‘These people don’t float into hospital’: Australian paramedic perspectives on pre-hospital neck of femur fracture care

Objectives Neck of femur (NOF) fractures are a common and clinically significant presentation within paramedic practice, yet Australian paramedics currently manage these patients without dedicated evidence-informed pre-hospital guidelines. Previous quantitative research has identified variability in assessment and management practices, suggesting uncertainty surrounding care. This study explored how Australian paramedics perceive and navigate the pre-hospital management of suspected NOF fractures. Methods An exploratory qualitative design was undertaken using eight online focus groups with 21 registered paramedics, recruited from a preceding national survey. Discussions followed a semi-structured interview guide and were conducted via Zoom, audio-recorded, transcribed verbatim and analysed using the framework method. Analysis was iterative and interpretive, with themes developed through sustained engagement with the data and reflexive discussion amongst the research team. Results Four themes were identified: (1) balancing rapid assessment with diagnostic uncertainty; (2) managing immediate care amid competing priorities and limited information; (3) sources, strengths and limitations of the existing knowledge base; and (4) envisioning clearer, evidence-informed guidance for future practice. Participants described NOF fracture care as shaped by uncertainty, experiential learning and contextual judgement rather than standardised guidance. Decision-making extended beyond clinical assessment alone to include ethical and patient-centred considerations regarding movement, communication, dignity and analgesia. Participants frequently described relying on tacit knowledge, peer learning and accumulated clinical experience to guide care in the absence of condition-specific pre-hospital guidance. Discussion revealed a shared perception that clearer evidence-informed guidance could support greater consistency, confidence and patient-centred care. Conclusions Australian paramedics describe NOF fracture management as a complex and interpretive practice shaped by uncertainty, experience and contextual decision-making. In the absence of dedicated guidance, paramedics rely heavily on experiential and relational forms of knowledge to navigate care. These findings highlight the need for evidence-informed pre-hospital guidance and educational support for NOF fracture management that better reflects the realities and complexities of paramedic practice.