Rural physiotherapy service provision and service level decision making: an exploration of rural physiotherapy stakeholders' perceptions

The principal aim of this research was to understand how decisions are made about which physiotherapy services are provided in regional, rural and remote settings. Rural physiotherapy in Australia has been characterised by workforce challenges such as shortages and maldistribution, workload stress, tensions between specialist and generalist career options as well as a lack of positions. Descriptions of areas of work of rural physiotherapists, access, prioritisation and developing service models are available. However, the factors affecting decisions about service provision or how decisions are made about the range of physiotherapy services provided for a community is not readily evident in the literature. The diversity that is a feature of the people and the environment in rural and remote Australia is reflected in the health services provided. Deciding what health services are provided is a key consideration in delivering appropriate and accessible health care for rural and remote populations. Obtaining insight into factors influencing both service provision and decision making about services such as physiotherapy in rural areas may inform such decisions. A range of stakeholders across the organisation and broader health system are likely to influence decisions about physiotherapy service provision. The research design was shaped by the aim of obtaining perspectives of multiple physiotherapy service stakeholders. A priority-sequence mixed methods model was used to guide the practical integration of qualitative and quantitative approaches to explore rural physiotherapy service provision and service level decision making within a collective case study-system theory mixed methods research framework. An interpretivist approach within a qualitative research paradigm supported understanding of stakeholder perspectives. Stratified purposive sampling permitted exploration of subgroups of interest. The subgroups include physiotherapists, their colleagues, managers, other key decision makers and consumers. Combining systems theory and case study methodology enabled a focus on the issue of interest and to consider that issue a system. This permitted exploration and description of a set of interrelated elements that together form a system. Adopting both qualitative and quantitative approaches enhanced exploration of the identified system. The system, which in this study is the rural physiotherapy service level decision making system, was then able to be explored within and across cases. The use of collective instrumental case studies maintained a focus on the issue and permitted exploration of the issue in different contexts described by the definable aspects of the research. Data collection included 39 surveys returned from physiotherapists [n=21] colleagues/managers [n=13] and consumers [n=5]. Nineteen semi-structured interviews enabled further exploration of issues identified in the surveys. Interviews were conducted with public sector physiotherapists [n=9], private physiotherapists [n=5], key decision makers [n=4] and, at the suggestion of a key decision maker, a colleague [n=1]. The data set provides rich and detailed descriptions about decision making and factors affecting physiotherapy service provision in the regional, rural and remote sites of the study. The focus on service level decision making adds a previously undocumented perspective to the current understanding of rural physiotherapy service provision. Consideration of research rigour guided the research conduct. The research design included data collection from multiple sources to enable triangulation of data and constant comparison. An auditable trail of evidence was maintained throughout the conduct of the research. Member checking, the use of a second coder, further add to the credibility of the findings. Decisions informing rural physiotherapy service provision are made by multiple stakeholders at all levels of the health system. Decisions, conveyed in the language of the stakeholders' position and perspective, reveal varying levels of connectivity to the communities in which services are provided. A greater sense of community responsibility and accountability was expressed by participants embedded within their community. The greater the distance, geographically or organisationally from the service provider-recipient interface, the more the language of decisions reflected organisational objectives. The scope of physiotherapy led decision making about services they provide in rural areas varied with service sector, size and rurality. The research findings and current literature were considered in the development of conceptual models of decision making informing rural physiotherapy service provision. The tension that was evident between centralised service models and locally based services has the potential to continue to grow if factors impacting rural service provision are not systematically addressed. Funding models, service fragmentation, organisational imperatives and workforce availability are key drivers of service and workforce models. Fundamental decisions are required about the health services people in a regional, rural, or remote community should be able to access. Decisions require continued consideration of broader collaborative frameworks to minimise service gaps arising as accessibility criteria are narrowed in line with system or business imperatives. New service and funding initiatives should not increase service and workforce fragmentation between services and sectors. Increasing gaps between services with narrowly defined criteria and target populations compounds issues of access in already underserved areas.