Thirteen facility managers were contacted and twelve responded to the invitation for interview; eleven were conducted face to face and were approximately one hour long; one telephone interview took approximately twenty minutes. All the managers interviewed were nurses, women and responsible for the management of at least one hospital, and in some instances also community services. Participants explained how their facilities functioned to provide emergency care and recounted their experiences of traveller presentations. No participant had ready access to any reports of hospital routine data on traveller presentations; all accounts were based on their experiences and recollections.
Thematic analysis identified three key themes: services in and for the community, met and unmet expectations, and preparations.
Services in and for the community
This broad theme encompassed an explanation of the healthcare and support services that were provided at the sites (and some of the challenges faced) and the ethos and culture of care for which these participants were responsible.
In describing their culture of care, all participants clearly expressed that they did not differentiate between local people and travellers in relation to how they are managed. Participants stressed the function of their facilities as serving their communities:
“We are a community hospital, and we are here to serve the community” [HCP8] and
“… I could get sick, you’re sick, that’s OK that’s what we are here for..”. [HCP12].
They also acknowledged the contributions of travellers to their local economies, for instance when they stop to re-fuel their vehicles, stay overnight or longer, purchase groceries and visit local coffee and gift shops, museums and art galleries.
Participants explained that services were provided on a holistic basis, which could be interpreted more broadly than is generally the case with metropolitan health services. Managers recounted events where the hospital staff had provided care that was extended to meet the needs of their patients’ partners and vehicles and even their dog (see Supplementary File 1, Case Example One). This was not viewed as anything out of the ordinary but part and parcel of serving their community, which was what they considered the basis of their role. The care provided was no different for grey nomads than for local community members.
“We treat them as we treat our community or anybody... we don’t treat them any different to anybody else” [HCP12].
Nonetheless, all the managers described the recruitment of nursing (and other) staff as a particular challenge in maintaining service delivery and all were heavily reliant on overseas nurses. They expressed disappointment that, unlike for teachers and police officers [in NSW], few incentives were available for nurses to work in remote and very remote areas.
“We always have a recruitment problem… there’s a perception that everyone needs to be really experienced to work and that’s not necessarily the case. The remoteness of and the aging population of our nurses has become a very intricate weave” [HCP3].
Participants went on to describe the services delivered at their facilities. They explained that they provide emergency care but are not equipped for longer term inpatient care. In the one nurse-led facility, they were able to keep patients overnight or for a couple of days as the highly skilled nurses could implement nursing interventions, within their scope of practice, to address conditions such as dehydration or mildly unstable diabetes. Telehealth was described at this site, so a doctor could talk directly to the patients. At all sites, emergency care was provided via high resolution digital cameras. Generally, an emergency services doctor was on the other end of the camera reviewing the patient and giving instructions for treatment. In other instances, retrieval services and their networks of specialties were accessed. For example,
“We had a penetrating eye injury a few years ago where an ophthalmology surgeon told us what to do to avoid optical nerve damage… If someone’s had a stroke and they are in ED … instead of getting an ED doctor, we get a cardiovascular consultant to talk us through” [HCP11].
Patients were generally airlifted to larger facilities when their illnesses could not be adequately treated locally. Where tertiary care was required, the patient could be stabilised onsite and then retrieved by the Royal Flying Doctor Services (RFDS).
Some participants expressed their personal purpose as the pursuit of service rather than career development. For some, but not all, this was linked to having grown up in the area.
“I try to put back into the community and to help others that need it” [HCP2].
“You just wouldn’t come for climbing the corporate ladder type of thing and I mean, I grew up here, so it’s because you want to give the best back to the people who live in your community, and I mean I live here I grew up here so I’ve got that connection” [HCP3].
Participants discussed the frequency and characteristics of grey nomad presentations to their facilities.
The initial point of contact for accessing health services in these remote towns was the hospital emergency departments. With the exception of two participants, the managers agreed that few grey nomads presented to their EDs, and presentations were not often. One manager reported they could increase the ED throughput by about 10% during the main travelling season. Another stated that grey nomads doubled the number of presentations to their ED. This manager had been in the area only six months and requested a telephone interview due to her workload related to COVID-19; she did not elaborate in response to questioning, during what was the briefest of the interviews. The other participants reported the number of presentations fluctuated and are seasonal, depending on what activities were happening locally. They described significant events attracting travellers during the annual seasonal migration north between March—October (although most events were cancelled in 2020 and 2021 due to the COVID-19 pandemic).
Participants reported that generally more men than women travellers were seen in their EDs. They commented that while they might see solo women in the towns, they seldom presented to the hospital. One manager described a convoy of women passing through the town on their way to an event but reported that travellers were predominantly heterosexual couples. However, no site data were available to support these accounts, which derived from their recollections.
When asked about the impact of traveller presentations, participants said that, as numbers were small, the overall impact on their services was no different to that of local people. One participant recounted that grey nomads presented for the same reasons as local people: mainly accidents and exacerbation of chronic illness. This reinforced the view of grey nomads as no different to the local community in terms of service need and demand. No-one reported hospitals requesting an increase in staffing because of grey nomads or suggested this was necessary, irrespective of their recruitment issues. These services were all small (see Table 1), with clinical and administrative staff covering a range of functions. Any presentation that tied up a member of staff impacted these services. In participants’ view, whilst grey nomads had some presence in their EDs, this was not anything out of the ordinary. Only one manager saw grey nomads specifically as having an impact, but even she described this as, “they impact normally…” [HCP5]; that is, no different to other presentations. This was further explained:
“Ah look, anyone that is significantly unwell impacts on a small rural site because we have one registered nurse on per shift and that’s the only person in this facility who can triage so the triage can take them away from something else they would be doing...” [HCP1].
Resource-intensive episodes necessarily resulted in significant disruption to routine services, regardless of whether the patients were local people or grey nomads. Examples were provided where local people had experienced serious illness and major traumas such as cardiac events and farm accidents and where presentations by travellers were similarly resource-intensive. For example in one ED a grey nomad died from a ruptured abdominal aortic aneurysm; motor vehicle and caravan accidents were also recounted (see Supplementary file 1, Case Example Two). Grey nomad presentations were reported as most commonly men attending with chest pain or known cardiac disease. Medication-related attendances were almost as frequent, when travellers had left their medications at home, had run out of pills, or didn’t have a prescription to refill. Accidents and injuries also featured, such as:
“ dropped the tow ball or the trailer on their leg [HCP8]; …sepsis, fractures, ankles, lots of falling over including the curb, that’s quite common; ankles or wrists, just those accidental things that happen…” [HCP5].
One participant gave accounts of grey nomads presenting to the facility during winter for a dose of annual influenza vaccination (and other vaccines) and explained that this site is allocated additional flu vaccine doses for this population. The consistent picture was that participants applied an inclusive definition of community: they did not differentiate presentations by grey nomads, who were not perceived to be a particular burden, and there was no difference in the care they received from that of local people.
Met and unmet expectations
This theme related to the expectations of some grey nomads of the services they anticipated would be available, what services are normally delivered and what can be provided where staff go out of their way to meet peoples’ needs.
The majority of presentation anecdotes illustrated travellers presenting with needs that were within scope for the facilities either to address directly or arrange care delivery elsewhere. However, services that are taken for granted in metropolitan areas are not always available in these remote sites. Some travellers or even urban service providers were not aware of this.
“We have people from the city hospitals ring us and want to speak to our CT person or our pharmacist. So that would be me, and that would be me, and that would be me. We don’t have a CT scanner, we only have an xray machine. It’s not just travellers, it’s other people in general… they don’t know” [HCP11].
“…So you know most of them are great but there’s the odd few who will say “fly me out, what do you mean?” “We don’t do that here, we’ve got to fly you out”, and most of them handle it well but being several hours from a Base hospital, I think some of them don’t necessarily get the distance and what a rural hospital does…” [HCP6]
As specialty services are not necessarily available, patients may have to be flown out to larger centres. One participant recounted a conversation with a patient who seemingly did not understand the available services or the requirement to be flown to another hospital, saying:
“… do I have to? (be flown out)” [HCP3].
Where services were available, this could be because people were multi-skilled, for example, where wardsmen and nurses were qualified to take X-Rays.
Sometimes staff rose to the challenge even where expectations were not realistic. In Case Example Three (see Supplementary file 1), despite unrealistic expectations, staff were able to arrange what was asked. In Case Example Four (see Supplementary file 1), advanced practice skills were employed by a single nurse in a Primary Healthcare Centre (PHCC), not just to manage seriously decompensated diabetes but also to understand the mental state of vulnerable people in high-risk situations. In these instances, whilst the expectations were described as unrealistic, they were met.
Grey nomads’ unrealistic expectations could extend beyond the services to encompass the countryside and their travel within it. Not all travellers had an awareness of the vastness of the country, the remoteness, the distance between towns, and the need for this to inform their level of preparedness for their travel and their health maintenance.
“The towns are an hour apart but … some people just don’t understand the distances” [HCP 11].
Participants described grey nomads with various levels of understanding and preparation for their travels. They were more generally characterised as educated and informed, knowing their doctors and conditions, having a care plan, discharge summary or some type of health information pack, and a list of their medications and scripts. Whilst MyHealthRecord (Australian online national voluntary health record) was viewed as potentially useful, not all managers knew how to access it and not all grey nomads had a digital record. Those with chronic illness were described as the most prepared, reflected in having plenty of medication and a medical history from their GP.
“…The travellers that come seem to be well prepared and have GPs and things which is always good so maybe that’s why we don’t see as many as we could, they might take a little bit better care of themselves I’m not sure cause they are planning to be away so maybe they organise that stuff….” [HCP 1]
“…Those who are well prepared usually have chronic health issues; have plenty of supplies such as food water spare tyres; know where they are going; have plenty of medication; letter of introduction from their GP and bring a medical history with them”. [HCP10]
However, this wasn’t always the case. There were other instances, albeit not so commonly described, where forward planning and preparation was lacking, especially for problems or sudden ill-health:
“…Some just get in their car, pack their car up and the car might be 20 years old and off they go. That can be male or female because we do have single male travellers as well not prepared at all. They might only have a little bit of water with them, not even have an idea of the distance between towns...” [HCP 8]
“…Some are, some aren’t. Some haven’t got a clue and don’t understand what resources are and are not available in the outback...” [HCP10].
In one facility the story was recounted of a male traveller and his wife who presented to the ED to have blood collected for pathology tests every couple of days. Although not considered a burden on the service, the participant expressed concern that this man was in such a remote location with a compromised immune system, and questioned how prepared he was, should he become ill enough to warrant admission to hospital. The concern was about the patient, not the impact on the service. Another manager recounted how a man and his wife towed a caravan to the hospital but had no contingency plan when the man became ill and required retrieval to another hospital: the wife could not drive let alone tow a caravan (see Supplementary file 1 Case Example Five). Another manager described a couple who presented where the husband, who was the driver towing the caravan, had dementia and his wife did not drive. In some instances, travellers’ preparedness was linked to their expectations of the support available to them in remote Australia: expectations that were not always realistic. Poor preparedness could reflect a failure to think through the implications of remote travel. In other cases, however, good preparedness seemed an extension of usual self-management: of routine accommodation of health needs within their lifestyle, whether in a house or caravan.
“…I do find that people who travel are organised, they’ll come with their list of medications and their medical conditions, all their paperwork together and hand it to you..”. [HCP6]