Table 5 Barriers—Summary of rural clinicians’ experience and example quotes

Barriers

Patient

A life-changing event

He had lots of comorbidities, he was a bit of a ticking time bomb. DR1

the smallest of things can happen and it significantly changes their life pathway. RN2

For a lot of people in this age bracket, it’s life changing. They don’t get to go back home or when they do, they find it so difficult that they can’t cope. RN1

If something like this happens, this is life changing and it’s incredibly complex. They often spend significant time in hospital. This is often probably their last 1000 days really. RN1

Being alone

In rural areas, people often live quite remote on a farm. They get to a certain age and they have an accident. Then they completely lose their independence from one day to the other because they don’t have the support they need and it’s very difficult to live on a farm by yourself. DR6

That causes a lot of social dislocation for the patient. They can be quite isolated because their partner may be elderly, can’t visit them – especially with COVID, it’s been really difficult – their families can’t visit them, especially when they’re palliative. [DR4]

Old people who sustained terrible intracranial injuries who get put on a flight… six hours away from their loved ones, only to be then said, “Oh no, this is palliative… The outcome is still the same but they’d be surrounded by loved ones when they died, not at (city hospital) with no one there.” [DR6]

Not speaking up

They’re just a different generation… they are a more vulnerable generation because they don’t advocate like they should. And the country folk particularly.” [RN1]

You’ll get someone who’s been sick for a month, “Oh I just didn’t want to bother you” [RN2]

“Remember that question you asked me eight times and I told you to ask the doctors? They’re here” “I won’t bother them. They look busy” OT1

Staff

Rural clinicians feel unsupported

I don’t think there is specific lack of resources for old people. There’s a specific lack of resources for everything. DR6

More community support would be better … it’s all a bit thin on the ground. DR3

[we] are always understaffed…always struggling to get a full trauma team together. So often it’s a GP and the nurse and that’s it”[DR4]

[it is] uncomfortable looking after a patient who’s got some blood in their head… what do you do if they do go off (deteriorate)? You’re miles away from help” [DR7]

Very often in this situation, after hours, I’ll be there by myself with a resident. … you’re pretty much on your own. I can think of a situation where one of our guys who has recently left desperately wanted a hand…. But there was literally no other surgeon… for 300 to 400 kms. DR2

We have sometimes a spinal service – it’s one consultant, so obviously he can’t work all the time. RN1

We tried to sponsor [rural clinicians] to go for courses. But it was extremely difficult because they’re so understaffed, they can’t take the time off. DR5

Older trauma is hard and not sexy

The fracture is the littlest part, but everything else is super difficult around it. DR5

[Younger trauma patients] are a great trajectory –they just need a little bit of allied health and then off you go. Versus the older person, “it’s just a couple of ribs,, but they’re going to here for four weeks because allied health can’t get them out of the hospital”. OT1

It’s paradoxical, but when the mechanism of injury is less… rural patients have less access to care, because it’s either not recognised or they don’t have access to the early imaging that they would normally and decision making. [DR3]

If you’ve got a 15 year-old who’s got multi system trauma, people get excited about that. But if you say you’ve got an 87 year-old who’s on home oxygen and blah, blah blah, it’s a different dynamic. DR7

System

The tyranny of distance

People come here by road up to a couple of hours away. West of here there is essentially no hospital for 800 kms. DR3

I saw people where we were the first hospital they’d landed in and it was about 14 h after their trauma. DR9

We talk about these people having to be in theatre within 24 h. These folk are lucky if they get to a hospital with a surgeon within 24 h. DR2

The systemic lack of resources in rural practice

There’s often delay in getting the patient back into their community because of the lack of allied health, lack of rehab, lack of brain injury [services]. OT2

They’ll end up being discharged to one of the outlying hospitals and they just sit in a hospital bed and eventually end up in a nursing home. Whereas many of those patients in the city with better care would be getting back home and living independently. DR4

A fragmented health system

“this gentleman with chest injuries lay flat on his back for maybe two to three days before … (the specialist centre) got back to us about what they wanted for his spinal care. I just think that’s unacceptable care” [RN1]

I only own it when it is on my own soil, and if it’s not on my soil, then it’s not my [problem]. DR1

Patients … heli-retrievaled in from out of our district, are not actually eligible for rehab within our hospital. So they need to be transferred back to their local hospital or to a tertiary hospital within their own catchment to be able to complete their rehab. DR10