d theme rows. Leveraging the case study research design, the six practices studied were conceived to provide representations of the first three levels of academic engagement: beginning, emerging and consolidating. The features of an established academic rural general practice were supposed from the literature, from extrapolation of the progression of beginning to consolidating rural academic practice, and from the experience of the research team in the rural general practice and academic environments.
Table 5: Framework for rural academic general practices
Considerations were identified for progressing on a trajectory from a rural general practice without a training focus to one that has extensive training activity to one that undertakes both training and research and thus could be described as a rural academic general practice. Stages on this pathway have been conceptualised as beginning, emerging, consolidating and established. To effectively foster education and research activity in rural general practices, the considerations identified in the thematic analysis and represented in the framework need to be addressed.
A beginning practice may be reluctant to host learners because of uncertainty about the impact of learners on the patient population and on the doctor-patient relationship. They may be concerned about the additional workload that learners might bring and how to manage this. They may be unsure of the financial consequences of hosting learners, may not have the physical space and may be uncertain of their knowledge and capacity for teaching. To encourage these practices to take on learners, training providers and universities need to be able to clearly articulate how these concerns might be addressed.
Emerging practices in the framework have had some involvement in education while health service delivery remains the primary focus. Usually only one level of learner and a single supervisor are present in the practice. A culture of teaching is appreciated but is not significant. Patients may or may not be aware that the practice hosts a learner. The supervisor's interest in teaching is often the motivator for the practice's involvement in education. The practice receives a small amount of educational income. Resources required to support several learners and a strong culture of education (more than one supervisor, physical space for learners and administrative support) are often the barriers for these practices moving towards the consolidating and established academic status. There may be the concern that hosting more learners will erode the financial viability of the practice. To encourage an emerging practice to take the next step in increasing their engagement in education, support for infrastructure and training supervisors is critical. Also there needs to be clear financial value in making education a stronger focus. This value needs to be well articulated.
Consolidating practices are likely to have been involved in education for some time and to hold learning to be a significant priority within the practice culture. Patients within these practices are well aware of the presence of learners and generally expect and accept learner involvement in consultations. Consolidating practices have multiple supervisors who are involved in teaching and who value the presence of students, interns and registrars. As teaching is a developed activity in these practices, educational payments form an important component of the practice's business revenue. Dedicated administrative support for education is present. While research is appreciated, there is minimal engagement. For advancement of research activity, a clear route needs to be articulated for developing research skills with mentoring and role models. Research networks are essential to supporting research activity development in the practice. There also needs to be a good business case for practices to engage in research.
In an established practice, service, education and research are viewed as equal priorities. Strong relationships with educational and research insti