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Abstract
Objective To explore rural hospital doctors’ experiences of providing care in New Zealand rural hospitals.
Design The study had a qualitative design, using qualitative content analysis.
Setting The study was conducted in South Island, New Zealand, and included nine different rural hospitals.
Respondents Semistructured interviews were conducted with 16 rural hospital doctors.
Results Three themes were identified: ‘Applying a holistic perspective in the care’, ‘striving to maintain patient safety in sparsely populated areas’ and ‘cooperating in different teams around the patient’. Rural hospital care more than general hospital care was seen as offering a holistic perspective on patient care based on closeness to their home and family, the generalist perspective of care and personal continuity. The presentation of acute life-threatening low-frequency conditions at rural hospitals were associated with feelings of concern due to limited access to ambulance transportation and lack of experience.
Overall, however, patient safety in rural hospitals was considered equal or better than in general hospitals. Doctors emphasised the central role of rural hospitals in the healthcare pathways of rural patients, and the advantages and disadvantages with small non-hierarchical multidisciplinary teams caring for patients. Collaboration with hospital specialists was generally perceived as good, although there was a sense that urban colleagues do not understand the additional medical and practical assessments needed in rural compared with the urban context.
Conclusions This study provides an understanding of how rural hospital doctors value the holistic generalist perspective of rural hospital care, and of how they perceive the quality and safety of that care. The long distances to general hospital care for acute cases were considered concerning.
- Organisation of health services
- Health & safety
- Adult palliative care
- GERIATRIC MEDICINE
- QUALITATIVE RESEARCH
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Organisation of health services
- Health & safety
- Adult palliative care
- GERIATRIC MEDICINE
- QUALITATIVE RESEARCH
Strengths and limitations of this study
In this study, both interviewer and interviewees had professional knowledge of the topic studied, thereby taking advantage of the researcher as an instrument of the research.
The diversity of sizes and services in the rural hospitals visited reflected different aspects of rural hospital care.
Qualitative content analysis was considered suitable as it is a methodologically flexible approach enabling interactive changes to the interview schedule as new information is gathered. Furthermore, this approach enables findings relevant to a specific problem/issue to be documented.
Male and female doctors with varying clinical experience and of different ethnic origin participated; however, no Māori doctors were interviewed.
Introduction
General practitioner (GP)-led community-based (rural) hospitals provide hospital care mainly in sparsely populated rural areas in many countries.1 2 The Cairns Consensus Statement3 defines Rural Generalist Medicine by the broad scope of medical care a rural doctor provides. This includes primary care, hospital inpatient care, emergency care and a population health approach to provide services responsive to community needs both locally and at a distance.
In New Zealand, hospitals are categorised by size (large, mid-sized and small) and by service provided: six levels along a continuum from level 1 (community services) to level 6 (supracomplex services).4 There are 33 rural hospitals (RHs) in NZ (21 in North Island, 12 in South Island), they are all categorised as small and with service levels 1–3 based on medical coverage and resources.5 RHs have evolved in response to local needs and economic circumstances, resulting in a variety of sizes, services and ownership models—a mix of public hospitals run by District Health Boards and Community Trusts.6 7 The medical and nursing care provided in RHs cover many vocational areas of clinical practice,8 as do rural community hospitals in other countries.1
Traditionally, RH medical care in NZ has been provided by local rural GPs and Medical Officer of Specialist Scale (a non-training position for not yet specialised doctors). RHs are defined as ‘a hospital staffed by suitably trained and experienced generalists (both medical officers and rural GPs), who take full clinical responsibility for a wide range of clinical presentations…’.6 Rural Hospital Medicine was recognised as a new scope of practice in 2008 and speciality-training programmes adapted for the needs of RH doctors were implemented.5 9 RH doctors would meet the Cairns Consensus Statement’s definition in their work at the RH, but approximately half of the workforce work full time at the RH and not as GPs.5
The Otago Rural Hospitals Study found that RH patients were older than those admitted to larger hospitals.10 This is consistent with studies on similar models of RH care in other countries.11–14 These studies indicate that some patient groups, mainly elderly patients with exacerbation of chronic diseases and infections, could be offered different levels of hospital care depending on the presence of an RH in their community.
A recent NZ policy document emphasises an estimated increase in hospital bed usage in the coming decades due to an ageing population, and states that the complexity of hospital cases will increase due to multimorbidity and frailty.4 Furthermore, new models of care are looking to provide more care in communities, closer to where people live, with earlier discharges of patients from general hospitals to RHs for step down care adding further pressure on rural healthcare systems.4 15
RHs provide hospital care for patient groups elsewhere treated at general hospitals and that are predicted to constitute an increasing proportion of future rural hospitalisations. RH medicine doctors will, therefore, be responsible for the care of an increasing number of complex patients. Little is known about RH doctors’ experiences of providing care in NZ.16 It is, therefore, important to explore how these doctors view their role and that of their RHs in their community in the context of the wider NZ healthcare system.
Aim
The aim of this study was to explore RH doctors’ experiences of providing care in RHs in Southern NZ.
Methods
Study setting
NZ’s South Island has a population of 1.1 million17 dispersed over a geographical area of 150 000 square kilometres.18 Secondary and tertiary hospital care is provided to the population mainly by the general hospitals in Nelson, Christchurch, Dunedin and Invercargill. These hospitals also serve as supporting base hospitals for their associated RHs, of which 12 are located in South Island. The study took place in rural parts of Otago, Canterbury and West Coast regions in the South Island of NZ.
Design and sampling
The study employed a qualitative exploratory design.19 A purposive sampling approach was used to invite RH doctors to the study, aiming to include men and women with different level of experience and of differing ethnic origin, from a variety of RHs in South Island. It was initially estimated that the study needed 15 participants with above variation.
Participants were recruited using email lists provided by the Managing Directors of the South Island RHs.
Data collection
Semistructured, face-to-face interviews were conducted by the PhD student MH at the doctors’ work or in another undisturbed place of their choosing between October and November 2018, using an interview guide (see online supplemental file 1) previously used in a Swedish interview study and modified for use in English and to the NZ context by the NZ collaborators (FDN and TS). The interview technique included open-ended and probing questions, with more specified questions used to orient the discussion towards areas of interest for the study. Interviews lasted on average 1 hour. All interviews were digitally recorded and transcribed. Transcripts were shared with participants for accuracy checking.
Supplemental material
Data analysis
The interviews were analysed according to qualitative content analysis using an inductive approach.20 21 Transcripts were read through several times to get a sense of the whole. The analysis sought to identify meaning units, which were condensed and labelled with descriptive codes. Codes were compared with identify similarities and differences and then sorted into categories according to content. During the analysis process, the codes and categories were discussed in the research group to seek consensus and subthemes and themes formulated (see table 1).22 Descriptions of subthemes including representative quotes from the doctors are presented in the Results section. Participant doctors were numbered 1–16.
Examples of meaning units, condensed meaning units, codes, categories, subthemes and theme
We used the Consolidated criteria for Reporting Qualitative research23 to structure reporting of study findings (see online supplemental file 2).
Supplemental material
Patient and public involvement
No patients or the public were involved in the design of this study.
Results
Fifty RH doctors were invited to participate in the study. Sixteen doctors agreed and were all included in the study. They worked in nine RHs in the West Coast, Canterbury and Otago/Southland regions, representing public and Community Trust ownership models. They ranged from 67 to 330 km from the nearest secondary/tertiary hospital (Dunedin, Christchurch, or Invercargill), and supported populations from 663 to 33 000 inhabitants. They had 4–24 acute beds and variable numbers of long-term care beds, and all three levels of RH services were represented. The characteristics of participating doctors are presented in table 2. Doctors worked in an RH for a part of or all their work time.
Participant characteristics (n=16)
Presentation of categories, subthemes and themes
Applying a holistic perspective to care
The first theme, ‘Applying a holistic perspective to care’ encapsulates two subthemes ‘Providing care close to home and family’ and ‘Seeing the whole patient’.
Providing care close to home and family
Doctors discussed three aspects of providing hospital care close to home and family: the ‘practical’, the ‘emotional’ and the ‘spiritual’. The importance of these aspects made it an ethical as much as a medical issue to keep a patient or refer them to the nearest base hospital.
Practical aspects included the ease for patients with the care close to home as well as for relatives to come and visit, compared with having to travel to a base hospital. For relatives on a low-income, travel costs could be an issue.
If your father gets admitted to Dunedin, what do you do? Do you take two weeks off work and stay close to your father, or do you drive up and down twice each day before and after work? (…) It is impractical for the family (…) But if it is here, they could just pop around for five minutes and have a chat and go home, go back to work. Much better for the patients who get to see their family members more. (Doctor 13)
Doctors described RH rooms for palliative end of life care, with the possibility for family members to stay overnight, often with kitchenettes. Alternatively, these rooms could be used for children and their parents in RHs that accept paediatric inpatient care.
Emotional aspects were considered essential for the local population’s feelings of safety and well-being linked to the personal connection and homeliness of the facilities. Doctors perceived feelings of pride over the service the hospital provided to the local population.
And people also feel very proud of the hospital. Both the people that work here and the people who live here because they know that it is a hospital that understands them and understands the community they live in and provides the highest standard of care in a very effective and efficient manner. (Doctor 6)
Spiritual aspects of RHs close to home was particularly prominent when discussing end-of-life care for Māori patients (the indigenous people of NZ). Dying close to home was described as a very important spiritual aspect for Māori patients. As none of the participants were Māori, these conversations led participants to reflect on their shortcomings in relation to their understanding of Māori tikanga (Māori customary practices), and they recognised that there was room for improvement in the RH care of Māori patients.
Seeing the whole patient
Doctors described the importance of seeing the ‘whole patient’, particularly for patients with multimorbidity or palliative needs. These aspects were brought out when discussing ‘Medical generalist perspective’, ‘Holistic perspective’ and ‘Continuity of care’.
Medical generalist perspective: all RH doctors claimed to have a generalist perspective in the care of their inpatients, that is, a medically wider role compared to that of base hospital specialists. It was stated to be difficult for a generalist to turn down patients and say that the patients’ problems were not within the scope of their competence, leading to a preparedness to do unfamiliar tasks in a way other hospital specialist doctors would restrict themselves from doing, not being in their area of expertise. This aspect of the RH generalist role was described by the doctors, as “We specialize in everything that comes in through the door.” (Doctor 6).
RH doctors problematised that deeper specialisation leads to the loss of a broad perspective, claiming that hospital specialists more often need to consult with other specialists about things outside their scope of practice. RH doctors who had experienced working in urban hospitals expressed their frustration with this approach, which meant they had to deal only with the problem the patients come for and nothing else.
…just deal with the problem and send them back out, even if sometimes their other problems were actually contributing to the presentation. (Doctor 10)
Holistic perspective: RH doctors professed to having a broader mindset, that supported a more holistic, person-centred approach.
I think the biggest difference here and the thing we do best compared to the bigger hospitals, is that we treat people as individuals. (Doctor 9)
It was recognised that having a holistic perspective helped acknowledging the challenges patients faced due to the context in which they lived.
… that’s the advantage I have, and I like about working across primary care is you see the context in which people live and realize how hard it is for somebody who doesn’t have a car … to even get to (Rural Hospital x) for an X-ray… (Doctor 1)
Doctors considered that RHs offer some aspects of palliative care better than bigger hospitals. Such aspects were familiarity, continuity and ability to avoid unnecessary procedures and treatments when patients would not gain from the intervention. This was expressed as an ability to ‘let people die with dignity’. One doctor described a patient who was terminally ill from heart failure. He experienced a small gastrointestinal bleed and went through many invasive investigations in a larger hospital, even though this would not lead to either cure or symptom relief. Instead, it added to anxiety and confusion for the patient and family. Finally, this rural doctor found out about what was happening and managed to stop further (unethical) procedures. This holistic perspective was together with the practical aspects described above considered important and many doctors compared RH palliative care provision to that of a hospice.
The good deaths, people who are … they’ve just reached the end of their time. They may be well on in years, they may have been suffering their heart condition or their cancer or whatever, and their family are here. They come into hospital and their symptoms are well controlled, and everybody is happy and accepting. You know, it’s … if you can call any death a good death. We do have plenty of those. (Doctor 12)
Continuity of care: another aspect of holism was relational continuity, typical for the GP–patient relationship. A minority of participating doctors were working as GPs in parallel to their work as RH doctors. These doctors witnessed the advantage of being familiar with the patients’ circumstances when making medical decisions. It could also be reassuring for patients in difficult situations to know the doctor. One rural GP who had been working for decades serving the local population exhibited his compassion and empathy for those individuals with unfortunate fates that he had supported through the years.
I could have up to four generations of a family in my care at one time. So after … excuse me (sobbing)… After nearly 30 years, I get very close to them… …a kid I delivered who I then picked up off the road, dead in a drunken car crash, 18 years later. (Doctor 12)
Doctors also described a continuity of care for patients associated with repeated hospital admissions at RHs, including familiarity with the healthcare professionals working on the ward. Continuity of the patient/doctor relationship throughout the hospital stay was expressed as important for the patients.
Striving to maintain patient safety
This second main theme, ‘Striving to maintain patient safety’ summarises subthemes ‘Weighing distance issues, to keep or to refer patients?’ and ‘Handling issues related to a dispersed population’.
Weighing distance issues, to keep or to refer patients
Doctors considered that rural people deserve the same healthcare access as urban people. They described how healthcare in RH areas struggle with patient safety issues related to long distances to base hospitals, and the need for safe transportation of severely ill patients requiring ambulance access. It was also discussed that even though many referred patients need transfer to a larger hospital because of their condition—that is, that they cannot be safely treated in the RH—some patients are referred because of practical issues related to long distances.
Ambulance access: as an ambulance could be gone for hours when transporting a patient to the base hospital, doctors described concern about what to do if another sick patient needed ambulance transfer in the meantime (rural ambulances are crewed by dedicated volunteers, consequently most rural areas just have one active ambulance at any one time):
But if I have got a sick patient who I need to transfer, that’s where I’m worrying for where the ambulance is (…) And if it’s out of town doing a transfer, you’re always aware that it’s out of town doing a transfer. (Doctor 15)
As there was limited access to the local ambulance, any patient that could go safely to base hospital by any other transportation (eg, friend or family member’s care) would not be sent by ambulance.
Referral because of distance: RH doctors reported that local access to basic radiology and laboratory facilities was sufficient for most, although not all, acute situations. Some patients needed acute laboratory testing or radiology examinations to guide further actions, that were not available in rural areas. In such situations, the decision had to be made as to whether the patient needed referral to the base hospital for these investigations.
Handling issues related to sparsely populated rural areas
Among issues related to sparsely populated rural areas, limited experience of or training in handling different conditions, limited medical resources and limited medical staff were discussed. Related to these were discussions regarding vacancies among medical staff and recruitment initiatives like ‘rural practice for medical students’.
Limited experience of handling different conditions: doctors described a sense of insecurity when severely ill patients arrive at the RH. Although trained in emergency medicine, they do not often meet these patients in the clinic
I’ve put chest drains in people before. I’ve intubated people before, but not often. Doing those sorts of procedures, I’ll do it if my back is shoved against the wall, and I had to. It’s gonna make me really uncomfortable. Yeah. Some of that stuff is scary. (Doctor 10)
It was discussed that, since midwives took responsibility over the obstetric care in NZ in the 1990s, rural GPs have lost their competences to deal with obstetric complications. Only one RH doctor interviewed was a trained obstetrician. Consequently, in some regions, expectant mothers can have a long way to go to give birth.
… if a midwife is looking after that woman, identifies she’s in need of an emergency caesarean she has to call an ambulance or a helicopter to get them to (a big hospital) for an urgent operation, therefore the delay will be a minimum of probably an hour and a half. Probably more likely two hours. (Doctor 5)
Some patient groups are not admitted to all RHs, such as psychogeriatric patients and children.
Limited medical resources: all RHs were reported to have access to plain X-ray, and many of the RH doctors do point-of-care ultrasound examinations. However, with few exceptions, RHs do not have a CT scanner, consequently patients with stroke symptoms, for example, would be referred to a base hospital for diagnostics, which, including travel time, could take hours.
The availability of point-of-care lab tests were also reported to differ between RHs, and additional tests were wanted to improve patient safety.
Limited medical staff: the generalist rural health workforce across South Island was acknowledged as having high turnover rates of doctors. Some doctors reported a lack of nurses, physiotherapists, midwives and dentists as well.
Midwives, we had the one midwife who was … you know, her only, 24 hours a day, 7 days a week, 365 days a year. She was our only midwife here for years and finally she just had enough and said, "I quit. (Doctor 12)
Different reasons for this were discussed: living and working in the countryside does not suit everybody, “GPs either hate it and they leave, or they love it, and they can't leave.” (Doctor 12). Working in isolation far from hospitals could be frightening, especially for unexperienced doctors. And “…if you work there as a doctor, what does your partner do?” (Doctor 14).
Rural practice for medical students: one problem described was that urban-centric health professional training programmes do not support a rural healthcare workforce. Doctors appreciated the Rural Medical Immersion Programme run by the University of Otago (Dunedin), where medical students do part of their clinical practice at RHs. Doctors stated that students get closer to the patient work and take more responsibility when doing their practice rurally compared with in a university hospital.
It’s very different if you’re the first person to see the patient. And then you have to think about the patient and the diagnosis and that’s a bit. It’s not… You can’t just go and open the notes and say, “ah yes the registrar said it was this” (Doctor 15)
Perceived patient safety: many doctors argued that patient safety in RHs was as good as or better than patient safety in larger hospitals, providing patients needing a higher level of hospital care were not retained. Arguments for this were shorter decision paths in RHs and medical staff knowing the social context of the patients, which could favour discharge planning. Furthermore, in RHs patients are often seen by an experienced doctor sooner than in a big hospital.
I’ve been here nearly 10 years and I can’t think of a specific example of somebody who I’ve thought, “If that happened in central Auckland then they would be alive”, so that must be quite rare, I think it’s safe (Doctor 9)
Cooperating in different teams around the patient
The third theme, “Cooperating in different teams around the patient” summarises subthemes “Working in small teams in flat organizations around the patient” and “Consulting hospital specialists”.
Working in small teams in flat organisations around the patient
The RHs take a central position in the healthcare pathways of rural patients. Rural doctors report team working when describing patient care together with other doctors within the RH, with local GPs and with hospital specialists in base and tertiary hospitals. They are also part of multidisciplinary teams with nurses, physiotherapists, occupational therapists, social workers and needs assessors within the RH and within their locality. This does not differ from other hospitals, but rural doctors discussed how small team sizes promote simplified collaboration between team members. The impact on patients of varying numbers of staff involved in the hospital care was also discussed. Specifically, the RH nurses’ role was highlighted as being central to the delivery of patient-centred care and adaptive to various clinical situations.
Simplified collaboration: doctors stated that the small size of RHs promotes non-hierarchical multidisciplinary teams, where personal acquaintances and deeper understanding of each other’s roles simplify collaboration. In this sense, the small team size in RHs was expressed as an advantage compared with big hospitals.
I think there’s less hierarchy here than in the bigger hospitals. I think it’s much more egalitarian. (Doctor 9)
Impact on patients: the limited number of medical staff in RHs was described as an advantage for patients, as they would not meet so many different medical staff.
He’s in his 80’s. If he got a pneumonia and went to Wellington Hospital where he lives, he’d be seen by an emergency nurse, an emergency doctor, and then he’d probably be admitted to a ward and see a junior doctor on a ward. And then he might see a registrar on a ward, and he’d probably have a whole other set of nursing staff see him and do some sort of care plan. And then you’d have the specialists might see him for five minutes at some point. And he’d probably have some imaging at some point. (…) But that’s already, probably 15 different people would have been involved in his care, whereas, if he came to (our RH) and got a pneumonia, well, my colleague xx, who’s on call tonight, would see him and put him in the ward and organize his treatment and the nurses would, the nurses that are there would be the ones that care for him. (Doctor 7)
Conversely, small team size was also considered a weakness and a vulnerability. Rural health professionals need broad clinical competencies, whereas urban hospitals have more specialised staff available and if a member of staff falls ill, it does not have such an impact on patient care.
We’re always one nurse short of a catastrophe down here. If one nurse goes on leave and another nurse gets sick, then all of a sudden, we haven’t got enough RNs (registered nurses) to man the roster. (Doctor 12)
Nurses’ role: many doctors expressed their appreciation of the RH nurses, for their broad competence, their ability to adapt to different clinical situations, and their clinical judgements.
Particularly the nursing care, I think that’s probably the best thing about the ward (…) some of the nurses are really exceptional at adapting to a whole lot of roles (Doctor 7)
Consulting hospital specialists
In different medical situations, rural doctors need to consult hospital specialists for advice on patient care. They emphasised the interdependency between rural doctors and hospital specialists, and the need for mutual recognition of each other’s situation. They also reported varying levels of collaboration with different hospital clinics.
Interdependency and mutual recognition: overall cooperation with those working in urban hospitals was described as good. This cooperation was improved by personal knowledge and mutual recognition of each other’s circumstances.
… I think we work alongside each other. I couldn’t do my job without a cardiologist who I refer to, or a cardiac surgeon to refer to. They also couldn’t do their jobs without me doing what I do and finding patients for them and treating them before and after… (Doctor 10)
However, some doctors described limited understanding from urban hospital staff about the restricted resources available in RHs and about contextual factors that influence the medical decisions taken in RHs. The perception that some RHs were more trusted and listened to by hospital specialists than others was discussed.
Varying collaboration with different hospital clinics: it was considered that some hospital clinics tended to collaborate better with RH doctors than others.
Things like oncology and paediatrics. We have really good, easy access to the specialists. And they are really personable, and you can ring them about anyone (…) Whereas, orthopaedics, oh my God, it’s like a nightmare. You can never get the same person on the phone, and then you always have to talk to the junior staff, so you can’t actually ask questions about people that might be quite sophisticated… (Doctor 7)
Discussion
Principal findings
Three themes were identified: ‘Applying a holistic perspective in the care’, ‘striving to maintain patient safety in sparsely populated areas’ and ‘cooperating in different teams around the patient’. Participating doctors considered RHs provided a more holistic perspective on patient care based on closeness to home and family, a generalist care perspective and greater relational continuity than hospitals in larger centres. Findings also demonstrate the different assessments RH doctors make, which urban doctors are not required to do. The central role of the RHs in the healthcare pathways of rural patients was discussed, as well as advantages and disadvantages with small non-hierarchical multidisciplinary teams for patients.
Comparison with existing literature
The RH doctors appreciated providing holistic care in contrast to the alleged narrow biomedical perspective of hospital specialists in larger hospitals. RHs were considered a suitable setting for the care of multimorbid elderly patients.6–9 Moffat et al concluded that management of multimorbidity requires a holistic approach by a generalist,24 in agreement with our findings.
‘Close to home’ is multifaceted as both ‘close’ and ‘home’ can have different definitions. In a geographical sense, our findings are consistent with those from interview studies involving patients that describe having hospital care close to home as a great advantage.25 The emotional sense of ‘home’ including homeliness and personal connections discussed in our study is also described in patient interviews.17 18 26 It was obvious that RH doctors in our study not only considered the patient’s treatment as important but also the patients’ ‘lived experience’ of their hospital stay as important, reflecting the social aspect of their holistic perspective.
‘Home’ means different things for different individuals depending on their ethnicity and beliefs. Our study recognised that being near to their whānau (extended family) is particularly important at end of life for Māori patients, as also reported in the study from the North Island by Blattner et al.16 A systematic review27 concluded that home is the preferred place of rural death, and that when symptom control cannot be catered for at home RHs may act as substitute hospices. Compared with general hospitals, rural/community hospitals have been regarded as preferable places for end-of-life care.28
Continuity of care is often discussed in relation to primary care, with an established positive relationship between interpersonal (relational) continuity in the GP–patient relationship and patient satisfaction.29 Our results show, that in the RH setting, relational continuity could include interpersonal relationships within the community and, for patients with repeated hospitalisations, familiarity with health professional on the ward, as reported elsewhere.30 From the RH doctors’ point of view, this continuity was helpful in medical decision-making, particularly for RH doctors working as GPs in the community as well. Strong overlapping personal and professional relationships with community members/patients can emerge over time,31 described at times as a burden for the small town doctor by McCarthy32 and reported in our study as well.
Long distances to the nearest ED increase mortality risk for patients with specific emergency care-sensitive conditions: intracranial injury, acute myocardial infarction, other acute ischaemic heart disease, fracture of the femur and sepsis.33 34 In South Island, long distances to EDs are the rule rather than the exception, due to the dispersed population. Many rural areas are serviced by only one ambulance crewed by volunteer St John staff, so when the ambulance is away transporting a patient, this could delay transportation of subsequent acute patients.
Some acute conditions present as ‘high-risk, low-frequency situations’ to RH teams, and doctors may lack recent management experience of these, so such situations can be very stressful for the team and potentially dangerous for the patients as discussed by our participants and described elsewhere.35 To address this, rural-specific postgraduate training programmes have been developed and implemented in NZ,4 27 36 including simulation-based training.37
Patient safety is a wide subject to discuss. In this study, the expression was used without definition, and therefore discussed intuitively by the doctors. RH doctors stressed the importance of treating the right patients in RHs. This highlights the significance of the assessments made when deciding whether to keep a patient or to refer to a base hospital. This decision process has been studied elsewhere,38 39 and a common finding is that these decisions are not governed solely by the patient’s medical condition, but by contemplations of the doctor about RH capacity regarding available beds and diagnostic investigations, staff competences, transferring capacity and so on. Our study confirms the heterogeneity of assessments RH doctors perform when making these decisions.
Most RH doctors asserted that the patient safety in their RH was high, even possibly higher than in a base hospital. Studies in NZ and internationally have not found any association between rural location and increased risk of hospital harm, but patients in need of interhospital transfers were at increased risk,40 41 as would be expected with patients with emergency care-sensitive conditions.
RH doctors considered that their small sized, informal and egalitarian teams enhanced holistic care, simplified collaboration, and reduced the impact on patients of fragmented care driven by a high volume of healthcare professionals. This finding is similar to a Swedish interview study on interdisciplinary teamwork that identified a holistic care approach and proactive non-hierarchical interaction as important factors for quality geriatric care.42 Small working teams do not need formalised reporting mechanisms if they have relationships that enable open disclosure and resolution of errors.43 However, due to the overlapping of professional and personal roles, some small medical communities may need structured reporting mechanisms to ensure anonymity.43
Strengths and limitations of the study
The interviewing researcher (MH) had specific knowledge in rural medicine as a Swedish rural GP, but no previous relation to the RHs or the medical staff interviewed, which is considered a strength. Conversely, his preunderstanding could cocreate the messages from interviews with participants and play a role in the subsequent analysis. However, the latter was balanced by other experienced qualitative researchers in the process (FD-N, TS, MB) looking at the text data through different analytical lenses. Another strength is the diversity of RHs visited. The interviewer’s first language is Swedish, and interviews were performed in English. Therefore, linguistic nuances could be misinterpreted. However, repeated readings of the transcripts and interviewees’ reports from reviewing their transcript did not reveal such misinterpretations. Many of the doctors had long clinical experience from working in NZ and overseas, that would add to richness in information. When discussing gender-related aspects on their work in RHs, the female doctors did not report anything of value to the study. We aspired to have Māori representation among interviewees, but in the RHs visited, no doctor identified as Māori, and it is acknowledged that Māori are under-represented in the NZ medical workforce.44 In the last two interviews, no new information of importance was added, indicating that saturation was met. The chosen perspective in this study is that of RH doctors. Perspectives of other members of RH teams, patients and relatives are important and require exploration in subsequent studies.
We emphasise that some of our findings are not necessarily transferable to RHs in North Island, as there are considerable sociodemographic differences between the populations of North Island and South Island, notably in distribution of the Māori population in rural areas.45
Implications for clinical practice and health policy
A recent NZ policy document emphasises the estimated increase in hospital bed usage in the coming decades due to an ageing population, and emphasises that the complexity of hospital cases will increase due to multimorbidity and frailty.4 Hospitals need to work ‘more closely with community, social and primary care services in locally integrated systems to ensure that people are only cared for in hospital when appropriate’.4 Generalist-led hospital care is considered especially suitable for multimorbid elderly patients that require a holistic approach by the caregiver.24 The 2006 Otago Rural Hospital study6 suggested that ‘approximately 40% of admissions from urban populations to base hospitals could be handled at a generalist level’—as is now provided in rural settings using the RH model. Given the need for more hospital beds in future,4 the RH model of care could be suitable for piloting in semirural and urban NZ.
Conclusion
This study provides an understanding of how NZ South Island RH doctors perceived the importance of the provision of a holistic generalist model of hospital care for patients and for their rural communities, as well as the significance of the RH to rural communities.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Otago Human Ethics Committee (17/141). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to thank all the participating RH doctors and the Managing Directors of their rural hospitals for their involvement and effort.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @StokesTim63
Contributors MH designed the study and developed the interview guide in cooperation with MB, TS and FD-N. MH conducted the interviews. Initial data analysis was undertaken by all authors. Subsequent data analysis was undertaken by MH and MB, with input from TS and FD-N. MH led the writing of the manuscript with inputs from MB, TS and FD-N. MH is the guarantor.
Funding This work was supported by Region Västerbotten, National Research School in General Practice, the Kempe Foundation, Svenska Läkaresällskapet (SLS-787391) and DLF Provinsialläkarstiftelsen.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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