Table 2.

Summary of relevant direct quotations from participants represented within the Walt and Gilson framework [8].

Context
Location and rurality	“The only thing they have there is X-ray services available half a day a week, and they have no other radiology available, and so for a place as remote as that, bedside ultrasound would be invaluable because you have nothing else, so I mean it’s great that you can at least get an ultrasound there next to you.” [C01] “We have to do our own ultrasound after hours in lieu of X-rays and CTs and formal ultrasound. So that’s where it’s very useful. You get the benefit of ultrasound when there’s no other imaging after hours.” [C08]
Social context	“Being confident in how to manage people prior to transfer, and potentially better patient outcomes in that respect. They’d be in better condition by the time they get there.” [C04] “It helps with knowing the acuity of the patient. So, it helps with management as well, and communicating with people back in the city.” [C06] “You could make a more informed referral. You can talk in a more informed way to the person on the other end. So, it makes the referral process more specific, and when it needs to be urgent, you can often get the people on the other end to respond more appropriately if they know what you are dealing with.” [C08]
Political context	“That was purely out of interest because I wanted to learn how to do things a bit more independently and do procedural things independently, as opposed to having to find someone to do something for me or refer things on.” [C01] “I could see its use in the emergency setting. I think I did it because I just wanted to increase my confidence in emergency settings.” [C04] “It’s one of those things, you get no incentive for it. Other than just wanting to be better at just doing things.” [C06]
Content
Standardised exposure and training	“If it was something that was sort of better accessible or something that we were potentially taught in medical school even that will be quite useful.” [C01] “It is becoming a requirement, so that trainees coming through the emergency medicine college have to become competent in bedside ultrasound.” [C08]
Provision of equipment	“It’s reliant on your local health service getting on board and recognising that this should be standard.” [C05] “You put the onus back on the health service. You know, is this standard for a rural facility of this size? Really, we should have 2 ultrasound scanners, you know in case one breaks down.” [C06]
Financial incentive	“I think if there was an MBS (Medicare Benefits Scheme) item associated with bedside ultrasound, you’d find the use would skyrocket, if there was an MBS item”. [C01]
Suggested policy changes	“And for resus as well, I want to get everyone to use the scanner for resus. So, I’m putting it in, you know you go through your ABC [Airway, Breathing, Circulation] approach, and then you add in ultrasound. By just putting things into policy, you can change things as well.” [C06]
Actors
Clinician driven	“That was purely out of interest because I wanted to learn how to do things a bit more independently and do procedural things independently, as opposed to having to find someone to do something for me or refer things on”. [C01] “I could see its use in the emergency setting. I think I did it because I just wanted to increase my confidence in emergency settings.” [C04] “It’s one of those things, you get no incentive for it. Other than just wanting to be better at just doing things.” [C06]
Patient driven	“Particularly as our patient population is getting bigger and bigger it’s actually getting harder to find veins.” [C04]
Workplace driven	“That course was part of an emergency course that we do every two or three years to enable us to be more confident managing emergencies.” [C04]
Process
Training	“I definitely think training is a big part of it, and training people earlier in their medical careers”. [C01] “I think the cost of training is pretty much covered by a lot of the grants that we do get, and I think the government are very good at providing that.” [C04] “There’s a large range in skills, mainly because the training for it is off your own back, it’s all ad hoc. Like there’s no formalisation of it. There’s no way to standardise your level of expertise.” [C06]
Access to equipment	“We actually have just the one machine in the hospital. There’s this weird concept that because it’s a rural facility you only need one, it doesn’t matter what size.” [C06] “We don’t have a dedicated ultrasound machine in the ED [Emergency Department]. And that becomes quite annoying because you have to fight the labour ward for the ultrasound machine, and theatre too. And it’s not available for those places all the time.” [C07]
Cost	“I think the other thing is definitely the cost to the doctor, the cost of owning the machine. And obviously, you can’t bill through MBS (Medicare Benefits Scheme) for bedside ultrasounds, so there’s no real financial kickback for it”. [C01] “The main difficulty I think, is the cost, the cost of the machines. I think that is where people struggle because there is no money in it. You know, you have no way of billing if you’ve added in an ultrasound, so unfortunately you don’t have a way of recuperating that cost, because all you can bill it as is a standard consult.” [C09]
Maintenance of skills	“One of the barriers that people run into that have done training, whether it be the 5 day or the 2 day or whatever training they have done, they then need to perfect the techniques in their own practice, and make sure that they are doing that enough that keep the skills that they’ve learned up, and they often say there’s a real drop off from when they finish the course to when they can implement their skills in practice.” [C10]
Quality assurance	“I think that’s one of the reasons people don’t pick it up, is they’re too scared because they do worry about their skills. So, then you end up getting this fear of interpretation.” [C06] “Quality assurance, so what things are in place for you to consolidate your skills or, you know, just make sure you’re doing it properly. Because for us, like I’ve said already, this is not something that we’re doing very often.” [C05]