GHB.”

S_155. “The current IET should be reduced and medics trained on the skills they will use in their units. Then have more advanced courses as your progress up the ranks. By the time you make WO2 you have higher clinical skills and maybe qualified at a Bachelor level.”

S_86. “We should have more simulation and more on the job training to consolidate what we have learned on the ADFMC. There should also be more courses for CPL, SGT and WO medics as they don't seem to have the same skills as us new medics.”

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S_167. “We must accept that we are field medics so there is no use training to be ENs. We should have a number of advanced and specialist courses and some special unit type course, like in 2 GHB that's where you train as a nurse.”

S_145. “Primary Health Care is what we do so our training should include Primary Health Care and less nursing. I know we do paramedics training for emergencies, but we should also do TCCC.”

S_130. “Not enough emphasis on primary health care and remote medicine. Need more pharmacology for more primary health acre drugs. We need a specialist course for more competent medics who can do much more, like a PA.”

S_83. “The need for new trainees to complete a period in Garrison health helps to consolidate knowledge before dropping people into the deep and expecting them to be able to function by themselves helps. Continued access to courses, e.g. PHTLS, ITLS, MIMMS, ALS2, etc, help to confirm and develop further knowledge.”

S_169. “Everything we do as medics is providing primary health care. So our training should reflect this and reduce the nursing at the school. Need the paramedic training for emergency trauma, but we need more primary health care. Should also have an advance [advanced] clinical course and a supervisor type course.”

S_141. “Have re-training on skills every few months as a refresher. You lose your skills way quicker when you don't have the opportunity”

S_132. “Focusing more on the military role a medic plays rather than civilian nursing. Military skills weren't practical and the majority of the course was civilian run other than 2 weeks. CBC training was the most beneficial of the course in my opinion. Make more available courses.”

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Skills Maintenance

Skills and knowledge maintenance were viewed negatively by most participants (~89%). The two areas of skills maintenance discussed by respondents were clinical placement and simulation. Simulation was more positive than responses regarding clinical placements, with the use of positive/negative responses being more common for simulation than for placements. Responses regarding simulation were generally negative (~59%), while the majority (~81%) of responses about clinical placement were negative.

S_93. “I haven't done too much placements or deployments, but the one I have done have all been in hospitals and in the Gallipoli Barracks HC. I was used to working on the wards because we did 10 weeks on our ADFMC. Being a medic now for over a year, I realised that working in a hospital on a ward is not the same work I do as a medic. I'm not sure if it's very relevant. You do though get to practice working with patients and their families. It also develops your clinical decision/diagnostic skills. More useful is working in garrison, but the couple of time I worked in the health centre I just did paper work for the week. The staff would let us do anything hands on with patients.”

FG4_F. “Not very sure. Most of my clinical placement was in a medical ward and working with my scope of practice as an EN, I wasn't able to do too much. I also feel that since the majority of what we do as Med Tech is primary health care, I cannot see the relevance of working in a ward. I suppose just dealing with patients does improve how we deal with patients.”

S_138. “I was lucky to get a week in maternity during my two week placement. The maternity was relevant in preparing me for humanitarian deployments. Working on the surgical ward was not very relevant to me as a medic in 11 CHC. I normally work as an integral medic so I need to work more in GH.”

S_29. “All clinical placement has been relevant due to exposure to patients but I didn't actually get much benefit as a medic. I understand that any type of clinical placement will always be of benefit, I would prefer if my placements

148 were more relevant to what I do. I think we should do time in an ambulance for our trauma skills, but the rest of the time we should work in the health centre.”

S_109. “I'm not sure that being thrown out on a ward, or in ED or in Garrison without a preceptor is very useful. All we do in the hospital is more of what we have already done during our course, so we got nothing more from the 10 days. ED was a bit better because we could do much as ENs but at least the staff included us and when they had the time explained what was happening. My garrison placement was ok, but again spending time with a NO who can't do more than me as a medic/EN was not very educational. We should get to work with the MO.”

S_45. “I would say that my clinical placement was relevant as far my primary health placement in the health centre is concerned, but when it comes to working on a ward it has very little relevance as an integral medic. Ward placements is most spent washing and feeding patients. While I take lots of obs, there is very little opportunity to practice my nursing skills. Working in the health centre gives me more opportunity to learn rather than practice. Since we get little PHC training, most of my garrison placement is spent watching triage and sometimes the MO call us to have look at something. I would like to see more placements in garrison and less hospital placements.”

S_77. “I suppose it has been relevant. Even though I feel that my placements in RBH was not relevant, I was in contact with patients and so there is some benefit. But if I was asked if it is directly related to my role as a medic, not too relevant. I thought placement was to not only practice the skills we will do on operations, but to also learn new skills. But most of our placements are either shadowing hospital staff or if we do get a patient load, depending on the shift we spend most of the time washing and dress our patients and then cleaning. Not much medic type work.”

FG1_H. “Could have been better. To get the most of our placements, they must be more structured and use the opportunities as training and not just practice.

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I also noticed some of my mates go more from their placements that me or some other mates because when they went the staff let them do more and there were more patients.”

S_138. “Yes. Very relevant. I have only worked in the health centre so far and I picked up heaps of knowledge about PHC. I was luck as the staff were happy to let me do clinical work. The MOs did call us in when they thought there was something we could get from seeing it.

S_50. “Working as a EEN has allowed me to better develop and improve my nursing skills. The NO I worked with on placement explained that every patient interaction is a chance to practice our skills in communicating with patients, assessing them and dealing with medications. So yes my placements were good and help me get better as a medic.”

S_103. “No. Not relevant at all because what we do and the way ENs are employed there is little benefit. But I work in a nursing home on weekends and I do lots of thing that help me improve as a medic. On weekends I get to do medications rounds, general health assessments, dress wounds and lots more hands on nursing/medical skills.”

S_12. “We should have more different types of simulation. Most of our simulation is SimMan, but we can use other models. We also need more structured sessions instead of randomised training”

S_107. “Simulation should be more regular and cover more type of scenarios.”

S_100. “More realistic. More money for moulage.”

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Sense of Duty

The common thread that ran through participants’ reasons for becoming Medical Technicians was their sense of duty in helping others, especially other Australian soldiers who are willing to sacrifice for others. The intent of the following statements was common in various forms:

S_170. “I joined to help the people who can't help themselves. But I also joined as a medic to serve Australia and to help the soldiers who put their lives on the line so others can have a chance at theirs.”

S_15. “I had a mate who was badly injured in Afghanistan, so I decided that I wanted to join as a Med Tech so I could make sure that others injured on ops where looked after and that they would come home.”

S_144. “I decided to join the Army to serve my country and thought I could better serve by helping look after our wounded and ill.”

This sense of duty was also present, but not as common in the responses from participants who had prior military service and Corps transferred to RAAMC and Medical Technicians:

S_1. “Working with medics and then doing my CFA26 course convinced me my future was as a medic. Having seen the amazing work name deleted [our medic] did in Afghanistan to save name deleted life was my life changing moment. As soon as I RTA [Retuned to Australia] I put my request for transfer in. I wanted to make sure that my mates were saved if something happened to them.”

S_88. “CPL [Corporal] name deleted [medic] was the most professional solider I’ve severed with and when we deployed and I saw the difference he made to

26 Combat First Aid (CFA). The CFA course is a 12-day advanced first aid course that members form all Army Corps can undertake to learn a range of point on injuries emergence skills.

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us. We new [knew] he had our back always. I said that’s what I wanted to do so I became a MT.”

Interest in Health

An interest in health/medicine was another common theme to emerge from participants’ responses.

S_106. “I did some research on the job role before finishing my Year 12 Certificate I wanted to work in health. After researching Medical Technician in the Army I was interested in the experience, travelling, income would be steady and most of all to wear the uniform and serve the country.”

S_21. “I enjoy helping people, I have a high interest in learning about health in combination with the intensity and active lifestyle of the Army it was a perfect combination.”

S_6. “I wanted to do humanitarian work so I decided to join the Army and train as a medic. This would give me the medical education and the military skills to work in disasters around the world.”

S_178. “I joined because I wanted a job in the health industry and thought the training and experience I would get in the Army would help me when I decided to leave.”

Civilian Qualifications

Gaining civilian qualifications was common amongst many participants’ responses, but was a major reason given by in-service Corps transferees.

S_41. “I was tired of being a grunt after 5 years and 2 deployments, but with no real qualifications. After doing my CFA course in 2009 it opened my eyes to the medical world, I felt I had a purpose as a CFA and enjoyed doing medical things, so why not make a career of it.”

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S_149. “I had to do something before my body broke after about 6 years, so I looked for a job that gave me the best civvie qualifications. So I applied and transferred to medics. Having heaps of mates who are medics, they all said that being a medic was the best job to get civvie qualifications and the best trade to get posted to Brisbane.”

S_13. “Wanted to Corps transfer, but wanted a trade that would allow me to work with the infantry again.”

S_91. “Thought that doing a job with good civilian qualifications was smart.”

Segue to other Health Professions

Another common theme was the number of participants that stated the reason for becoming a Medical Technician was to use their training and experience as Medical Technicians as a segue to other health professions.

S_180. “Getting two Diplomas would help me get into Uni to study nursing.”

S_31. “Though that it would be better to get some experience under my belt and then go and study medicine.”

S_73. “Having a Diploma in Nursing gave me almost 50% credit towards my Nursing Degree, which I then hope to become a Nursing Officer.”

S_64. “I want to become a doctor, so having experience and qualifications to get to university is a good thing”

Family History

A family connection with either RAAMC or being a medic was another common motivation factor. A family history was most common with ab-initio Medical Technicians.

S_4. “I have a family history with RAAMC, so it was just going to happen.”

S_40. “My father is a Paramedic. I decided to follow him into medical.”

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S_108. “Both my parents were in the Corps so I wanted to follow in the family tradition.

Miscellaneous Themes

In addition to the key themes identified from the codification process, some less common codes identified, though limited to individual responses added to the rich narrative as to why people joined the Army as Medical Technicians.

S_8. “Joined as a medic because they had the shortest wait time to get in.”

S_11. “Joined the Army in 1985 RAAMC was my second choice”

S_163. “Due to being colour blind I was unable to be in a combat corps. Also upon looking further into it medic course offered good civilian qualifications”

S_91. “My sister is as RN and I was working as a receptionist at a Physio clinic, enjoyed learning new skills and for the above reasons though Defence might be a good fit with travel and education opportunity”

S_49. “MT was the most interesting job that I looked at.”

Qualitative data from the open forum discussion and focus group discussions provided the same themes as reasons for joining as Medical Technicians that were collect during the survey. There was one issue raised during all the focus discussion sessions regarding the quality and honesty of recruiting information regarding Medical Technician. While my research did not consider the recruiting process, it is worth rising here as it was a cause of animated discussion.

FG4_A. “I was told I would be spending most of my time working in a health facility, not that I would be spending over 200 days out field.”

FG1_F. “The recruiters really sold being a med tech, though they never tell you about the nine months out field or the time you’ll be spending repacking store.”

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FG3_C. “They told me that I would be working in a clinical role every day. They made it sound like I was going to work as a EN in a hospital and then as a paramedic out bush. It’s all bullshit.”

FG3_G. “I was told being a medic would be all clinical and working with the latest equipment. But my dad told me they’re simply doing their job sell every job to get you to sign up. So I knew they were lying.”

FG8_D. “Other than our training and the locations of where we may be posted, nothing that recruiting told me ended up being true.”

Expectation Management

More than half of the participants responded that their expectations of their service were unmet, with comments such as “I have been very disappointed so far” being a typical response. The next most common response was from participants who indicated that their service to date has met their expectations with some caveats, “overall yes, but there are things that disappoint me”. Few study participants stated that their service had met their expectations, “so far so good, our training has been really good and getting to the unit was good, but time will tell.” It seems participants’ expectations being unmet are equally split between unmet expectations relating to their Army service generally, “my service as a Med Tech has been what I thought and told it would be, but being is the Army has been disappointing”, and being a Medical Technician, “the Army has been what I thought being in the Army would be, but being a medic has not been what I was told at recruiting.” Generally, participants with less than 12 months post Initial Employment Training, or with a family history in RAAMC, or had prior military service were more likely to have indicated met expectations:

S_171. “With my family history in medical Corps, I knew what I was getting myself into.”

S_34. “My course has been the highlight of my career. But once in the unit, being a medic is nothing like what I expected.”

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FG6_B. “My service has allowed me to do a broad range of training and employment.”

S_23. “Doing my training and being posted to Brisbane is what I expected when I decided to become a medic.”

S_80. “Deployment experience. Good health education. Good job security.”

S_163. “It is what I knew my training would be and how I would work in the unit.”

FG7_G. “Having served in the Infantry, I had a realistic idea of what to expect as a medic. While it has not been the best all the time, our training was really good. Life in the unit is pretty bad, but it’s no different to other units. The biggest issue is that everyone is unhappy because we don't get to do our job as a medic. We do spend heaps of time out field, but we don’t do much clinical work. But it could be worse.”

Respondents who had more than 18 months in their units, or had been in the Army before the Combat Health restructure, or had never deployed were more likely to have responded that their service expectations were unmet.

FG1_A. “It has not met my expectations at all. Other than our training which was really good, I haven't done any further training or skills development.”

FG4_C. “My course has been the highlight of my career. But once in the unit, being a medic is nothing like what I expected.”

S_58. “Everything about being a medic is what I expected, except the restructure means that we don't get to work with the battalions as much as they used to.”

S_59. “Other than my training which is exactly what I was told at DFR, everything else is nothing like I was told or expected.”

S_41. “I knew what being in the Army would be like, but I thought being a medic would have more opportunities to deploy, but all we do is spend time out field.”

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FG2_E. “I became a medic because if thought it would be a challenging and varied job. To date the most challenging aspect of my job is keep up my morale when in barracks. When out field, my service has met my expectation.”

S_177. “I always thought being a medic would mean I would be working in health centres and out field working as a medic supporting a unit, but I seem to spend a lot of my time working in the stores and then get smashed working out field providing health support so the other units can train.”

Career Management

Career management was another common theme, again the divide between positive and negative comments were based on duration in units post Initial Employment Training. For most participants with less than two years post Initial Employment Training, career management was not raised as an issue. Participants with over two years post Initial Employment Training service had a generally negative view on career management.

S_20. “No chance for the career opportunities I seek and the lack of progression is really disappointing.”

S_111. “Dissatisfied with career path, posting opportunities and who you have to suck off to get nominated for courses.”

S_174. “After three years there is no talk of promotion, even though there are CPL vacancies. You have to suck up hard to get promoted, even to lance jack [LCPL].”

S_67. “Have been a SGT for five years and still haven’t been nominated for a sub 2 [Subject Two for Warrant Officer].”

OF4. “If your [you’re] male and MEC 1, then you never get looked after. Me and my mated have spent so much time out field that when there are opportunities for promotion cse [courses] or other training we miss out and the medics in the unit get rewarded. “

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S_38. “I’m fully qualified for WO1 for trade (Ha Ha) but trying to get nominated for a JLC [Junior Leaders Course] is impossible since I’m always away on task. I really want to get posted to JHC but I keep getting told by my CoC [Chain of Command] that this is unlikely since for service reasons I need to stay in the close [1 CHB].”

FG5_A. “Career management doesn’t exist for medics. We have so many vacancies and non-deployable members that it’s impossible to get out of 1 or 2 [1 CHB or 2 GHB] if you’re MEC 1 or 2. And you can forget about promotion, since you’re never seen by the boss they focus more on the medics that are around in the units.”

Operational Tempo

Operational tempo was a common theme and was the underlying reason for unmet expectations, family pressures, inability to maintain clinical currency, failure to maintain mandatory continuing professional development requirements, and unable to undertake additional education. In all responses, operational tempo applied to external support tasks away from their parent units, more likely out field, and not to the work load while in barracks.

S_96. “The work tempo at the unit is not conducive to studying.”

S_122. “Work tempo. Too many tasking's. Unit makes it hard to undertake placement. Not supported by Chain of command.”

S_99. “Someone must look at what medics do and then produce a [an] instruction that can be achieved in the current unit tempo. AHI5 thinks we don’t do anything all day.”

S_39 “The high tempo with no reward = jaded members!”

S_131 “I’m waiting to get posted to a unit with lower tempo so I can continue studying.”

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S_101. “Tempo will not allow for additional clinical placement…”

S_6. “The tempo of the workplace/Brigade. Spending numerous months out field over 12 month period.”

S_32 “Look at something that can be done in the current unit tempo. Should look at what is really needed and no more. Get rid of the time in hospitals and replace it with more primary health care time in the health centres.”

S_162. “It’s impossible to do anything, study, placements, CPD because there are to [too] few medics on the ground, or when there are only a handful of us can actual go field because we are MEC 1.”

S_10. “More medics. Longer time of lower tempo. More time off for decompression after long tasks.”

S_55. “People only de-skilling over time and the little time we have of reduced tempo periods is not enough to maintain skills. We need less work or more people. We are exhausted and are both mentally and physically drained.”

In addition to operational tempo, the other interrelated reason restricting Medical Technicians’ ability for ongoing development was the lack of resources to pay or provide for development activities and education opportunities.

S_8. “Not enough time and I was told we couldn't get any DASS”

OF3. “Every time we ask for money to pay for some external training we’re told there’s not enough money available for CPD and that there are higher priorities in the unit. For some reason our chain of command doesn’t see Med Techs development as important as the Nursing Officers or MO’s.”

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Leadership, Supervision and Mentoring

While the theme of leadership, supervision and mentoring were raised in both positive and negative terms by participants. At unit level, leadership, supervision and mentoring were viewed more positively than when discussing the senior leadership of RAAMC and the AHS more broadly. At unit level the majority of negative responses were reserved for the level of clinical supervision and mentoring, with comments such as:

S_129. “The level of clinical supervision is almost non-existent. I don’t know if this is a problem in my unit or a problem of our training since we’re trained to work independently so the unit is happy to send out new medics out with little to no supervision. We have our protocols but nothing else.”

S_17. “If I have to ask a question when out on task and I’m unsure, there is no one to ask. We keep getting told its going to get fixed but were still waiting. We have set up our own little network of MT and if you have a question, you msg [message] them and someone will answer or they might ask one of the docs.”

S_161. “Last year we had really good officers who took an interest and would always make sure we had some level of supervision even if it was over the phone but this year I have spent about 180 days out field with nothing no supervision.”

S_33. “You can’t get clinical supervision if the MOs are always out of the unit doing the placements or working in the civvy [civilian] GP practice.”

S_65. “Your level of supervision depends on your MO and NOs. If they are good they take an interest in us if they don’t know what they are doing then we are felt alone.”

FG8_A. “When working in the HC or out field as a treatment team is when you get the most supervision. In five years I haven’t had anyone formally take me under their wing to mentor me or develop me.”

FG5_C. “I’ve had good supervision, but our officers are also being smashed so they don’t have time to worry about us.”

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While formal unit mentoring attracted much negative commentary from respondents, there was universal positive feedback regarding the informal mentor networks established in units:

S_28. “Since our COC [Chain of Command] do have a mentoring program we created a network of experienced medics to look after the baby medics. We mostly take them through what equipment they will need for different support tasks and discuss the types of conditions they are likely to have to treat. Sometimes we get calls from the baby medics when on task asking about possible diagnosis and suitable treatments.”

S_147. “Being able to call my mates when on out field alone has helped me many times. If I’m not sure about something I usually call one of my mates before calling the MO I know others do the same. It stops you looking like a dick to the MO by having a better idea.”

FG1_3. “When I arrived at the unit, there was no formal induction process, oh there was for marching in, but nothing to help understand what I was expected to do and who things ran. We picked most things up from our mates. Even when going out on a support task, we would speak with our mates who had been out with that unit before or what type of CL8 I should pack for the trip.”

Unit leadership was well regarded by the majority of respondents, with the common theme being that the officers in the soldiers’ chain of command were generally proactive, supportive and protective of their soldiers.

S_135. “Our officers look out for us and will try whenever they can to say no to all the med support tasks coming through. But our HQ is being smashed by BDE to do more so we keep getting smashed.”

S_124. “The CO is trying to make things better but her hands are tied.”

FG2_G. “Our OC and the CO do care about how much field time we’re doing, but they can’t stop it. When our CO visit’s she looks like she really cares, but 17 Bde is the problem.”

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S_142. “When the CO finds out about problems he usually fixes them. But sometimes the problems never get raised outside the COY.”

S_118. “The problem is Army and brigade. Everyone needs medical support to train so they keep tasking us. I know the unit is trying to get money to get contractors for some task, but not for the short notice jobs.”

On the whole, responses regarding RAAMC and AHS senior leadership was negative, with the main criticism focused on the Combat Health Restructure and the current structure of the ADFMC:

FG4_F. “The restructure was not explained to us properly, the people that were employed with the old structure and things were told to us that have not yet happened but were told that the structure would have to change for them to happen. e.g. resources needed to do our job, clinical placement, etc.”

S_70. “More position at the SNCO/WO level to open up IOT be promoted. There is a bottleneck at WO2 due to positions being culled thanks to the health restructure.”

S_82. “Everything about being a medic is what I expected, except the restructure means that we don't get to work with the battalions as much as they used to.”

S_104. “Whoever came up with the ADFMC had no idea what MT do. ADFMC trains us to be EN and work in a team. We have good knowledge but little confidence in doing anything more than working on a ward or in the back of an ambulance as part of a team. We need more skills in primary health care and knowledge to be able to work remotely.”

S_136. “Getting out dealing with patients is relevant. But I don't think it increases out knowledge. We are all EN so working on a ward gives us nothing more. Working in the back of ambulances is again not really giving us any more knowledge. In JHC is where we get the most out of placements as we are learning and doing PHCT which we did not do much during our ADFMC. The

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ADFMC is all about getting civvie [civilian] quals. DAH should not have left this happen. The course was designed by nurses for nurses.”

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Chapter 7: Discussion and Conclusion

“If you follow reason far enough it always leads to

conclusions that are contrary to reason.”

Samuel Butler (n.d.)

Introduction

This chapter discusses the results of this study in light of existing literature as a basis for the development of key recommendations and research conclusion. The chapter begins with reviewing the research aim, integrating the quantitative and qualitative results from Chapters 5 and 6, then interpreting the study’s findings, and relating them to the existing body of knowledge of health workforce preparedness. It includes discussion of potential limitations of this study, followed by the conclusions and future perspectives for related research. Finally, this chapter, as well as this research project, is brought to a close by some concluding remarks.

This chapter draws upon the data and relevant literature to develop and discuss the human capital model developed to answer the central research question: how to develop and maintain a high readiness and adaptive health workforce. Interpretation, integration and comparison of the data with the literature will be presented in three sections, each addressing one of three human capital elements of people capability:

Training, Education and Development – developing a training continuum to ensure Medical Technicians are trained, educated and developed to deliver meet the required level of clinical care.

Maintenance of Skills, Knowledge and Attitudes – maintaining the critical skills, knowledge and attitudes required to maintain Medical Technicians’ clinical readiness.

Workforce Retention – addressing the key challenges to retaining a capable health workforce.

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Summary of the Research

The aim of this study is to present a human capital model for developing and enhancing a high readiness and adaptive health workforce, by examining the preparedness of the Australian Army’s Medical Technicians. This study suggests that the current measures used to determine the readiness of Army Health Services personnel fails to assess or measure clinical readiness. To address the challenge of maintaining clinical readiness during peacetime, the Australian Army must move from readiness system that is focused on measuring readiness inputs to one focused on measuring outputs.

Review of the Research

As discussed in Chapter 3, a convergent parallel mixed method (see Figure: 20) was used to collect and analyse the results as presented in Chapters 4, 5 and 6. The study began by situating the research through an examination of the nature of military operations, the characteristics of warfare, and how the Australian Defence Force generates military capability in order to meet Australia’s military strategic intent. This examination of how the Australian Defence Force generates capability, showed that capability is the sum of Force Structure and Preparedness (see Figure: 20), which is both a long term, and dynamic process (DoD, 2013a; DoD, 2016b). Additionally, this research looked at military medicine, how it is applied in the Australian Army, and how Medical Technicians are trained, developed and employed in order to contribute to the operational success of the Australian.

Figure 20: Convergent Parallel Mixed Methods (adopted from: Creswell, 2014)

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As discussed in Chapter 1, Preparedness is the product of the sum of Sustainability and Readiness (see Figure: 21), with readiness being the physical application of the Fundamental Inputs to Capability (DoD, 2013a).

Figure 21: Relationship of Readiness to Capability (adopted from: DoD, 2013a)

This study focused on the Personnel element of Fundamental Inputs to Capability, which focused on the People as a capability, allowing for the examination of the individual training, development, skills maintenance, and the retention of Medical Technicians.

Limitations of the Research

As with all research, this study had limitations that are worth noting in order to acknowledge the boundaries of this research. Limitations associated with selecting a convergent parallel mixed methods design were addressed in Chapter 4, including the measures taken to minimise the impact of these and other methodological limitations. Therefore, the limitations of this research to be discussed will focus on selection of research participants and on the conduct of the data collection and analysis.

Participation in this research was limited to Australian Regular Army Medical Technicians posted to the 1st Close Health and the 2nd General Health Battalions. The study may have produced different results if study participants included Medical Technicians posted to Joint Health Command health centres, and to Medical Technicians posted to non-clinical positions. Similarly, including Medical Technicians from the Royal Australian Navy and from the Royal Australian Air Force may also have

166 resulted in different research outcomes. Furthermore, broadening the research to include other Army clinical craft groups may have impacted research findings; especially in the area of skills maintenance, differently.

Undertaking face to face data collection using a paper based survey instrument may have limited the number of Medical Technicians participating in the study. Furthermore, using an on-line survey may have also reduced the amount of time taken for data analysis. In addition, undertaking open forum discussions and focus group discussions before administrating an online survey may have provided participants with a better understand of the purpose of the research. This may have produced different results. The research may have benefitted by including a series of workplace field studies by observing Medical Technical in their workplace, allowing for better contextualisation of some of the study findings.

The research did not investigate or undertake a study into the specific range of tasks and skills Medical Technicians perform in order to provide the range of clinical effects within their scope of practice. Therefore, a task inventory was not undertaken as part of this research as it was beyond the scope of this study. Though it should be noted that the Australian Defence Force has undertaken a number of task Inventories for Medical Technicians, including the two Occupational Analysis conducted in the 90’s (DoD, 1991; DoD, 1995). Undertaking a task inventory, or an Occupational Analysis as part of this study may have provided a further validation of the data regarding actual workplace activities. Furthermore, since the aim of this study was to develop a conceptual model that can be utilised to develop and maintain a high readiness health workforce, the development of metrics to measure readiness is beyond the scope of this research.

Finally, this study only examined the clinical aspects of Medical Technician’s employment requirements. This study did not examine the range military skills and competencies Medical Technicians require in order to carry out their duties. The range, depth and type of military tactical skills required by Medical Technicians vary, and change depending on the type of unit they are supporting, as well as the environment they are operating in. There are a broad range of military skills that everyone in the

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Australian Army is required to be trained in and to maintained, which are delivered throughout an individual’s career. All Corps skills, knowledge and attitudes are delivered during the All Corps Soldier Training Continuum (ACSTC), that commences with the soldier’s recruit training, and continues as the progress in rank. The decision to include All Corps skills, knowledge and attitudes may have had an impact on the overall outcome of the study, though it is difficult to judge, since the focus of the research was purely on Medical Technician’s clinical preparedness and the maintenance of their clinical competence.

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Integration of Quantitative and Qualitative Findings

The findings presented in Chapters 5 and 6 show that the quantitative and qualitative elements of the study were closely aligned with each other in terms of providing confirmation of trends. The integrated data highlights consistencies in responses, with no contradictions between the quantitative and qualitative responses. This enhanced the external validity of the overall research, which apart from the triangulation of the results, the combination of the quantitative and qualitative approaches overcame the limitations of each research method.

Training, Education and Development. It was found that when considering their training, education and development, respondents were generally negative. While the quantitative responses were generally less negative than with their qualitative responses, participants were able to provide further insight as to their perceptions. As mentioned in Part 2, where respondents provided a positive response to a quantitative question, they usually expanded on this by providing a “positive-negative” explanation. For example, participant S_134 provided positive quantitative responses regarding their training, but went on to explain that their training “… prepared me adequately (Positive) for working on a ward or dealing with trauma, but provided me with very little training (Negative) for providing primary health care when I’m working out field or in the Health Centre, which is what I do 90% of the time.” This manner of responding was especially common when respondents were discussing their initial training. An explanation for this response pattern can be that when provided with a Yes or No option, the positive aspect of their overall training experience was their focus, thereby attracting a positive response. But once they explained their response, participants were able to highlight the negative aspects of their training, more specifically the training shortfalls that impacted them once they were posted to their units. Though, it was noted that when discussing ongoing training, education and development opportunities, both datasets were similarly negative.

Maintenance of Skills, Knowledge and Attitudes. When integrating both datasets regarding skills and knowledge maintenance, responses were consistent. The generally negative responses were related to the participants own clinical readiness and their

169 inability to maintain the skills and knowledge they require to deliver primary health care. Although the majority of respondents were positive in their ability to respond to trauma and to provide advanced life support due to use of simulation, rather than their clinical placements in civilian ambulances. While there was consistency in the mostly neutral responses in the area of health simulation, most of the negative responses were regarding the use of simulation was directed towards the amount of simulation conducted, and in the use of particular simulation models.

Workforce Retention. There was universal consistency regarding workforce retention between the quantitative and qualitative datasets. The negative responses (~60%) surrounding member expectations were due to lack of ongoing clinical training, continuing education and development opportunities and the amount of time spent away from home providing health support.

There was some inconsistency between the reasons given as to why participants have decided to separate, and with what they indicated would help retain them in the Army. While most identified family issues, too much time out field or posting location as reasons for leaving, these same members stated that more clinical training, relevant placements and continuing education opportunities would/could encourage them in remaining in the Army.

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Section 1 – Training, Education and Development

Training and education, together with experience collectively contribute to “professional mastery”, which is a constituent element of fighting power (DoD, 2015d). For it is through professional mastery that the Australian Army facilitates individuals and teams to develop the skills, knowledge and attitudes that enable the successful conduct of military operations (DoD, 2017a). Since mission success relies upon the individual to respond, and adapt to an unpredictable and constantly changing situation (DoD, 2017a), it is vital individuals are competent and have the skills knowledge and attitude to perform their foundation warfighting skills 27 . For Medical Technicians, professional mastery is achieved through the combination of Clinical Professional Mastery and Military Professional Mastery, underpinned by the Australian Army’s values and culture, see Figure: 22. Clinical Professional Mastery is achieved through the combined achievement (see Figure: 23) of:

Clinical Skills Knowledge and Attitudes: i.e. Initial Employment Training, etc.

Military Specific Clinical Skills, Knowledge and Attitudes: i.e. Medical aspect of CBRN injuries, etc.

Recency of Clinical Practice: regular application of clinical SKA, either on the job or through simulation.

Ongoing Clinical Education/Training: i.e. advanced clinical training through attendance of promotion courses/advanced clinical courses and training

Continuing Clinical Professional Education: i.e. attending conferences, publishing papers, etc.

27 Foundation warfighting skills includes both All Corps soldier competencies such as weapon handling, marksmanship, navigation, field craft, battle fitness, etc; as well as the core specialist trade skills; i.e. the Medical Technician’s clinical skills, that allow the individual to operate with confidence, speed and agility in environments where operational uncertainty is the enduring characteristic (DoD, 2014b).

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Figure 22: Medical Technician Professional Mastery

Figure 23: Elements of Clinical Professional Mastery

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Initial Employment Training

ADF Medic Course. Every Medical Technician’s journey towards Clinical Professional Mastery begins with undertaking Initial Employment Training, which is delivered during the ADF Medic Course. As discussed, Australian Army Medical Technicians undergo 76 weeks (376 days) of competency-based training, focusing on Nursing and Paramedical Science (DoD, 2015c). As detailed in Table 5, 53% of the ADF Medics course is allocated to delivering the Diploma of Nursing (198 days), with 19.1% (72 days) allocated to the Diploma of Paramedical Science (DoD, 2015c; DoD, 2016e).

As discussed in chapter 6, most Medical Technicians provided positive/negative answers when responding to questions regarding their initial employment training. Comments from participant S_19 are typical of the positive/negative comments regarding Medical Technician’s initial employment training:

“My ADFMC was a great. It was pretty challenging on the academics, but gave us a great foundation in medical knowledge. When we graduated we felt 10 feet tall. I was wrapped that I now had two Diploma’s and was a trained EEN and Paramedic. (Positive) The problem is after getting posted to the unit I didn’t know what I didn’t know. When I was sent out to provide health support as an integral medical was so out of my depth. I didn’t do any nursing and lucky for me had no emergencies. All I had to treat was rashes, gastro and sprains etc conditions. Looking back now the ADFMC didn't prepare me for my posting to 1 CHB where I provide primary health care for 100% of my time. (Negative)”

The research highlights that the ADFMC is not providing Medical Technicians with all necessary skills, knowledge and attitudes they require to adequately perform their current duties, both on operations and in Australia during peacetime. The study revealed that while 71% of respondents were positive about the ADFMC, 78% were concerned that the course did not prepare them adequately them for their primary role; the provision of primary health care, both in garrison and while out in the field.

It should be noted that the ADFMC does cover some primary health care training, including training on the use of the Primary Clinical Care Manual. Modules 3 – Military

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Medicine, and 7 – Provide Combat Health Support, are the two modules that provide primary health care and military specific clinical training (DoD, 2015c). These modules also contextualise the application of the skills attained during module 2 – Diploma of Nursing, and module 5 – Diploma of Paramedical Science. The two modules cover 44 days or ~12% of the total ADF Medic course cover (DoD, 2015c).

A common phrase used during the open forum disunions and during the focus groups discussion was ‘sink or swim’. Medical Technicians provided numerous examples where newly graduated Medical Technicians were ‘thrown in the deep end’, as highlighted by the comments of participant S_35:

“…within four weeks of marching in28 I was thrown in the deep end by being sent out to support a 1 RAR training activity with no consolidation of my training… or additional training in primary health care…it’s like the chain of command wants us to sink or swim…’.

While all the reasons why newly graduated Medical Technicians are being ‘thrown in the deep end’ are beyond the scope of this research, being considered job ready immediately post training is a key feature of competency-based training. Competency based training is outcome-based training whereby the trainee demonstrates they have met all the workplace competency standards; i.e. skills required to perform their ‘job’ (Guthrie, 2009). The Civil Aviation Safety Authority defined competency-based training as training whereby a person is trained and assessed to meet the specific standards that define the skills, knowledge and behaviours required to do a job safely and effectively, which includes complex and simply tasks (Civil Aviation Advisory Publication [CAAP], 2009). This means that at the end of their training, a person is able to perform their job or task to the appropriate standard in the workplace (Guthrie, 2009; CAAP, 2009; DoD, 2011b).

28 Marching-In is a common military phrase that describes an officer or other rank arriving to a new unit on positing. It includes activities such as arriving to the unit, undertaking a series of administrative processes.

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Since being ‘job ready’ is the cornerstone of competency-based training, Medical Technicians concerns that they are being ‘thrown in the deep end’ because they feel they are not ready, means there is a problem with the content their training, and not how the training is delivered. Under competency-based training and assessment a soldier is assessed as being either ‘competent’ or ‘not yet competent’ in a particular workplace skill (DoD, 2003). If deemed competent the soldier has demonstrated through application in a workplace environment, the knowledge, skills and attitude required to a specified level of competence (DoD, 2003). While some post training consolidation is expected, this is usually limited to providing an opportunity for supervisors to identify any skills shortfalls relevant to that particular workplace, or to impart any unique workplace requirements (DoD, 2003).

Therefore, in light of data collect during this research, Medical Technicians graduating from the Army School of Health as competent, are failing to meet the workplace competency requirements without further on the job training. This means that Medical Technicians are not being trained in the skills, knowledge and attitudes they require in the workplace. Since the majority of a Medical Technician’s time in the workplace is spent providing primary care in a pre-hospital environment, then spending 198 days (~53%) out of a 376 day course training Medical Technicians as in-patient health care providers seems rather illogical.

The research findings that Medical Technicians provide primary health care for the majority of their time, collaborates the findings from the Department of Defence own research (DoD, 1991; DoD, 1995). In 1991 and again in 1995, Defence undertook two extensive Occupational Analysis 29 surveys of the Medical Technician employment

29 Occupational Analysis is a systematic method of gathering and analysing data about a worker (job incumbent) and about the work they do. It involves the analysis of the components of an occupation. An occupation is described as a set of jobs and a job is described as a set of tasks. Occupational Analysis begins at the task level and links commonly performed tasks belonging to a common set of workers to form a job type. These job types combine to form an occupation. This form of analysis allows sponsors to make management and training decisions using factual, objective information (National Research Council, 1999).

175 category. The objective of the two studies was to provide occupational information in order to identify the training requirements for a potential tri-Service Medical Assistant course (DoD, 1991; DoD, 1995). The findings from the two Occupational Analyses concluded that Medical Technician training need to be refocused towards pre-hospital care training and advanced emergency life support training (DoD, 1991; DoD, 1995). It should be noted that despite the fact that the two Occupational Analyses were conducted at a time when the Australian Army had major hospitals in Sydney and Brisbane, and regional Camp Hospitals, where Medical Technicians provided the majority of in-patient care, the requirement to refocus training away from in-patient care is telling.

Despite the findings of two Defence sponsored Occupational Analyses; the closure of all Army and Defence run in-patient care facilities, and that the majority of Medical Technicians work in the pre-hospital care environment, Medical Technicians continue to be trained and registered as Endorsed Enrolled Nurses (EEN). Furthermore, the Australian Army has only one unit, 2 GHB, that provides medium to high intensity nursing care the area of operations (DoD, 2016g), accounting for less than 15% of all of Army’s Medical Technicians engaged in the provision of direct nursing/in-patient care.

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Primary Care. The issue of Primary Health Care was identified as the most significant shortfall in the current Medical Technician training continuum by over 92% of research participants. While Primary Health Care training on the ADFMC has been discussed above, what exactly defines Primary Health Care requires further examination in order to better understand the Medical Technician training requirements.

Primary health care is a term which has many different meanings to different people, therefore to understand the complexities behind the term, the relationship between Primary Health Care, Primary Care, Population Health and General Practice must be discussed. The modern definition of Primary health care originates from the 1978 International Conference on Primary Health Care, held in Alma-Ata, USSR, and known as the Declaration of Alma-Ata (Declaration of Alma-Ata, 1978; Cueto, 2004). The definition of Primary Health Care, as defined by Declaration VI (Declaration of Alma- Ata, 1978) has been adopted and adapted by countries around the world to suit their specific community and cultural needs. The common Australian definition for Primary Health Care, developed by the Primary Health Care Research Institute (PHCRI), and based on the Declaration of Alma-Ata is “…health care [that] is socially appropriate, universally accessible, scientifically sound first level care provided…[by] a suitably trained workforce comprised of multi-disciplinary teams…that gives priority to those most in need…[and] includes health promotion, illness prevention, treatment and care of the sick…” (PHCRI, 2017).

Primary Care on the other hand is considered as being the first point of engagement with the primary health care system, where the focus is on early diagnosis, and where required, on the timely and effective treatment (Declaration of Alma-Ata, 1978; Keleher, 2001; Rogers & Veale, 2003; Awofeso, 2004; Cueto, 2004; Patterson, Price & Hegney, 2005; Muldoon, Hogg & Levitt, 2006; PHCRI, 2017). As an element of a public health strategy, primary health care is derived from the social model of health, which is based on the understanding that to achieve and sustain people’s health and wellbeing; a comprehensive primary health care approach that addresses a range of social and environmental factors that cause ill-health, as well as those that sustain and create good health is required (Declaration of Alma-Ata, 1978; Keleher, 2001; Rogers

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& Veale, 2003; Awofeso, 2004; Cueto, 2004; Patterson, Price & Hegney, 2005; PHCRI, 2017). In simplistic terms, primary health care is a noun that describes a system, while primary care is the verb describing the effect that is being provided by a primary health provider within a system. Therefore, while the Medical Technician may be the first point of contact between an individual and the health system, this engagement takes one of two courses. This may be the individual’s only such health engagement, or this engagement may result in the Medical Technician referring the individual to a higher level health care provider within the primary health care system. Therefore, to effectively deliver the training Medical Technicians require to perform their duties, the narrative must focus on the clinical effect being delivered; i.e. Primary Care, rather than on a core principle of health care delivery within a system, Primary Health Care.

This research reinforced Defence’s own research (DoD, 1991; DoD, 1995) that the majority Medical Technicians; when working as independent practitioners, predominately provide primary care to treat a range of acute and chronic medical conditions (‘general practice’ or traditional ‘doctor’ type presentations), and point of injury life support in pre-hospital environments. In other employment settings, generally as part of multi-disciplinary health teams, Medical Technicians provide additional types of health care, including in-patient care, injury and disease prevention (DoD, 2015c; DoD, 2016e). Taking a purist view of the Primary Health Care, Medical Technicians do in fact receive training on the current ADFMC that meets the Primary Health Care definition. The ADFMC does provide Medical Technicians the skills, knowledge and attitudes to deliver health care that is “scientifically sound, first level care”, which is provided by “a suitably trained workforce comprised of multi- disciplinary teams” and “includes health promotion, illness prevention, treatment and care of the sick” (DoD, 2015c; DoD, 2016e; PHCRI. 2017). Unfortunately, the ADFMC does not deliver the range or depth of skills, knowledge and attitudes Medical Technicians require to provide Primary Care in the pre-hospital environment, as an independent primary care provider, as is actually both practiced in the workplace and is the required capability.

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The Australian Army’s coalition partners have also identified the provision of primary care by their Medical Technician equivalents as a capability shortfall in their ‘medics’ training. To address the need for additional primary care skills in Combat Medics, the US Army has developed a 26-week Expeditionary Combat Medic course (Moore, 2017; Gallagher, 2018; Bimson, 2018). According to Bimson (2017), the Expeditionary Combat Medic is trained to provide advanced primary care to treat common conditions. The rationale for development of the Expeditionary Combat Medic is that “disease non-battle injuries continue to be the number one reason for evacuation off the battlefield [with] more soldiers are removed from the fight by diseases than bullets and bombs’ (Bimson, 2018, p. 12).

Similarly, the British Army Combat Medical Technician is a major provider of primary care in the field (Hawksley et al., 2011; Randall-Carrick, 2012; Parsons, Rawden and Wheatley, 2013). According to Hawksley et al., (2011), of the 1,903 primary care consultations over a six month period in 2009, Combat Medical Technicians accounted for 47% of the primary care interventions, without referral to, or consultation with a Medical Officer. The provision of ‘medic’ delivered primary care seen as essential to operational success (Hodgetts and Findlay, 2012).

While the majority of primary care will continue to be delivered by Medical Officers it is important to recognise the critical role Medical Technicians play in delivering primary care both on operations and during field training activities. While the British Army has captured the type of common primary care cases treated by Combat Medical Technicians (Hawksley et al., 2011), no similar study has been undertaken by the Australian Army. Such a prospective study in primary care presentations will allow for Medical Technician training to be developed that matches the capability need.

Furthermore, changing the emphasis from Primary Health Care to Primary Care should allow the ADFMC to be redeveloped to deliver a range of skills, knowledge and attitudes required by Medical Technicians to treat a range of acute medical conditions commonly treated in the pre-hospital/field environment.

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Prolonged Field Care. An issue raised in the study by approximately 19% of the respondents, was the concept of prolonged field care. Prolonged field care is, “field medical care, applied beyond doctrinal planning time-lines30 by a Special Operations Combat Medic or higher, in order to decrease patient mortality and morbidity [utilising] limited resources, and is sustained until the patient arrives at an appropriate level of care” (Keenan, 2015, p. 125). While the principle of prolonged field care can apply across the spectrum of military operations, it is unlikely that Medical Technicians supporting conventional forces, i.e. non-special operations forces, will need to apply the principles of prolonged field care, based on current operations.

The probable future environment the Australian Army may find itself operating in will be dynamic and complex (Kilcullen, 2014; DoD, 2017a), creating a range of challenges in the delivery of tactical health care (Smith & Withnall, 2017; Keenan & Risenberg, 2017). It is anticipated that future military operations may occur in environments that challenge current medical planning guidelines31; requiring a rethinking of how clinical effects will be delivered in the field, in an environment of increasing threat (NATO, 2009; DoD, 2015a Keenan, 2015; Ball & Keenan, 2015; Mohr & Keenan, 2015; DoD, 2017a; Keenan & Risenberg, 2017; Smith & Withnall, 2017).

Despite the increasing likelihood that the Australian Army will undertake conventional military operations in highly complex operating environments (DoD, 2017a), there is

30 In 2009, NATO Allied Command Operations (ACO) Directive 83-1 Medical Support to Operations, was amended to reflect the new NATO Life & Limb Saving Timelines, 10-1-2. 10 minutes — immediate life saving measures applied by personnel trained in Tactical Combat Casualty Care within 10 minutes of wounding: 1 hour — damage control resuscitation (DCR); resuscitative measures initiated by emergency medical personnel within 1 hour of wounding: 2 hours — damage control surgery (DCS) within 1 hour, but no later than 2 hours of wounding. (NATO, 2009; DoD, 2015a) 31 In 2009, NATO Allied Command Operations (ACO) Directive 83-1 Medical Support to Operations, was amended to reflect the new NATO Life & Limb Saving Timelines, 10-1-2. 10 minutes — immediate life saving measures applied by personnel trained in Tactical Combat Casualty Care within 10 minutes of wounding: 1 hour — damage control resuscitation (DCR); resuscitative measures initiated by emergency medical personnel within 1 hour of wounding: 2 hours — damage control surgery (DCS) within 1 hour, but no later than 2 hours of wounding. (NATO, 2009; DoD, 2015a)

180 little evidence from current or past operations that casualty evacuation will be significantly contested beyond current planning metric of 10-1-2 (DeSoucy, et al., 2017). Results from a study into the delay of casualty evacuations over the past 16 years (2001 – 2016), identified only 54 patients whose evacuation was delayed for between four to 120 hours (DeSoucy, et al., 2017). The majority of casualty evacuations over the past 16 years, have seen wounded soldiers transported from point of injury; many occurring under fire, to an operating room within 60 minutes of being wounded (Smith & Withnall, 2017).

Comments such as, S_56, “…my EN training will be helpful in case I need to perform prolonged field care as an integral medic”, and FG2_2, “…as an integral medic I need the skills to be able to keep a casualty alive for up to 72 hours before evacuation, [therefore] my EEN skills may become useful”, incorrectly imply that prolonged field care is simply a form of nursing care. Without downplaying the importance of nursing skills in the provision of Prolonged Field Care, nursing skills are but one of its components. Contrary to study participants linking the skills required to deliver prolonged field care to the skills gained from their enrolled nurse training, the literature shows that prolonged field care is much more than just nursing care (Keenan, 2015; Ball & Keenan, 2015; Mohr & Keenan, 2015; Mohr, et al., 2015). The nursing skills required for prolonged field care are at an advanced nursing level usually found in intensive care wards (Keenan, 2015; Ball & Keenan, 2015; Mohr & Keenan, 2015; Mohr, et al. 2015), and are not the skills taught or covered in enrolled nursing training. Furthermore, comparing Prolonged Field Care is not only simplistic, but fails to recognise the high level medical interventions required to keep a casualty alive for extended periods.

The 2014 Prolonged Field Care Working Group (PFCWG) Position Paper, Prolonged Field Care Capabilities details ten core medical capabilities. These Prolonged Field Care capabilities provide a basic, yet essential set of skills and equipment required to allow a medical provider to provide care to a casualty for an extended period of time (PFCWG, 2014). The ten core medical capabilities are:

monitor – obtain, interpret and understand a patient’s vital signs

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resuscitate – initiate appropriate fluid (including whole blood) resuscitation to improve outcomes

ventilate and oxygenate – provide positive pressure ventilation

airway management - control and maintain a patient’s airway

sedation and pain control – use adequate and appropriate pain control and sedation to accomplish procedural tasks

physical examination and diagnostics – obtain information about patient’s present condition and predict unseen injuries

nursing care – ensure patient is warm, clean, and dry, perform wound care, manage basic biological needs and prevent further illness

advanced clinical procedures – perform interventions necessary for preserving life, preventing morbidity, and improving clinical outcome

telemedicine – establish communications to detail patient’s condition effectively with a Medical Officer to guide medical treatment

prepare for evacuation – ensure patient is prepared for aeromedical evacuation (PFCWG, 2014).

These core medical capabilities highlight that Prolonged Field Care is closely aligned to Remote/Wilderness medicine, where the provision of medical care in austere environments is a specialised area of medicine that draws on knowledge and skills from a number of clinical craft-groups, including nursing (Wordsmith, 2011; Iserson, 2013; PFCWG, 2014; Llewellyn, 2017).

Because of the advanced skills, equipment and stores required, the anticipated provision of prolonged field care becomes part of the deliberate planning process for a specific mission (Mohr & Keenan, 2015). As described by Keenan (2015) prolonged field care is the provision of medical care, when it is unlikely that the 10-1-2 evacuation planning time-line will be achieved on a particular mission. It is for these reasons that

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Australia’s coalition partners currently limit the practice of prolonged field care to special operations forces, who operate in austere, remote and hostile environments, without, or limited medical redundancy or resupply.

Notwithstanding the additional costs in training and equipment, and the fact that contemporary operations have rarely seen the need to provide prolonged field care, there is a growing need to develop a specific prolonged field care training package in order to mitigate an existing critical medical capability gap, especially for special operations. Developing a Prolonged Field Care training package is more effective than assuming the skills gained from enrolled nursing training will provide the skills, knowledge and attitudes Medical Technician require. While the concept of Prolonged Field Care provides flexibility when conducting operations in austere and remote locations, there is a risk that it may become a substitute for sound planning, or the willingness to provide appropriate medical assets, especially when operating in environments where evacuation may be contested.

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Registration of Medical Technicians. When discussing Medical Technician’s initial employment training, it is important to discuss the issue of the registration of Medical Technician’s as Endorsed Enrolled Nurses; and the future registration as Paramedics. The study revealed that outside of clinical placement in civilian hospitals, Medical Technicians work outside the scope of enrolled nurse registration while working in garrison health facilities and while providing health care in the field:

S_117. “My registration as an EEN limits my clinical placement because I can only work on a ward. When I’m at work I work as a medic doing stuff that is way outside the scope of practice for an EEN.”

FG2_9. “I haven’t done any clinical placement this year, since I’ve spent most of my time on out tasks, so I can’t see any benefit to being registered.”

FG1_4. “I have dual registration as a RN and EEN, but and because I have to maintain both because I’m not allowed to be a CPL RN, then I need to do double the CPD and clinical placements. I never meet the EN through Army though. They just expect us to be registered and not support us to meet our registration obligations.”

As stated previously, the ADFMC is structured to award Medical Technicians a Diploma of Nursing and a Diploma of Paramedical Science (DoD, 2015c). The granting of the two Diplomas allows Medical Technicians to meet the educational requirements for registration as Extended Enrolled Nurses (DoD, 2016e), and from late 2018, registration as Paramedics in accordance with the standards set by Paramedics Australia (Townsend & Eburn, 2017). While there is little background information available regarding the decision for mandating Extended Enrolled Nurse registration, the justifications for registration are similar to the often-stated benefits registration provides to the broader community, such as:

“enforceable entry level qualifications, probity checking and other requirements before practitioners can commence practice,

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more robust systems for identifying and dealing with complaints and to deal with poorly performing, impaired or unethical practitioners and, in serious misconduct cases, mechanisms to prevent such practitioners from continuing to practise,

the public availability of a national register of regulated practitioners and a separate listing of those deregistered, and

better linkages with a variety of regulatory and funder/provider agencies that have a role in detecting poor or unethical practices...” (Australian Health Ministers' Advisory Council, 2009, p.16)

While Australia’s health workforce employs over 1 million people, only 600,000 Australian health workers are registered, while close to 400,000 health workers are not (AIHW, 2017). In Australia, there are two broad groups of health care workers; registered and unregistered; each with different laws, regulations and rules relating to their practice (Australian Health Ministers Advisory Council, 2015):

registered health practitioner – any person who provides a health service and is registered under the Health Practitioner Regulation National Law.

unregistered health practitioner – any person who provides a health service and who is not registered with one of the 15 professions regulated under the Health Practitioner Regulation National Law (Australian Health Ministers Advisory Council, 2015).

From 2015, all unregistered health practitioners in Australia are covered under the rules established under the National Code of Conduct for Health Care Workers. The purpose of the National Code of Conduct for Health Care Workers, is to protect the public by setting minimum standards of conduct and practice for all unregistered health care workers who provide a health service (Australian Health Ministers Advisory Council, 2015). It sets national standards against which disciplinary action can be taken and if necessary a prohibition order issued, in circumstances where a health care worker’s continued practice presents a serious risk to public health and safety. The

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National Code of Conduct for Health Care Workers is regulated through the enactment of legislation by each Australian State and Territory, establishing standardised statutory powers to enforce the code by investigating breaches and issuing prohibition orders; including a nationally accessible register, and mutual recognition arrangements between states and territories to support national enforcement of the code (Australian Health Ministers Advisory Council, 2015).

There is no evidence that registration contributes to operational capability, or that mandating all health workers maintain registration improves clinical outcomes. The argument for registration as detailed by Australian Health Ministers' Advisory Council (2009) has little relevance to Defence. For unlike other Australian employers, the Australian Defence Force has a legislative framework that provides equal or greater powers in dealing with the issues detailed by Australian Health Ministers' Advisory Council (2009, p.16). The range of legislative Acts, Regulations and Rules that govern the Australian Defence Force include: Defence Act 1903, Defence Force Discipline Act 1982, Defence Regulation 2016 and Defence Force Discipline Regulations 1985. Furthermore, the National Code of Conduct for Health Care Workers provides a regulatory framework that covers health care workers who are not registered. Therefore, the question remains, why does the Army require its Medical Technicians on being registered? The existing Defence regulatory framework, together with the National Code of Conduct for Health Care Workers, supported with a clear scope of practice will not reduce the opportunities for Medical Technicians to undertake training and clinical placements in civilian health environments. The Australian Army will need to work with civilian health providers to develop the relationships and systems required to place Medical Technicians in relevant and suitable clinical environments, that meet capability needs.

The main issue surrounding registration is not the registration itself, but rather its impact on the delivery of training. As discussed previously, training in the Australian Defence Force is focused on providing individuals with the skills, knowledge and attitudes to enable successful military operations (DoD, 2011b, p. 1.1). Put simply, all Army training is about contributing to the successful achievement of Army’s mission,

186 preparing land forces for war (DoD, 2017a), and it is not about training so soldiers and officers gain civilian qualifications. While some commentators espouse a concept of ‘military-civilian’ to justify training towards civilian qualifications, the Australian Army view since 2007 has been: training soldiers for traditional/conventional warfare, that also develops the skills, knowledge and attitudes that permit soldiers to undertake other tasks such as humanitarian assistance, stabilisation and reconstruction operations, or peace-keeping tasks (Leahy, 2007; DoD, 2011b; DoD, 2015d. Ryan, 2016). This reinforces the concept that foundation warfighting skills ensure the success against an adaptive enemy (DoD, 2015d. Ryan, 2016).

Furthermore, the issue of having Medical Technicians register as Extended Enrolled Nurses, or as Paramedics, is not simply that Medical Technicians scope of employment and clinical tasks are beyond that of either an Extended Enrolled Nurses or Paramedics. The issue is that the ADFMC has been developed to achieve civilian qualifications that do not align with the capability that Army requires from its Medical Technicians. This not only impacts the length of training, but also under trains Medical Technicians in the skills they actually need. By training to qualification as opposed to the actual capability requirement results is a misalignment of the training, transfers of actual job skills training to the workplace, and restricts the actual employment of the employment category in the workplace. Medical Technical training should be capability based and not designed to provide Medical Technicians with civilian qualifications that do not meet the workplace requirement.

The research highlighted that no Medical Technicians entered the Australian Army with existing Enrolled Nurse or Paramedic qualifications. This suggests that removing civilian qualifications and registration will not affect recruiting of ab initio members with relevant skills. It should also be noted that the ADF Medic Course structure and how military specific competencies are delivered, an ab initio trainee with Enrolled Nurse or Paramedic qualifications will still be required to undertake the majority of the ADF Medic Course in order to qualify as a Medical Technician (DoD, 2015c). In fact, there is no evidence that removing civilian qualifications and registration from the Medical Technician employment category will impact or reduce ab initio recruiting into this

187 trade. The main recruiting risk associated with removing civilian qualifications may be to the 16% of members with prior military service who use Medical Technician training as an opportunity to gain such qualification as a prelude to separating from the Army; though the exact impact to lateral recruiting requires further research to assess the actual impact.

Therefore, having Medical Technicians registered makes sense considering the costs in time and money. In fact, training to meet registration standard makes workforce management challenging, and seems counterproductive from a workforce perspective. Furthermore, clinical placements in civilian health sector will be limited to the scope of practice of either an Enrolled Nurse or Paramedic. Employing Medical Technicians as unregistered health care workers, with clearly defined and detailed scope of practice, will allow Defence to work with civilian health authorities to find suitable clinical placements where Medical Technicians will be able to utilise the complete range of their clinical skills.

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Continuing/Advanced Clinical Training

The study identified that the lack of continuing/advanced clinical training within the Medical Technician training continuum is not only a major capability shortfall, but is a major factor in contributing to workforce dissatisfaction. Continuing/advanced clinical training is essential for providing safe and effective health care (Institute of Medicine [IoM], 2011). The 2011 Institute of Medicine report into the Future of Nursing: Leading Change, Advancing Health, suggests that continuing/advanced education is vital for developing and maintaining new skills, knowledge and attitudes required throughout an individual’s career (IoM, 2011).

The research highlighted Medical Technicians’ concerns, that apart from their Initial Employment Training, they receive no further clinical training or education. At present, ADFMC is the only formal clinical course Medical Technicians undertake throughout their career 32 (DoD, 2016e). This confirms participant S_38 observation that he is “…fully qualified for WO1 for trade.” While S_38 comments may seem flippant, they highlight that Medical Technician training does not acknowledge the changing nature of clinical skills required as Medical Technicians progress through the ranks from Private to Warrant Officer. The research findings identified a range of additional skills Medical Technicians believe they require to successfully undertake the range of clinical interventions they require in the workplace:

S_148. “Definitely advance [advanced] primary health care. There is so much to know and I know so little, not without lack of trying! But all these important procedural skills too such a NGT [nasogastric tube], Catheterisation, needle Thoracentesis, etc…”

S_102. “As a CPL I defiantly think we need advance [advanced] primary health care skills and PHTLS as a minimum.”

32 This refers to clinical courses within Medical Technicians employment category training continuum that apply to all Medical Technicians. It excludes unit needs courses, short clinical courses or courses that Medical Technicians undertake when posted to Special Operations Command units.

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S_71. “Primary health care. ALS. Trauma training.”

From both the open forum discussions, and the focus groups, there was general consensus for the need to introduce additional clinical courses in the Medical Technician training continuum. Based on the experiences of the participants as integral medics, and as members of treatment teams, approximately 92% of Medical Technicians identified the need for an additional training course between two to four years post ADFMC. The focus of this course should be on advanced primary care skills and advanced emergency care skills. In addition, over 80% or research participants suggested that the introduction of advanced training to prepare Medical Technicians for the ranks for Sergeant and Warrant Officer were important, again focusing on high end primary care skills, and other specialist clinical practice. While detailed analysis will be required to determine exactly how the Medical Technician training continuum will look and what topics will be covered, Figure 24 details the range of subject areas that could be included for each rank level. In addition, a range of specialist and unit needs courses should be developed that select Medical Technicians can undertake ‘just in time’ based on specific unit or mission profile. Figure 24 includes a range of such courses that can be developed or are currently available and being delivered in Defence. Furthermore, depending on how such training will be delivered, the Australian Army can engage with any number of Australian tertiary institutions to collaboratively develop this training, allowing for advanced standing towards a civilian qualification.

Figure 24: Example of Future Medical Technician Training Continuum

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Review of Medical Technician Training

This research examined the underlying and common causal factors of the shortfall in the capability of current the Medical Technician training continuum. The study highlighted that training reform is necessary to sustain the Medical Technical capability, now and into the future, and to ensure the employment category meets its primary mission of providing health care across the spectrum of operations (DoD, 2016e). According to Army Training Instruction 1-1/16 (2016h, p.5), “the purpose of individual training is to provide the skills, knowledge, attitudes and behaviours needed to perform a specific individual role or task at job standard, and to prepare individuals”, which this research suggests that the current ADFMC falls short in effectively achieving this.

The study identified the need for a structured and systematic approach to the analysis, design, development, implementation and evaluation of Medical Technician training to address the current capability gaps, in accordance with Systems Approach to Defence Learning (SADL) model (DoD, 2016h; DoD, 2016i). This must be undertaken without any preconceptions regarding: the length of training; gaining of civilian qualifications; civilian registration, and alignment of other/existing clinical craft groups.

To determine the training requirements, it is important to examine the range of operational health effects Medical Technicians are required to produce from the rank of Private through to Warrant Officer Class One 33 . While, the combat health restructure did not significantly change the composition of agreed JP2060 team-based health capability bricks from the early 2000’s (DoD, 2008), the restructure did change who, and where health interventions are provided (DoD, 2015b). Lessons learnt from 16 years of conflict, in particular the introduction of Tactical Combat Casualty Care

33 Prior to the restructuring of Garrison and Combat health, Medical Technicians were employed in direct patient care/clinical roles from Private to Sergeant. The majority of Medical Technician at the range of Warrant Officer Class Two and Warrant Officer Class One were in what is called Regimental stream, i.e. ceremonial/command appointments. Since 2011, Medical Technicians can serve in clinical roles from Private to one of seven Warrant Officer Class One clinical/trade appointments, though without any further clinical training or education beyond the current ADFMC.

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(TCCC), improvements in body armour and timely casualty evacuation, has resulted in the highest combat survival rate (ABS, 2012; Brennan, 2015).

Therefore, Medical Technician training must be re-examined to take into account the combat health restructure that fundamentally changed the method of how combat health support is provided in support of land based forces (DoD, 2011e). Furthermore, the review of the Medical Technician training continuum must acknowledge and take into account the critical role played by non-medical first responders, in the provision of point of injury trauma care and reducing preventable death on the modern battlefield (Veliz, Montgomery & Kotwal, 2010; Grabinsky, Williamson & Ramesh, 2011; Savage, 2011; Defense Health Board, 2015).

Considerations for future Medical Technicians training

As discussed, the fundamental nature of military medicine has remained constant throughout the millennia (Gabriel & Metz, 1992; Gabriel & Metz, 1992b; Haller, 1992; Salazar, 2000; Hodgetts, 2012; Johnston, 2014). The basic concept of care provided by ‘medics’ throughout history; i.e. point of injury care, battlefield clearance and casualty evacuation to a higher level of health care, has remained the same (Gabriel & Metz, 1992; Haller, 1992; Salazar, 2000; Johnston, 2014). While the nature of military medicine remains constant, its character changes (Wright, 2011; Rostker, 2013; Hodgetts, 2012). Just like previous advances in medical interventions, medical technologies and improvements in evacuation platforms have changed how wounded, injured and ill soldiers are treated (Salazar, 2000; McCallum, 2008; Hodgetts, 2012; Rostker, 2013), they will continue to do so as new and emerging technologies are developed and introduced into service. While some argue that the changing charter of modern war, with complexity, confusion, congestion and constraint, will change how Medical Technicians will be trained in the future, there is little to support this observation. By the very fact that discussion about the future character of warfare is speculative, so is any discussion about the future nature of military medicine (Hodgetts, 2012).

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While not dismissing the importance of changes in the future battlefield, and how it may impact the provision of tactical medical care, the utility of such navel-gazing lies “in shaping the direction and boundaries of medical intent rather than directing the development of techniques and procedures (Hodgetts, 2014, p. 277). To address the future training requirements of Medical Technicians to successfully operate in the future battlefield requires regular review and constant adaptability through lesson learnt. By ensuring Medical Technician training remains relevant and contemporary is the greatest safe guard against irrelevance. As discussed throughout this study, Medical Training must be developed to meet the extant capability requirement, which can then be adjusted to meet new or emerging capability requirements.

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Section 2 – Skills Maintenance

The original intent of Army Health Services Personnel Clinical Readiness Standards was to ensure that Army clinicians maintain their clinical skills, and to “build on [their individual] skills, knowledge and attitudes attained during training” (DoD, 2011c, p. 1). Based on the findings of this research, the Australian Army’s clinical readiness framework is failing to ensure its clinical workforce is ‘current’, and therefore able to perform their primary role as clinicians. Over 59% of research participants questioned the relevance of Army’s current clinical readiness framework, since 62% of research participants failed to meet the mandated readiness standard in 2015. Furthermore, with over 68% of respondents having never achieved the required clinical readiness standards since 2012, it is reasonable to questioning whether the current framework is sound in meeting its intent.

The genesis of this study was to understand and develop a readiness model that enhanced the clinical readiness of Medical Technicians. The major challenge in developing a robust and flexible clinical readiness framework is to clearly define the skills, knowledge and attitudes required by Medical Technicians to perform their job in their workplace. In the case of Medical Technicians this is not a straight forward endeavour, since their workplace varies, and as a consequence, so do their required competencies. Due to the relatively small size of the Medical Technician workforce, Medical Technicians are required to perform their job within two distinct, but related workplaces: during peacetime in support of the Raise, Training and Sustain activities, and while supporting military operations.

Medical Technician Scope of Clinical Practice

While both workplaces require Medical Technicians to provide a range of clinical functions, what is lacking in the Australian Army is a clear, single Scope of Clinical Practice that covers the spectrum of clinical practice that can be undertaken by Medical Technicians in all environments and workplace settings. As discussed, Medical Technicians are currently subject to two scopes of practice, with a third coming into effect in late 2018. This litany of scopes of practice is not on confusing, but potentially

194 places Medical Technicians in the precarious situation that they may be in fact working outside their scope, thereby creating a clinical governance minefield. The inconsistency between the existing scopes of practice was a major concern of 45% of research participants, especially the disconnect between their role as Army Medical Technicians and their registered role as Enrolled Nurses.

A single Medical Technician Scope of Clinical Practice will provide Medical Technicians with clarity and an unambiguous understanding of what they can do and when they can do it. It will also provide guidance as to the range of skills they must keep current. Furthermore, a single Medical Technician Scope of Clinical Practice will provide supervisors and commanders with a clear understanding of any supervisory requirements, and the of skills maintenance requirements of Medical Technicians by ranks and by place of employment.

A Medical Technician Scope of Clinical Practice will clearly establish the relationship between training and workplace performance. To ensure Medical Technicians have the appropriate skills, knowledge and attitudes to perform their range of duties, their training must be aligned to their Scope of Clinical Practice. For it is the Scope of Clinical Practice that defines the initial and continuing competence to practice. Once Medical Technician training has been redesigned to deliver the skills, knowledge and attitudes required to achieve competence to practice that is directly linked to capability requirements, then a skills maintenance plan can be developed.

Clinical Placements

The underpinning premise of Army’s readiness is the assumption that a Medical Technician who undertake more clinical practice, are safer and more competent than those who haven’t (DoD, 2016d), which to an extent seems to be supported by Su, et al. (2000) who claim that retention of knowledge and skills seem to be enhanced by increased experience with real-life placements. While this may seem a reasonable assumption, the literature does not fully support this position. Pearson, et al. (2002, p. 360-1) posit, “there is an assumption that nurses who have practiced in the last 5 years will be safer and more competent in their practice” compared to a nurse with less

195 clinical practice. In fact, according to AHPRA (2015) there is no research that definitively show the amount of recent practice a health practitioner needs to maintain their skills and knowledge, which is supported by the findings by the UK General Medical Council research into skills decay (UK General Medical Council, 2014).

Therefore, the answer to ‘how much clinical practice?’ is the holy grail of skills maintenance. The paucity, and often contradictory research regarding the amount of clinical practice makes it difficult to set an evidence-based framework. Though “this limitation is due to there being a limited number of studies on this topic” (UK General Medical Council, 2014, p. 28).

Another issue with random clinical placements is relevance. While 81% or respondents were negative about clinical placements, the majority (>57%) claimed clinical placements were not relevant to their practice as Medical Technicians; especially placements in civilian hospitals when undertaking their placements as Enrolled Nurses. The challenge of placing Medical Technicians in civilian hospitals is ensuring they are exposed to a wide range of clinical situations that are relevant to the clinical situations they will encounter when on operations. While civilian emergency departments may provide some relevant trauma exposure, as Enrolled Nurses, Medical Technicians are limited in what they can do clinically by the Nursing and Midwifery Board of Australia Standards for Practice: Enrolled Nurses (2016). Other shortcomings of civilian hospital placements, in particular inpatient placements, are that such placements do not provide Medical Technicians with the range of skills they require in their workplace. While some respondents (~43%) suggested that clinical placements should be undertaken with civilian ambulance services, just like Enrolled Nurse placements, such placements also fail to provide the breadth of skills Medical Technicians require in their workplace. According to Paramedics Australia (2012, p. 4), “paramedics respond to, assess and manage patients, transport them to a health facility for ongoing care if necessary or arrange alternative referral, treatment or care options”, which covers only one aspect of tasks Medical Technicians are required to provide.

The claim by Medical Technicians that their placements were not relevant, or prepare them for deployment, is supported by US Army research on the US Army Medical

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Department’s Professional Filler System (PROFIS). The US Army PROFIS places health care providers in both military and civilian health facilities when not deployed, on the premise that this will contribute to the maintenance of their medical skills (Sorbero, et al., 2013). While the intent appears sound and with merit, the failure of PROFIS is that health professionals feel they are unprepared for deployment, have major clinical skills mismatch, and are being under trained in critical clinical skills, all of which were identified post-OPERATION DESERT STORM in 1992 (US General Accounting Office, 1992). Subsequent research in the 21st century (Rivers, Wertenberger & Lindgren, 2006; Sorbero, et al., 2013) reinforced the US General Accounting Office findings on the shortcomings of PROFIS.

From a capability perspective, there is no one single clinical placement setting that provides the spectrum of clinical skills Medical Technicians are likely to practice on operations. It is therefore more practical to place Medical Technicians in clinical settings that provide them with maximum opportunity to, not only practice their skills, but develop new clinical skills. Since the majority or Medical Technicians identified their greatest skills deficiency in the area of primary care, placing them in Garrison Primary Health Care facilities providing primary care is critical. Furthermore, requiring Medical Technicians to provide primary care with their current level of training, usually unsupervised, presents significant challenges to the Medical Technician, to the patient and to the organisation, despite working within a protocol framework through the use of the Primary Clinical Care Manual. As the first point of care health providers, Medical Technicians are required to make an undifferentiated diagnose with minimal training in primary care. Therefore, the focus of training and clinical placement must be on developing Medical Technicians skills and knowledge across a range of medical conditions they are likely to come in contact with, usually out in the field and on operations.

Simulation

According to the Defence White Paper (2016), simulation systems provide ADF personnel with enhanced training opportunities, which is both cost-effective and efficient in increasing force generation capacity. In fact, the Chief of Defence Force

197 stated that, “simulation presents great advantages and opportunities to the ADF in terms of realistic and cost-effective training, supporting decision making, capability development and maintenance of a capability edge” (DoD, 2011e, p. 2).

Despite the importance placed on simulation within the ADF for enhancing military capability, only 51% of Medical Technicians undertook any simulation-based training during the previous 12 months. The limited use of medical simulation may be partly due to Army Health Services Personnel Clinical Readiness Standards directing that simulation should not be considered as an alternative to clinical practice, and is best limited for training during mass casualty scenarios (DoD, 2016d). Notwithstanding growing evidence that medical simulation as a real and effective alternative to clinical practice (Alinier, et al., 2006; Schlairet and Pollock, 2010; Cant and Cooper, 2017; Brien, Charette and Goudreau, 2017), this study identified an apparent organisational aversion to using medical simulation within the Australian Army.

Innovation in medical simulation over the past 20 years has resulted in a growing acceptance in the use of this type of training, by both civilian and military medical personnel around the world (Leitch, 2002; Rosen, 2008; Murray, 2010; Medical Corps International Forum [MCIF], 2014; Jones, Passos-Neto and Braghiroli, 2015). The increasing use of medical simulation in the areas of skills assessment, credentialing, quality improvement and research is being driven by a variety of factors, in particular cost effectiveness, repeatability and patient safety (Leitch, 2002; Rosen, 2008; Murray, 2010; MCIF, 2014; Jones, Passos-Neto and Braghiroli, 2015). Simulation is a critical element for ensuring clinical competency, therefore the use of multimodal simulation should be embraced by the Army Health Services, both as a tool to training new skills and to practice existing skills of Medical Technicians.

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Clinical Readiness Certification

Since the shortfall of existing Australian Army readiness model is being solely based on measuring inputs as a state of readiness, a new readiness model based on measuring outputs is required. It must be acknowledged up front, that some commentators may find the issue of annual certification of proficiency difficult to separate from the concept of ‘job ready’ that underpins competency-based training. Regular recertification or refresher training to confirm ongoing proficiency is a critical to many industries including the military, aviation, maritime and other, safety centred industries. The concept of ongoing certification is not at odds with competency-based training, in fact the two are complementary.

Regular certification is an acknowledgement that skills fade over time, despite the fact their proficiency was assessed at a point in time (Bishop, 1994; Misko, et al., 1999). In fact, both Bishop (1994) and Misko, et al. (1999) suggest that the only guarantee of an individual’s proficiency is at the time of assessment. A similar position is held by the Australian Medical Association (AMA), in its 2010 position statement on ‘competency- based training in medical education’. According to the AMA, it does not support the notion that if “a trainee performs to the required standard across discrete competencies at a particular moment in time, they are as a whole proficient” (AMA, 2010, p. 2). The literature on skills decay remains consistent, in that skills do decay over time. This supports the suggestion by Harris, et al. (1995), that competence has a “use by date”.

Therefore, the Australian Army must be confident its people are competent and capable of undertaking their duties safely. As an employer, the Australian Army can be held responsible for the action of its employees, through the concept of vicarious liability. So the Australian Army has a vested interested in ensuring its Medical Technicians are competent and safe through a regular regime of refresher learning followed with a certification of proficiency.

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To improve the existing clinical readiness model, a revised model based on measuring outputs should be developed. Such a model should be based on measuring the sum of the five identified core attributes: clinical skills knowledge and attitudes; military specific clinical skills, knowledge and attitudes; recency of clinical practice; ongoing clinical education/training; continuing clinical professional education, that create clinical competence. It is suggested that the most appropriate way to assess and therefore certify individual competence is through the use of an objective structured clinical examination (OSCE).

The OSCE was developed to be a practical, valid, and reliable evaluation tool of clinical competence by removing the variability introduced by the patient and examiner biases, and by assessing a wider range of knowledge and skills than traditional measures were able to do (Harden et al., 1975; Harden & Gleeson, 1979; Harden, 2016). Originally developed and established as a tool for medical student assessment in the 70's (Harden et al., 1975; Harden & Gleeson, 1979), it has, over the past 45 odd years been adopted to assess clinical competence across a range of health care professions (Harden, 2016).

The conduct of the OSCE requires participants to rotate through a series of stations, each with a medical condition where specific tasks have to be performed, usually involving a clinical skill, such as the examination of a patient or a practical clinical intervention, usually within a specified time limit. There is a different examiner at each station, with a standardised marking guide for that station, which has been determined in advance. The basic structure of an OSCE can vary in timing, use of a standardised patient, real patients or manikins, but the fundamental principle is that every participant must complete the same assessment in the same amount of time, to the same standard. The strength of the OSCE is that it assesses qualities that cannot be captured through traditional test formats, or through clinical placement that is unstructured and unpredictable. Furthermore, over the past 40 years, there is a growing body of literature that addressed the reliability and validity of the OSCE as an assessment tool, in a variety of settings for various purposes.

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Based on the findings of this research, it is suggested that a OSCE be developed to assess Army Medical Technicians across a range of critical tasks that subject matter experts have determined as essential. Furthermore, the Medical Technician OSCE should be conducted as part of an annual training workshop where Medical Technicians receive training and/or refresher lessons on new equipment, medications, procedures, etc that are relevant to Medical Technicians scope of practice. A suggested format for Medical Technicians certification is detailed in Figure 25.

Figure 25: Suggested Structure of the Medical Technician Certification Program

By creating a structured certification program that includes updating relevant information, combined with an assessment of proficiency will ensure Clinical Professional Mastery. This readiness model (see Figure 26) provides a quantifiable measure of an individual readiness to clinically practice, though the metric will need to be developed as part of the development of the Medical Technicians OSCE.

Figure 26: Recommended Clinical Readiness Model 201

Section 3 – Workforce Retention

According to the Defence White Paper, “retaining the future Defence workforce will be a major challenge (2016, p. 150). The issue of workforce retention in the ADF remains a critical issue, and has been the subject of numerous internal and external reviews, including Parliamentary reviews by the Senate Foreign Affairs, Defence and Trade Reference Committee, and audits by the Australian National Audit Office. These reviews have produced reports that detailed a range of factors associated with workforce retention, with many suggesting both reasons for separation, as well as plans to stem the flow of talent loss.

To understand why Medical Technicians leave the Army, it is important to understand their motivation for joining the Australian Army in the first place. Results from this study identified the majority of Medical Technicians, over 84% joined “to serve Australia”. The motivational factors identified in this study, reflect Defence’s research that show patriotism, career change, life challenge and development opportunities as the top motivators for joining the Army (DoD, 2008; DoD, 2010b). Regardless of the exact reason for joining, Medical Technicians enter into a ‘psychological contract’ between themselves and the Army, which is a series of “mutual, unwritten beliefs or expectations about the obligations between Army and its people” (Schmidtchen, 1999, p. 5).

Under this contract, Medical Technicians serve in the Army: willing accepting the unique nature of military service, with the expectation the Army will fulfil its mutual obligation to them. It is the members’ expectation that Army will continue to fulfil its obligation that motivates individuals to keep serving. A violation of this trust, on the other hand, usually leads to low job satisfaction, commitment, and ultimately retention (Schmidtchen, 1999). The findings from this research show that the level of satisfaction across the Medical Technician cohort is relatively low, which is reflected with over 58% of respondents indicating that their Army service has not met their expectation.

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The overriding themes identified contributing to Medical Technician’s lack of job satisfaction were lack of ongoing clinical training, continuing/ongoing education and continuing development opportunities. Therefore, addressing these issues should improve the level of job satisfaction in Medical Technicians, since more clinical training, relevant placements and continuing education opportunities were identified as issues that would encourage Medical Technicians to remain in the Army. In addition, a reduction in op tempo and the amount of time spent away from home supporting training activities will have a positive impact on job satisfaction.

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Recommendations

The following recommendations are presented in response to the central research question: How to develop and maintain a high readiness and adaptive health workforce?

Australian Army Medical Technician training should be reviewed, using a “first principles” approach to analyse Medical Technician capability requirements across the whole trade continuum from Private through to Warrant Officer Class One. Training must focus on providing the skills, knowledge and attitudes required by Medical Technicians to provide primary care and advanced life support to the level that meets Army’s Medical Technician capability requirements.

Focusing on capability; instead of delivering training to meet civilian qualifications, will improve the efficacy of Medical Technician training. Clinical training courses for Corporal, Sergeant and Warrant Officer should be developed, and delivered at three to four years intervals across the trade continuum. In addition, Medical Technician training should include the development of unit/capability needs courses, in areas such as prolonged field care for Medical Technicians posted to special operations units, and inpatient care (including medium and high dependency care) when posted to the 2nd General Health Battalion.

The removal of the requirement for civilian registration of Medical Technicians as Enrolled Nurses, and in the future as Paramedics, will ensure training is delivered to meet specific Army capability needs. It will also focus training to deliver the skills, knowledge and attitudes required by Medical Technicians at each rank level. Finally, it will reduce training duration and overall costs in both training and in ongoing registration fees.

Defence has a comprehensive regulative and legislative framework that allows for a higher level of governance oversight than is currently provided by national registration legislation. By ‘chasing’ civilian registration, Medical Technicians are being trained in skills they do not require, thereby unnecessarily extending the length of training at

204 significant cost. To better govern the Medical Technician capability, the Army should develop a single Medical Technician Scope of Clinical Practice. This will ensure that Medical Technicians and their clinical supervisor have a clear understanding of the range of clinical skills they can perform in their relevant workplace, and during their clinical placements.

Medical Technicians must undertake clinical placements that are relevant, and improve their level of clinical competence. The majority of Medical Technician’s clinical placements should be undertaken in Joint Health Command health facilities. This will allow Medical Technicians to both consolidate their primary care skills, and further develop their confidence as primary care clinicians. In additional to clinical placements, Medical Technicians should undergo regular training in advanced life support using both high and low fidelity simulation models. The use of simulation must be planned and scheduled to meet specific clinical capability needs.

To ensure clinical readiness, Medical Technicians should undergo an annual certification of individual clinical readiness (see Figure 18). This recertification should include both theoretical and practical examination against the relevant Medical Technician Scope of Clinical Practice, focusing on primary care and emergency medicine. The practical element of recertification should be based on the Objective Structured Clinical Examination concept of station type examinations. Certification will move away from the current clinical readiness model that measures inputs, to a clinical readiness model that measures clinical output. The frequency of Medical Technician certification will require further examination, and while annually certification seems the most logical, certification will need to be balanced against competing operational needs.

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Future Research

This research provides a relevant start point for future research into maintaining a clinical workforce. While this study focused on a clinical craft group who do not undertake clinical practice on a full-time basis, the question of readiness equally applies to other clinical craft groups. Even if working in a clinical setting on a daily basis, the risk of competency atrophy remains high for a variety of reasons.

An important area of future research identified by this study was the issue of “task substitution” which has been the point of much discussion in Australia since 2005, following release of the Productivity Commission Research Report, Australia’s Health Workforce, 2005. The allocation of clinical tasks to other workers who can work within a narrower scope of practice may present opportunities for the Australian Army, especially in the areas of advanced point of injury care, and some peer mental health counselling opportunities.

Research into the contribution that Army Reserve clinicians make to Army’s health capability is required. This research should examine whether certain clinical craft groups are better aligned to remaining a Reserve capability due to the impost of maintaining highly degradable skills. Similarly, this research should look into which clinical crafts cannot be maintained in the Army Reserve. Research into the Army Reserve Health Services should also examine models for service and remuneration.

Further research is required to not only quantify the minimum amount of clinical practice required by clinical craft groups, but should include the critical skills each clinical craft group requires to safely and competently practice. Further research in the area of team skills maintenance and competence, as well as the impact that staff turnover has on team competence is required. Finally, operational tempo and its impact on clinical readiness should be examined and it affects both skills maintenance, as well as job satisfaction.

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Finally, it is suggested that the Australian Army must undertake a study to define the exact skills, knowledge and attitudes required by Medical Technicians by rank, and for specific mission profiles. A detailed capability needs statement, followed by an analysis to determine the exact training requirements is required. Furthermore, this research should include the development of clinical readiness certification standards, and the relevant metrics of clinical readiness.

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Conclusion

The purpose of this research was to develop a model that enhances the development and maintenance of a high readiness and adaptive health workforce, by examining the Australian Army Medical Technician workforce. In filling the void from the lack of evidence-based literature specific to military health workforce, this research identified the importance of human capital theory in generating military health capability.

By reviewing workforce preparedness through the lens of human capital theory, the study identified that preparedness of current Medical Technician workforce must be enhanced to better deliver its core clinical effects. The research found that the current Medical Technician training is failing to deliver the range of skills, knowledge and attitudes required for this high readiness and adaptive health workforce. Furthermore, the limited opportunities for professional developments and no opportunities for ongoing clinical training are leading to skills decay, and therefore contributing to low job satisfaction.

Training is expensive and resource intensive, therefore over training in skills that are not relevant for a craft group in the workplace is a waste of precious and scarce resources. Training must be designed to deliver the skills, knowledge and attitudes to meet Medical Technicians capability requirements as they change throughout their career, rather than pursuing civilian qualifications. The study found that the ADFMC produces highly qualified Medical Technicians, with its prime focus on delivering training to meet the education standards required to gain registration as Endorsed Enrolled Nurses and Paramedics. In doing so, it fails to adequately prepare Medical Technicians to provide primary care, in garrison, out field and on operations. Since this research identified that the majority of clinical practice performed by Medical Technicians is providing primary care; therefore, primary care must be the focus of Medical Technician training.

Findings from this research identified a training gap for Medical Technicians from the rank of Corporal and above. Since the establishment of a clinical career pathway for Medical Technicians in 2011, Medical Technicians require the appropriate skills,

208 knowledge and attitudes to perform the range of high level clinical effects as changing as they progress in rank during their career. Therefore, the Medical Technician training must be redesigned from a single initial course to a training continuum from Private through to Warrant Officer. By establishing a Medical Technician training continuum based on a capability need will not only improve the generation of Army’s health capability, but will contribute to improving overall workforce job satisfaction.

While this study did not quantify the exact amount of time health professionals require to remain current and clinically safe, it did identify a readiness model that can be used to measure an individual’s clinical professional mastery. This study identified that the Australian Army’s existing clinical readiness model is invalid since it measures readiness inputs, as opposed to clinical outputs. This model reinforces the notion that a simple increase in readiness inputs will result in an increase clinical outputs. The research found that with no existing empirical evidence to measure clinical readiness, it suggests a clinical readiness model that will help measure clinical outputs to a standard.

The study found a clear connection between job satisfaction and ongoing clinical training, continuing/ongoing education and continuing development opportunities. The recommendations made by this research should make a positive impact towards improving job satisfaction, resulting in an improvement in workforce retention, especially in the senior ranks of Sergeant and Warrant Officer.

Finally, some observers may consider the concept of reducing the length of training, changing the focus of clinical practice and replacing clinical placement with simulation as counter intuitive. But as Samuel Butler (n.d) stated, “if you follow reason far enough it always leads to conclusions that are contrary to reason.” As an employer the Australian Army has a responsibility to ensure its clinical workforce is safe to practice. This requires the organisation to be able to quantify the level of clinical readiness as a measure of the quality and safety of the health output. This can only be achieved by measuring the clinical competence of Medical Technicians through regular certification. The evidence based clinical readiness model posit by this study, ensures Medical Technicians are clinically ready; i.e. clinically competent, current and confident to practice.

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The contribution to the Australian Army’s war fighting capability by Medical Technicians cannot be underestimated. Their selflessness in providing care to the men and women of the Australian Defence Force since before Federation is the hallmark of the highest form of human endeavour. But to be successful in their calling, Medical Technicians must be provided with not only the skills to do their job, but must be given to opportunities to practice and to undertake further development.

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Appendices

Appendix 1: Ethics Approval

Appendix 2: Informed Consent

Appendix 3: Expression of Interest

Appendix 4: Survey Instrument

Appendix 5: Results from first round open coding

Appendix 6: Research Timeline

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Appendix 5: Results from first round open coding

• Acquisition of competence • More practice manager training • Ad hoc training • More Primary Health Care experience • Advanced Primary Health Care Skills • More Primary Health Care placements • AHI 05 not relevant in current form • More Primary Health Care simulation • Advanced Life Support Level 2 • More promotion opportunities • Always asked to do more with less • More specialist clinical training • Always out field • More team simulation • Always shouted down if your raise • More tropical medicine training concerns • Aero Medical Evacuation training • Most interesting employment • Underwater Medicine • Move away from time-based currency to skills based • Bachelor Nursing • Must have more medical emergency training • Bachelor Paramedicine • Must do more military training • Be sponsored to become a Nursing Officer • Need more trained simulation operators • Cannot balance between unit tempo and • Need other simulation models family • Career prospects • Nepotism • Certificate III Pathology • Never get the opportunity to work with the same people • Certificate III Sterilisation • Never work with the units we are expected to support • Certificate IV Nursing • No clinical mentorship program • Challenging work • No governance training • Civilian qualifications • No loyalty from the Army • Clinical placement • No mentoring to improve • Clinical placements are irrelevant • No money • College of Nursing • No on the job education or training • Conferences • No ongoing skills maintenance in areas • Confident in trauma but not in managing • No opportunities for sponsored education medical emergencies

262 • Continuing advanced health training • No opportunity to work with units we will support • Continuing health education • No say in postings • Continuing Professional Development is a • No supported to meeting registration low unit priority requirements • Deployment opportunities • No team training • Diploma Business Management • No trust in unit leadership (Government) • Diploma Nursing • Not a hands-on clinician • Diploma Paramedicine • Not enough equipment and resources • Disaster medicine • Not enough people to be released • Division of labour • Not enough Primary Health Care • Do something for Australia • Not ongoing education or training • Emergency Management of Severe Burns • Not prepared to become a clinical supervisor • Enjoy maintaining level of fitness • Nursing placements are not relevant • Family and partnership • Obsolete equipment • Family connection • Other units do not appreciate what we do • Future career prospects • Over training • Future education opportunities • Overall balancing • General ideas about life • Paediatrics • Go to university to finish degree • Paramedics Australia • Great friends • Partner is in the Army • Great friendship network • Pay • Help people • Performance punishment • High operating tempo • Prehospital Trauma Life Support • Identify minimum skills for each job and • Posting locality rank • Impressed with medic’s professionalism • Pre-deployment • Introduce more Primary Health care on job • Primary health care skills training • Improve soldier career management • Proud of serving • Improved deployment opportunities • Proud to be in the Army

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• Increased opportunities to undertake • Promotion opportunities Continuing Professional Development • Infantry Minor Tactics • Public Health • Interest in health care • Readiness • Introduce fixed teams • Realistic simulation • Irregular and unpredictable work hours • Reduce field support tasks with no clinical work • Job security • Registration • Join Army Reserve • Relook at clinical placements • Lack of career prospects • Rewarding work • Lack of challenging work • Safety • Lack of clinical relevant placement • Satisfying work • Lack of clinical supervision • Self-identification • Lack of Continuing Professional • Short notice tasks Development • Lack of control over career • Should undertake annual recertification • Lack of Corps leadership to make things • Simulation is ad hoc better • Lack of experience • Simulation is always working on SimMan in doors • Lack of focus • Simulation needs to be structured • Lack of freedom of action • Skills maintenance • Lack of leadership • Social network • Lack of relevant clinical placement • Specialist training • Lack of resources to support medics • Spend too much time on non-clinical work • Lack of respect from other Corps • Sponsored to complete degree • Lack of satisfaction • Sports Massage • Lack of skills consolidation • Strapping • Less hospital ward time • Tactical Combat Casualty Care • Less non-clinical work • Time poor • Little hands-on clinical work • Tiredness • Loss of enjoyment • Too busy • Make simulation relevant • Too many tasks

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• Make training relevant to our job • Trained to only work under supervision • Marriage and family issues • Training was the highlight • Mental Health • Unfair distribution of tasks • Military skills training • Unit • Major Incident Medical Management and • Unit culture Support training • More ambulance ride along • Unit does not organise regularly ongoing training • More clinical manager training • Unit not supportive • More deployment opportunities • Unsatisfying tasks • More emphasis on Primary Health Care • Unsatisfying work drugs • More mentoring • Work in civilian health sector • More Mental Health training • Work life balance • More occupational health training • Working hours • More ongoing clinical training • Under paid when compared to other trades

• More placements in primary health care settings

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