Table 3.
Health center/system and staff attributes that were identified as predominant barriers with example quotes.
| Health center/system attributes | Example quotes |
|---|---|
| Staffing, recruitment, and retention | “Many barriers are a result of combination of constant changing staff and low retention of staff.” (Nurse, Government health department, remote context, chronic illness survey, individual response) |
| “Staff employed at health centres are usually from emergency/acute background. There should be dedicated non-acute staff (child and family health nurses, chronic disease nurses) employed at the local level – who do not have to work on the roster for 24 hour on call – and therefore provide an uninterrupted community health centre to the community in partnership with Indigenous health workers which would provide much needed sustainability to program work.” (CQI facilitator, Government health centre, remote context, chronic illness care survey, individual response) | |
| “Lack of staff training, recruiting from emergency departments and just not enough permanent staff on the ground mean that brief intervention, program delivery and self-management support rarely get a look in. High staff turnover with some clinicsa having only relief staff – no permanent staff. Constantly training and orientating staff.” (Child health survey, Group response (less than 5 people), remote) | |
| “The biggest barrier is the lack of specialist child health nurses in remote health centres and high turnover levels of remote nurses in general so that upskilling of the remote area nurses is constant. The other biggest barrier is the lack of Aboriginal staff to work with the nurses and doctors.” (Researcher/Academic, University or research organisation, urban, regional and remote context, child health survey, individual response) | |
| “Lack of staff who actually live in the community to develop long term relationships and the lack of trained Aboriginal health workers” (CQI facilitator, community-controlled health centre, regional and remote context, child health survey, individual response) | |
| “There is a serious lack of Aboriginal health workers and allied health staff. There is also a lack of retention of these members of the workforce. It is extremely important to have Aboriginal health workers at community level with parents and carers to improve family and community practices – discussion nutrition, hygiene and when to seek care.” (Policy officer, Government health department, remote context, child health survey, individual response) | |
| “Barrier is lack of adequately trained child health nurses, and employment of generalist hospital nurses who have no idea about community, public or population health or child health.” (Policy officer, Medicare Local, regional and remote context, child health survey, individual response) | |
| Training and skill development | “Not all staff are accredited to provide immunisation, or have the knowledge on how to document when immunisation is given elsewhere” (CQI facilitator, Government health department, remote context, child health survey, individual response) |
| “Many staff go to a clinic without adequate training in the basic use of information systems and inadequate orientation to the organisation and the community. For some staff it is a case of they don’t know what they don’t know. Training when someone hits the ground running is difficult and in this day and age inexcusable.” (Nurse, Government health department, remote context, chronic illness survey, individual response) | |
| There are a lot of tools, training, and self-directed teaching available to staff but there is insufficient time and staffing to do all of the training constantly thrown at everyone. Due to gaps in availability of health workers and admin staff who are sufficiently trained and supported to do their jobs, the PHC facilities remain chaotic at best, particularly during periods of high turnover which continue to occur due to staff burnout/exhaustion battling in an under resourced/underappreciated and chaotic environment. (Chronic disease survey, Group response (more than 20 people), remote context) | |
| “The response to these gaps is typically to provide more packages for self-learning – eating further into front line staff time, and more management telling them they should be doing these things. There is simply insufficient number of staff to achieve every priority to the highest level.” (Chronic disease survey, Group response (more than 20 people), remote context) | |
| Decision support and clinical information systems | “The electronic medical record system is extremely slow in some communities and documentation takes ages, service may have been provided more often than documented particularly in the area of advice given.” (CQI facilitator, Government health department, remote context, child health survey, individual response) |
| “The current systems allow for creation of multiple recalls which are never able to be completed. Better system needed which provides some degree of prioritisation of the recalls.” (Policy officer, Government health department, remote context, child health survey, individual response) | |
| “Barrier is there are no standard guides on entering electronic data” (Policy officer, Medicare Local, regional and remote context, child health survey, individual response) | |
| “Communication between health sectors is appalling…. The epitome of the lack of communication are the IT services covering different health sectors and that they don’t cross reference patient information. When I would go to remote clinics (as a specialist) I would have to access four different information systems in four days – hospital, PCIS, Communicare and paper-based notes. It’s ridiculous the ehealth record has been a dismal failure, so this problem is not going away in a hurry.” (Researcher/Academic, University or Research organisation, remote context, child health survey, individual response) | |
| “The time to provide recommended care is a barrier – the electronic medical record system is extremely slow in some communities and documentation takes ages.” (Doctor, Hospital, remote context, child health survey, individual response) | |
| Quality improvement | “Barrier is managers who still think CQI is extra work and not their job” (CQI facilitator, Community-controlled peak body, remote context, child health survey, individual response) |
| “Managers who know about and understand the importance of quality improvement are also an important enabler of best practice.” (Researcher/Academic, University or Research Organisation, regional context, child health survey, individual response) | |
| “At organizational (and system) levels, there is lack of knowledge or commitment to support a culture of good clinical and information governance to ensure good documentation and assessment/management of data quality to ensure that routinely collected data are fit for clinical and quality improvement purposes.” (Researcher/Academic, University or Research Organisation, urban and regional context, chronic illness care survey, individual response) | |
| “Focused use of structured CQI methodology is dependent on the individual manager/leadership understanding and is often not consistent and well integrated into primary health care service functioning.” (Policy officer, Community-controlled peak body, urban, regional and remote context, chronic illness survey, individual response) | |
| Community capacity, engagement and mobilization | “Barriers are high turnover of staff, particularly in more remote areas – relationships and networks may be made with community, local health centres and regional services and then need to be remade with the next staff member coming on board.” (Researcher/Academic, University or research organisation, urban, regional and remote context, child health survey, individual response) |
| “Main barrier is community engagement and support” (Researcher/Academic, University or research organisation, urban, regional and remote context, child health survey, individual response) | |
| “Í believe an empowered and motivated community is the most important enabler for providing best practice. As long as the community demands better health care the health centres will improve. I have seen that health services that have a strong board to which the CEO and health workers are accountable tend to have better quality care.” (Researcher/Academic, University or Research Organisation, regional context, child health survey, individual response) | |
| Leadership and teamwork | “There is a relative lack of clinical and corporate leadership to enable the implementation, training and support of evidence-based care of patients with chronic illness. There is significant lack of informatics capability among managers and clinicians to implement systems, as espoused by the chronic care model, to provide effective decision support at point of care to prompt decisions and enable evidence-based action at the clinical level. At organizational (and system) levels, there is lack of knowledge or commitment to support a culture of good clinical and information governance to ensure good documentation and assessment/management of data quality to ensure that routinely collected data are fit for clinical and quality improvement purposes such as the ABCD program” (Researcher/Academic, University or Research Organisation, urban and regional context, chronic illness care survey, individual response) |
| Staff attributes | Example quotes |
| Intentions | “Whilst the intention to provide best practice care is there the capacity is not, therefore it is rarely implemented both due to patient expectation – e.g. attended for acute injury not to discuss diabetes – and staffing/time issues. [There is] insufficient time to truly provide best practice care, either due to only a handful of staff trying to do all components or too many other patients who will not wait for care if it takes too long to provide patients with all aspects of best practice care in accordance with guidelines. Patients generally are either keen to be involved in their health care, come for their appointments and follow through on plans or do none of this and are captured opportunistically but as they’re not engaged it is a long drawn out process to try and provide all components of “best practice” with them.” (Group response, + 20 doctors, remote context, chronic illness care survey) |
| “People have good intentions but are unable to do everything in the current set up with the current staffing levels” (Chronic disease survey, Group response (more than 20 people), remote context) | |
| “I truly believe that nearly every person who goes to work in remote clinics has the very best of intentions to provide the best possible care for all Indigenous children. I think that the high workload, lack of colleagues, lack of managerial support, lack of ongoing training and education and poor communication between health sectors causes issues such as “culture shock” with subsequent burn out and high staff turnover.” (Doctor, Public hospital, remote context, child health survey, individual response) | |
| Social influences | “Staff often have preconceived ideas about the success of interventions with regards to Aboriginal and Torres Strait Islander populations.” (Allied health practitioner, Government health service, remote context, child health survey, individual response) |
| “Social influences and attitude, such as new staff listening to old staff ‘it will make no difference what we tell them”; “I don’t know why we’re doing this.’” (CQI coordinator, Government health department, remote context, child health survey, individual response) | |
| “Managers feel pressured to deal with acute presentations before chronic disease. So managers need to be able to employ dedicated staff which do not deal with the day-to-day acute load.” (CQI facilitator, Government health department, remote context, chronic illness survey, individual response) | |
| Emotion | “Because of the uncertainty of PHC, staff are always on edge about the future, and this transfers into care provision to the client.” Nurse, Private practitioner, individual response, child health survey) |
| “I worry about the increasing workload for ground staff, i.e., the upcoming self-management assessments for clients, lack of health education for clients generally and staff on the ground feeling drained, incompetent and over-stretched and criticized. Many people work very, very hard and every now and then have a win but I think we need to be helping ‘on the ground’ staff a lot more than what we are currently doing.” (Nurse, Government health department, remote context, chronic illness survey, individual response) | |
aThe term “clinic” is commonly used to refer to a health center. CQI, continuous quality improvement; PHC, primary health care.