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Lindridge J, Edwards T, Blackwood L. Advanced paramedics' restraint decision-making when managing acute behavioural disturbance (ABD) in the UK pre-hospital ambulance setting: A qualitative investigation. PLoS One 2024; 19:e0302524. [PMID: 38753728 PMCID: PMC11098407 DOI: 10.1371/journal.pone.0302524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 04/07/2024] [Indexed: 05/18/2024] Open
Abstract
Acute behavioural disturbance (ABD), sometimes called 'excited delirium', is a medical emergency. In the UK, some patients presenting with ABD are managed by advanced paramedics (APs), however little is known about how APs make restraint decisions. The aim of this research is to explore the decisions made by APs when managing restraint in the context of ABD, in the UK pre-hospital ambulance setting. Seven semi-structured interviews were undertaken with APs. All participants were experienced APs with post-registration, post-graduate advanced practice education and qualifications. The resulting data were analysed using reflexive thematic analysis, informed by critical realism. We identified four interconnected themes from the interview data. Firstly, managing complexity and ambiguity in relation to identifying ABD patients and determining appropriate treatment plans. Secondly, feeling vulnerable to professional consequences from patients deteriorating whilst in the care of APs. Thirdly, negotiating with other professionals who have different roles and priorities. Finally, establishing primacy of care in relation to incidents which involve police officers and other professionals. A key influence was the need to characterise incidents as medical, as an enabler to establishing clinical leadership and decision-making control. APs focused on de-escalation techniques and sought to reduce physical restraint, intervening with pharmacological interventions if necessary to achieve this. The social relationships and interactions with patients and other professionals at the scene were key to success. Decisions are a source of anxiety, with fears of professional detriment accompanying poor patient outcomes. Our results indicate that APs would benefit from education and development specifically in relation to making ABD decisions, acknowledging the context of inter-professional relationships and the potential for competing and conflicting priorities. A focus on joint, high-fidelity training with the police may be a helpful intervention.
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Affiliation(s)
- Jaqualine Lindridge
- Department for Health, University of Bath, Bath, Somerset, England
- London Ambulance Service NHS Trust, London, England
| | | | - Leda Blackwood
- Department of Psychology, University of Bath, Bath, Somerset, England
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Leather JZ, Keyworth C, Kapur N, Campbell SM, Armitage CJ. Implementation of national guidance for self-harm among general practice nurses: a qualitative exploration using the capabilities, opportunities, and motivations model of behaviour change (COM-B) and the theoretical domains framework. BMC Nurs 2023; 22:452. [PMID: 38041157 PMCID: PMC10693142 DOI: 10.1186/s12912-023-01360-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 05/27/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Patients who self-harm may consult with primary care nurses, who have a safeguarding responsibility to recognise and respond to self-harm. However, the responses of nursing staff to self-harm are poorly understood, and opportunities to identify self-harm and signpost towards treatment may be missed. It is unclear how to support nursing staff to implement national guidelines. AIMS Among primary care nursing staff to: [1] Examine reported barriers and enablers to nurses' use of, and adherence to, national guidance for self-harm; and [2] Recommend potential intervention strategies to improve implementation of the NICE guidelines. METHODS Twelve telephone interviews partly structured around the capabilities, opportunities and motivations model of behaviour change (COM-B) were conducted with primary care nurses in the United Kingdom. The Theoretical Domains Framework was used as an analytical framework, while the Behaviour Change Wheel was used to identify exemplar behaviour change techniques and intervention functions. RESULTS Nursing staff identified a need to learn more about risk factors (knowledge), and strategies to initiate sensitive conversations about self-harm (cognitive and interpersonal skills) to support their professional competencies (professional role and identity). Prompts may support recall of the guidance and support a patient centred approach to self-harm within practices (memory, attention, and decision making). GPs, and other practice nurses offer guidance and support (social influences), which helps nurses to navigate referrals and restricted appointment lengths (environmental context and influences). CONCLUSIONS Two converging sets of themes relating to information delivery and resource availability need to be targeted. Nine groups of behaviour change techniques, and five intervention functions offer candidate solutions for future intervention design. Key targets for change include practical training to redress conversational skill gaps about self-harm, the integration of national guidance with local resources and practice-level protocols to support decision-making, and creating opportunities for team-based mentoring.
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Affiliation(s)
- Jessica Z Leather
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Jean McFarlane Building, Oxford Road, Manchester, M13 9PY, UK.
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PY, UK.
| | - Chris Keyworth
- The School of Psychology, The University of Leeds, Woodhouse Lane, Leeds, UK
| | - Nav Kapur
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Jean McFarlane Building, Oxford Road, Manchester, M13 9PY, UK
- Centre for Mental Health and Safety, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Stephen M Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Jean McFarlane Building, Oxford Road, Manchester, M13 9PY, UK
- Centre for Primary Care and Health Services Research, School of Health Sciences, University of Manchester, Manchester, UK
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria, 0208, South Africa
| | - Christopher J Armitage
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Jean McFarlane Building, Oxford Road, Manchester, M13 9PY, UK
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PY, UK
- Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, The Nowgen Centre, Manchester, UK
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3
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Clibbens N, Booth A, Sharda L, Baker J, Thompson J, Ashman M, Berzins K, Weich S, Kendal S. Explaining context, mechanism and outcome in adult community mental health crisis care: A realist evidence synthesis. Int J Ment Health Nurs 2023; 32:1636-1653. [PMID: 37574714 DOI: 10.1111/inm.13204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/25/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Abstract
Mental health crises cause significant distress and disruption to the lives of individuals and their families. Community crisis care systems are complex, often hard to navigate and poorly understood. This realist evidence synthesis aimed to explain how, for whom and in what circumstances community mental health crisis services for adults work to resolve crises and is reported according to RAMESES guidelines. Using realist methodology, initial programme theories were identified and then tested through iterative evidence searching across 10 electronic databases, four expert stakeholder consultations and n = 20 individual interviews. 45 relevant records informed the three initial programme theories, and 77 documents, were included in programme theory testing. 39 context, mechanism, outcome configurations were meta-synthesized into three themes: (1) The gateway to urgent support; (2) Values based crisis interventions and (3) Leadership and organizational values. Fragmented cross-agency responses exacerbated staff stress and created barriers to access. Services should focus on evaluating interagency working to improve staff role clarity and ensure boundaries between services are planned for. Organizations experienced as compassionate contributed positively to perceived accessibility but relied on compassionate leadership. Attending to the support needs of staff and the proximity of leaders to the front line of crisis care are key. Designing interventions that are easy to navigate, prioritize shared decision-making and reduce the risk of re-traumatizing people is a priority.
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Affiliation(s)
| | - Andrew Booth
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Leila Sharda
- School of Healthcare, University of Leeds, Leeds, UK
| | - John Baker
- School of Healthcare, University of Leeds, Leeds, UK
| | - Jill Thompson
- Health Sciences School, University of Sheffield, Sheffield, UK
| | | | | | - Scott Weich
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sarah Kendal
- School of Healthcare, University of Leeds, Leeds, UK
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Thorvaldsen NO, Husum TL, Sollid SJM. Exploring use of coercion in the Norwegian ambulance service - a qualitative study. Scand J Trauma Resusc Emerg Med 2023; 31:44. [PMID: 37667365 PMCID: PMC10478396 DOI: 10.1186/s13049-023-01104-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/21/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Healthcare laws allow for exceptions from the consent requirement when patients are not competent to consent or pose a danger to themselves or others. In these cases, the use of coercion may be an alternative to voluntary health care. Ambulance personnel are regularly confronted with patients who need healthcare but refuse it and/or refuse to cooperate. This study aimed to explore ambulance personnel`s experience with use of coercion and factors influencing the use of coercion in the ambulance service in Norway. METHOD We conducted two focus group interviews with a total of eight informants, all ambulance personnel from a large Norwegian ambulance service. Digital recordings of the interviews were transcribed verbatim and analysed using systematic text condensation. RESULTS The informants` stories revealed several methods of coercion used by the ambulance personnel; physical coercion, pragmatic coercion, pharmacological coercion and coercion used to ensure the patient is secured during transportation. The main reasons for using coercion were preventing patients from harming themselves or others and to ensure that patients unable to consent receive healthcare considered necessary. Systemic factors as difficulty of applying the law to real-life situations, and organizational factors as fear of breaching guidelines, experienced lack of support from the management, fear of charges of misconduct, and lack of training in assessing patients´ competence to consent seem to influence ambulance personnels use of coercion. CONCLUSION Ethical grey areas in clinical practice emphasize the need for clinical discretion. Despite the fact that regulatory provisions allow for exceptions from the requirement to obtain consent, transferring these regulations to real life prehospital settings can be difficult. Consequently, the decisions made by ambulance personnel in clinical situations are highly influenced by organizational ethos and guidelines. The informants describe the coercive interventions they have employed to manage patients who are deemed to require healthcare but refuse it and/or refuse to cooperate.
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Affiliation(s)
- Nina Oeye Thorvaldsen
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway.
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
| | - Tonje Lossius Husum
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Stephen J M Sollid
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Prehospital Division, Oslo University Hospital, Oslo, Norway
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Clibbens N, Baker J, Booth A, Berzins K, Ashman MC, Sharda L, Thompson J, Kendal S, Weich S. Explanation of context, mechanisms and outcomes in adult community mental health crisis care: the MH-CREST realist evidence synthesis. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-161. [PMID: 37837344 DOI: 10.3310/twkk5110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Background Mental health crises cause significant disruption to individuals and families and can be life-threatening. The large number of community crisis services operating in an inter-agency landscape complicates access to help. It is unclear which underpinning mechanisms of crisis care work, for whom and in which circumstances. Aim The aim was to identify mechanisms to explain how, for whom and in what circumstances adult community crisis services work. Objectives The objectives were to develop, test and synthesise programme theories via (1) stakeholder expertise and current evidence; (2) a context, intervention, mechanism and outcome framework; (3) consultation with experts; (4) development of pen portraits; (5) synthesis and refinement of programme theories, including mid-range theory; and (6) identification and dissemination of mechanisms needed to trigger desired context-specific crisis outcomes. Design This study is a realist evidence synthesis, comprising (1) identification of initial programme theories; (2) prioritisation, testing and refinement of programme theories; (3) focused realist reviews of prioritised initial programme theories; and (4) synthesis to mid-range theory. Main outcome The main outcome was to explain context, mechanisms and outcomes in adult community mental health crisis care. Data sources Data were sourced via academic and grey literature searches, expert stakeholder group consultations and 20 individual realist interviews with experts. Review methods A realist evidence synthesis with primary data was conducted to test and refine three initial programme theories: (1) urgent and accessible crisis care, (2) compassionate and therapeutic crisis care and (3) inter-agency working. Results Community crisis services operate best within an inter-agency system. This requires compassionate leadership and shared values that enable staff to be supported; retain their compassion; and, in turn, facilitate compassionate interventions for people in crisis. The complex interface between agencies is best managed through greater clarity at the boundaries of services, making referral and transition seamless and timely. This would facilitate ease of access and guaranteed responses that are trusted by the communities they serve. Strengths and limitations Strengths include the identification of mechanisms for effective inter-agency community crisis care and meaningful stakeholder consultation that grounded the theories in real-life experience. Limitations include the evidence being heavily weighted towards England and the review scope excluding full analysis of ethnic and cultural diversity. Conclusions Multiple interpretations of crises and diverse population needs present challenges for improving the complex pathways to help in a crisis. Inter-agency working requires clear policy guidance with local commissioning. Seamless transitions between services generate trust through guaranteed responses and ease of navigation. This is best achieved where there is inter-agency affiliation that supports co-production. Compassionate leaders engender staff trust, and outcomes for people in crisis improve when staff are supported to retain their compassion. Future work Further work might explore inter-agency models of crisis delivery, particularly in rural communities. Future work could focus on evaluating outcomes across crisis care provider agencies and include evaluation of individual, as well as service-level, outcomes. The implementation and effect of mental health triage could be explored further, including via telehealth. Barriers to access for marginalised populations warrant a specific focus in future research. Study registration The study is registered as PROSPERO CRD42019141680. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - John Baker
- School of Healthcare, University of Leeds, Leeds, UK
| | - Andrew Booth
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | | | - Leila Sharda
- School of Healthcare, University of Leeds, Leeds, UK
| | - Jill Thompson
- Health Sciences School, University of Sheffield, Sheffield, UK
| | - Sarah Kendal
- School of Healthcare, University of Leeds, Leeds, UK
| | - Scott Weich
- Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
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Altruism in Paramedicine: A Scoping Review. Healthcare (Basel) 2022; 10:healthcare10091731. [PMID: 36141343 PMCID: PMC9498595 DOI: 10.3390/healthcare10091731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
While altruism has been studied in healthcare professions such as nursing and medicine, the exploration of the characteristics of altruism, as related to paramedicine and emergency care in Australia, is limited. This scoping review explores altruism in paramedicine from the perspective of the paramedic as practitioner, learner, and educator as seen through the lens of the paramedic and the patient. Also discussed is the positive impact of altruism on the patient experience of care. A scoping review was used to assess the availability of data related to altruism in paramedicine. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was used to guide the process. Search categories were orientated around the subject (altruism) and discipline (paramedicine). A total of 27 articles are included in this scoping review. Initial searching identified 742 articles; after duplicate removal, 396 articles were screened with 346 excluded. Fifty articles were full-text reviewed and 23 excluded. The final 27 were extracted following full-text screening. None of the articles are specific to altruism in paramedicine. The data related to the practice of altruism in paramedicine are extremely limited. The preponderance of data arise from Europe and North America which, due to crewing and service differences, may impact the practice of altruism in different regions. Recent changes to the scope of paramedic practice, workload, education, and case acuity may influence behaviour regarding altruism, compassion, caring, and associated caring behaviours. The practice and education of paramedics including altruism, compassion, caring and caring behaviours in the Australasian setting warrants further research.
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Xanthopoulou P, Thomas C, Dooley J. Subjective experiences of the first response to mental health crises in the community: a qualitative systematic review. BMJ Open 2022; 12:e055393. [PMID: 35115355 PMCID: PMC8814746 DOI: 10.1136/bmjopen-2021-055393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To review and synthesise qualitative studies that have explored subjective experiences of people with lived experience of mental health-related illness/crisis (MHC), their families and first responders. DESIGN A systematic review of qualitative evidence was conducted. English-language articles exploring the content of interactions and participants' experiences were included. DATA SOURCES MEDLINE, PsycINFO, EMBASE, CINAHL; Google Scholar, SAGE journals, Science Direct and PubMed. DATA EXTRACTION AND SYNTHESIS Two reviewers read and systematically extracted data from the included papers. Papers were appraised for methodological rigour using the Critical Appraisal Skills Programme Qualitative Checklist. Data were thematically analysed. RESULTS We identified 3483 unique records, 404 full-texts were assessed against the inclusion criteria and 79 studies were included in the qualitative synthesis. First responders (FRs) identified in studies were police and ambulance staff. Main factors influencing response are persistent stigmatised attitudes among FRs, arbitrary training and the triadic interactions between FRs, people with mental illness and third parties present at the crisis. In addition, FR personal experience of mental illness and focused training can help create a more empathetic response, however lack of resources in mental health services continues to be a barrier where 'frequent attenders' are repeatedly let down by mental health services. CONCLUSION Lack of resources in mental healthcare and rise in mental illness suggest that FR response to MHC is inevitable. Inconsistent training, complexity of procedures and persistent stigmatisation make this a very challenging task. Improving communication with family carers and colleagues could make a difference. Broader issues of legitimacy and procedural barriers should be considered in order to reduce criminalisation and ensure an empathetic response.
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Affiliation(s)
| | - Ciara Thomas
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Jemima Dooley
- Mood Disorders Centre, University of Exeter, Exeter, UK
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First responder, clinician, and non‐clinical support staff knowledge, attitudes, and behaviours towards people presenting for emergency care following self‐harm: a mixed evidence synthesis. Cochrane Database Syst Rev 2021; 2021:CD014939. [PMCID: PMC8668017 DOI: 10.1002/14651858.cd014939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
This is a protocol for a Cochrane Review (qualitative). The objectives are as follows: The objectives of this review are threefold, as follows. Firstly, to assess the content of knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff towards service users with SH presentations. Secondly, to understand how service user and staff characteristics (e.g. age, gender, sociodemographic background), type of SH presentation (e.g. method, repetition), and contextual factors (e.g. hospital environment, presence of bystanders) affect the knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff in providing acute care. Thirdly, to assess whether clinicians' knowledge, attitudes, and behaviours have evolved over time.
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9
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Stander C, Hodkinson P, Dippenaar E. Prehospital care providers' understanding of responsibilities during a behavioural emergency. S Afr J Psychiatr 2021; 27:1545. [PMID: 33604073 PMCID: PMC7876971 DOI: 10.4102/sajpsychiatry.v27i0.1545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 09/21/2020] [Indexed: 11/01/2022] Open
Abstract
Background Prehospital emergency care providers are frequently called to assist with the management of mental healthcare users (MHCUs). The Mental Health Care Act no. 17 of 2002 regulates mental healthcare in South Africa, but the act fails to consider the responsibilities of prehospital emergency care providers in the provision of mental healthcare. Rather South African Police Services were given authority over the well-being of a MHCU in the prehospital setting. Aim To investigate prehospital emergency care providers' understanding of their responsibilities towards MHCUs and the community during the management of behavioural emergencies. Setting The research was carried out at prehospital emergency care providers from the three main levels of care, currently operational within the boundaries of Pretoria, South Africa. Methods A grounded theory qualitative study design was chosen using semi-structured focus groups for each level of prehospital emergency care - basic life support (BLS), intermediate life support (ILS) and advanced life support (ALS). Data from each focus group were collected through audio recordings and transcribed and analysed using a framework approach. Results A total of 19 prehospital emergency care providers participated; two focus group interviews were performed for each level of care. The BLS focus groups each consisted of two participants. The ILS focus groups consisted of three participants each, and the ALS focus groups consisted of six and three participants. Four key themes were identified: perceptions of behavioural emergencies, responsibilities, understanding of legislation and barriers experienced. Conclusion Participants placed high value on their moral and medical responsibilities towards MHCUs, which they described as ensuring the safety of themselves, MHCUs and the community; preventing further harm; and transporting MHCUs to an appropriate healthcare facility. There was a desire for revision of legislation, better education, skill development and awareness of mental healthcare in the prehospital emergency care setting.
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Affiliation(s)
- Charnelle Stander
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Peter Hodkinson
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Enrico Dippenaar
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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10
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Zayed MG, Williams V, Glendenning AC, Bulger JK, Hewes T, Porter A, Snooks H, John A. Care-pathways for patients presenting to emergency ambulance services with self-harm: national survey. Emerg Med J 2020; 37:752-755. [PMID: 32883751 PMCID: PMC7691809 DOI: 10.1136/emermed-2019-208967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 11/18/2022]
Abstract
Background Self-harm is among the top five causes of acute hospital admissions and ambulance clinicians are often the first point of contact. However, the Emergency Department (ED) may not be the most appropriate place of care and little is known about the existence or nature of alternative pathways available to UK ambulance services. This survey describes the current management pathways used by ambulance services for patients who have self-harmed. Methods A structured questionnaire was sent to all UK ambulance services by email and followed up by telephone in 2018. Three independent researchers (two clinical) coded responses which were analysed thematically. Results All 13 UK ambulance services responded to the survey: nine by email and four by telephone interview. Two services reported a service-wide protocol for managing people presenting with self-harm, with referral to mental health crisis team available as an alternative to conveyance to ED, following on-scene psychosocial assessment. Four services reported local pathways for managing mental health patients which included care of patients who had self-harmed. Four services reported being in the process of developing pathways for managing mental health patients. Six services reported no service-wide nor local pathways for managing self-harm patients. No robust evaluation of new care models was reported. Conclusion Practice in ambulance services in the UK is variable, with a minority having a specific clinical pathway for managing self-harm, with an option to avoid ED. New pathways for patients who have self-harmed must be evaluated in terms of safety, clinical and cost-effectiveness.
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Affiliation(s)
| | - Victoria Williams
- Hillary Rodham Clinton School of Law, Swansea University, Swansea, UK
| | | | | | - Tom Hewes
- College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Alison Porter
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Helen Snooks
- Swansea University Medical School, Swansea University, Swansea, UK
| | - A John
- Swansea University Medical School, Swansea University, Swansea, UK
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11
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Rothes IA, Nogueira IC, Coutinho da Silva AP, Henriques MR. When Emergency Patients Die by Suicide: The Experience of Prehospital Health Professionals. Front Psychol 2020; 11:2036. [PMID: 32982848 PMCID: PMC7483580 DOI: 10.3389/fpsyg.2020.02036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/22/2020] [Indexed: 11/13/2022] Open
Abstract
The suicide of a patient can be a disturbing experience for health professionals. According to literature, a patient suicide is a professional hazard in the path of prehospital emergency professionals. In the emergency context, several factors pointed out in literature as predictors of increased emotional impact and more severe traumatic reactions are present. However, the impact of patient suicide on prehospital emergency professionals is still an understudied subject. The aim of this study was to better understand the impact and emotional reactions of prehospital emergency professionals facing a patient suicide, using a qualitative approach. Semi-structured interviews were conducted with 19 prehospital professionals. Fourteen narratives about a patient suicide experience were obtained. Three main categories emerged from the process of content analyses: (1) emotional impact and related factors; (2) perceptions of impact; (3) emergency context and professional growing. Death by suicide in the prehospital emergency context had a considerable emotional impact on these professionals. Several participants described intrusive thoughts and images as a consequence of attending to the death scene. Regarding the perception of impact, there seemed to exist a variation between the levels of exposed to and affected by suicide. There are specific features of the prehospital emergency context that emerged in the narratives of participants as factors which increased the patient suicide impact, namely attending the death scene, encountering the family or other survivors, and managing the feeling of responsibility for not arriving in time of the rescue. The narratives of prehospital professionals also indicated some negative effects on their professional practice, such as doubts about their competence, training, and limits to liability. The death of a patient by suicide in the prehospital emergency context can be a difficult experience, marked with an intense emotional impact. Nevertheless, it can have some positive effects, such as professional growth and increased awareness for the phenomenon. Specific training appears to be fundamental to promote professional growth and to overcome the negative emotional impact.
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Affiliation(s)
- Ines A Rothes
- Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal.,Center for Psychology, Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal
| | - Isabel C Nogueira
- Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal.,Center for Psychology, Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal
| | - Ana P Coutinho da Silva
- Center for Psychology, Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal.,Department of Clinical Nursing, Health Sciences Center, Federal University of Paraíba, João Pessoa, Brazil
| | - Margarida R Henriques
- Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal.,Center for Psychology, Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal
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12
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Sjölin H, Lindström V, Vicente V, Hult H, Ringsted C, Kurland L. Prehospital emergency nurses' experiences of care in critical incidents. Int Emerg Nurs 2020; 51:100890. [PMID: 32502944 DOI: 10.1016/j.ienj.2020.100890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The ambulance care setting is complex and unpredictable and the personnel must prepare for upcoming assignments. Prehospital emergency care nurses (PENs), are frequently exposed to critical incidents (CIs). There are, to our knowledge, no prior studies describing experiences of requirements for management of caring for a patient during a CI in the ambulance care context. Therefore, the aim of the study was to explore PENs' experiences of care in CIs. METHOD A qualitative research design with content analysis has been used, based on semi-structured interviews with eleven PENs in Sweden. RESULTS PENs' experiences can be described as: "In a critical incident, personal ability based on experiential knowledge is central to patient care". Three generic categories underpinned the main category: "Clinical expertise", "Professional approach" and "Broad knowledge base". CONCLUSIONS The care given during a CI in the ambulance care setting depends on PENs' personal ability based on experiential knowledge. Employers need to build an organization providing prerequisites and support during an CI. Suggested activities are to create forums for PENs to share experiences with each other, possibility to get feedback on completed assignments and continued training to develop new knowledge and be prepared for the unpredictable environment that characterizes CI.
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Affiliation(s)
- Helena Sjölin
- Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Orebro, Sweden; Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Sweden.
| | - Veronica Lindström
- Academic EMS in Stockholm, Sweden; Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institute, Stockholm, Sweden.
| | - Veronica Vicente
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Sweden; Academic EMS in Stockholm, Sweden.
| | - Håkan Hult
- Department of CLINTEC, Karolinska Institute, Stockholm, Sweden.
| | - Charlotte Ringsted
- Centre for Health Science Education, Faculty of Health, Aarhus University, Aarhus, Denmark.
| | - Lisa Kurland
- Örebro University, Dept. of Medical Sciences, Örebro University Hospital, Dept. of Emergency Medicine, Sweden.
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Nelson PA, Cordingley L, Kapur N, Chew-Graham CA, Shaw J, Smith S, McGale B, McDonnell S. 'We're the First Port of Call' - Perspectives of Ambulance Staff on Responding to Deaths by Suicide: A Qualitative Study. Front Psychol 2020; 11:722. [PMID: 32373035 PMCID: PMC7186388 DOI: 10.3389/fpsyg.2020.00722] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/25/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction Exposure to suicide is a known risk factor for suicide. Ambulance staff are exposed to work-related stressors including attending suicides, which may elevate their risk for mental health problems/suicide. Little is known about ambulance staff’s perspectives on how they experience these events and whether they feel equipped to respond to bereaved families at the scene of death. This study explores the perspectives of ambulance staff about responding to deaths by suicide. Materials and Methods A convenience sample of ambulance staff recruited from one ambulance service in England. In-depth, qualitative, semi-structured face-to-face interviews conducted with nine ambulance staff (six male, three female) to explore experiences of responding to suicide. Data analyzed using thematic analysis. Results Participants reported the experience of job-related strain including exposure to the suicide/suicidal ideation of colleagues; they described suppressing their distress despite significant emotional impact. All participants had been personally bereaved by suicide and responding to suicide was a common part of their job. They were often the first professionals at the scene, and undertook varied and often conflicting roles: negotiating with patients in crisis; informing individuals of the death of a loved one; preserving the body/potential crime scene; dealing with the intense emotional reactions of bereaved individuals. Participants reported long-term, salient memories of these events; however, there was a reported lack of acknowledgment in the workplace that suicides may be traumatic and no guidance for staff on how to cope. Opportunities to debrief were reportedly rare, and there was reluctance to access work-based liaison services. Training in how to respond to individuals bereaved by suicide was also lacking. Discussion The study is the first to reveal the complex challenges faced by ambulance staff in responding to suicide without adequate training and support. It demonstrates the potential impact that responding to suicide can have personally and professionally on staff, and emphasizes the need for employers to support staff wellbeing in better ways. Training and postvention support could enable better coping among staff, more effective support for bereaved individuals and reduce the risk of death by suicide both in those bereaved by suicide and in ambulance staff.
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Affiliation(s)
- Pauline A Nelson
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Lis Cordingley
- Division of Musculoskeletal & Dermatological Sciences, Manchester Biomedical Research Centre, The University of Manchester, Manchester, United Kingdom
| | - Navneet Kapur
- Centre for Mental Health and Safety, The University of Manchester, Manchester, United Kingdom.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, United Kingdom
| | - Carolyn A Chew-Graham
- School of Primary, Community and Social Care, Keele University, Keele, United Kingdom.,NIHR Applied Research Collaboration, West Midlands, United Kingdom
| | - Jenny Shaw
- Centre for Mental Health and Safety, The University of Manchester, Manchester, United Kingdom
| | | | - Barry McGale
- Suicide Bereavement United Kingdom, Manchester, United Kingdom
| | - Sharon McDonnell
- Centre for Mental Health and Safety, The University of Manchester, Manchester, United Kingdom.,Suicide Bereavement United Kingdom, Manchester, United Kingdom
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14
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Behavioral Health Emergencies Encountered by Community Paramedics: Lessons from the Field and Opportunities for Skills Advancement. J Behav Health Serv Res 2020; 47:365-376. [PMID: 32016658 PMCID: PMC7223080 DOI: 10.1007/s11414-020-09687-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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15
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McCann TV, Savic M, Ferguson N, Cheetham A, Witt K, Emond K, Bosley E, Smith K, Roberts L, Lubman DI. Recognition of, and attitudes towards, people with depression and psychosis with/without alcohol and other drug problems: results from a national survey of Australian paramedics. BMJ Open 2018; 8:e023860. [PMID: 30514822 PMCID: PMC6286471 DOI: 10.1136/bmjopen-2018-023860] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Continuing stigma towards mental health problems means that many individuals-especially men-will first present in crisis, with emergency services often the first point of call. Given this situation, the aims of this paper were to assess paramedics' ability to recognise, and their attitudes towards, males with clinically defined depression and psychosis with and without comorbid alcohol and other drug (AOD) problems. METHODS A cross-sectional national online survey of 1230 paramedics throughout Australia. The survey was based on four vignettes: depression with suicidal thoughts, depression with suicidal thoughts and comorbid alcohol problems, and psychosis with and without comorbid AOD problems. RESULTS Just under half of respondents recognised depression, but this decreased markedly to one-fifth when comorbid AOD problems were added to the vignette. In contrast, almost 90% recognised psychosis, but this decreased to just under 60% when comorbid AOD problems were added. Respondents were more likely to hold stigmatising attitudes towards people in the vignettes with depression and psychosis when comorbid AOD problems were present. Respondents endorsed questionnaire items assessing perceived social stigma more strongly than personal stigma. Desire for social distance was greater in vignettes focusing on psychosis with and without comorbid AOD problems than depression with and without comorbid AOD problems. CONCLUSIONS Paramedics need a well-crafted multicomponent response which involves cultural change within their organisations and more education to improve their recognition of, and attitudes towards, clients with mental health and AOD problems. Education should focus on the recognition and care of people with specific mental disorders rather than on mental disorders in general. It is essential that education also focuses on understanding and caring for people with AOD problems. Educational interventions should focus on aligning beliefs about public perceptions with personal beliefs about people with mental disorders and AOD problems.
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Affiliation(s)
- Terence V McCann
- Department of Nursing and Midwifery, Institute of Health and Sport, Victoria University, Melbourne, Victoria, Australia
| | - Michael Savic
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Nyssa Ferguson
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
| | - Alison Cheetham
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Katrina Witt
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kate Emond
- Department of Rural Nursing and Midwifery, College of Health, Science and Engineering, La Trobe University, Bendigo, Victoria, Australia
| | - Emma Bosley
- Queensland Ambulance Service, Brisbane, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Louise Roberts
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Dan I Lubman
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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16
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Rees N, Porter A, Rapport F, Hughes S, John A. Paramedics' perceptions of the care they provide to people who self-harm: A qualitative study using evolved grounded theory methodology. PLoS One 2018; 13:e0205813. [PMID: 30332480 PMCID: PMC6192640 DOI: 10.1371/journal.pone.0205813] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 10/02/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Self-harm (SH) accounts for over 5% of the workload of emergency ambulance services, and therefore Paramedics are often the first health professional in contact with people who SH. The authors of this paper have reported elsewhere the significant gaps in our understandings which exist surrounding this early care interaction, and some of the challenges paramedics and opportunities in paramedic care for people who SH. This study aimed to explore paramedics' perceptions of caring for those who SH using Evolved Grounded Theory Methodology. METHODS This study took place between 2014-2016 in one UK ambulance service covering a population of three million people. Semi structured interviews were conducted, purposively sampling paramedics until saturation was reached. Interviews were recorded, transcribed verbatim, and coded through open, axial, and selective levels of coding, identifying the Basic Social Process (BSP) and developing a Grounded Theory. A second researcher (SH) independently reviewed early results, which were also member-checked with participants. RESULTS Eleven paramedics were interviewed. The following six categories emerged: Context; Judgements and values; Isolation and system failure; Managing risk; Competence at the boundary of mental and physical health needs; Professional, legal and ethical tensions. The BSP Decision making in a context of risk was identified. The final Grounded Theory that emerged was one of 'Wicked Complexity of paramedic care for people who SH, which includes usual factors such as tiredness and frequent callers, heightened factors including lack of support and pathways, and factors specific to SH such assessing mental health and suicide risk. CONCLUSIONS This study builds on a very small body of literature to have explored paramedic care for people who SH and has found that this care interaction provides uniquely complex challenges. The multiple influences within the categories defined in this study need considering conjointly when making improvements to care.
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Affiliation(s)
- Nigel Rees
- Pre Hospital Emergency Research Unit (PERU), Institute of Life Sciences, Swansea University, Swansea, Wales, United Kingdom
| | - Alison Porter
- Institute of Life Sciences, Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Frances Rapport
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Sarah Hughes
- Abertawe Bro Morgannwg University Health Board, Princess of Wales Hospital, Bridgend, Wales, United Kingdom
| | - Ann John
- Farr Institute, Swansea University Medical School, Swansea, Wales, United Kingdom
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