Ethnography in the pre-hospital field: An exploration of the culture of how paramedics identify, assess and manage psychiatric presentations in the community

Author: Louise Marie Roberts

Roberts, Louise Marie, 2013 Ethnography in the pre-hospital field: An exploration of the culture of how paramedics identify, assess and manage psychiatric presentations in the community, Flinders University, School of Nursing & Midwifery

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Over the last decade there have been marked increases in the utilisation of ambulance services nationally in Australia. These increases have been attributed to factors such as the shift in health care provision from acute settings to the community, pressures on the primary health care sector, an aging population, health workforce shortages and the prevalence of chronic conditions. These social and structural changes present the paramedic workforce with changing demands, expectations in service delivery and greater responsibility for clinical decision making and treatment. Paramedics attend and care for an increasing number of lower acuity presentations and those with complex needs which dictates triage, management and referral decisions. The shift from institutional to community based care in mental health reform has seen increases in emergency attendance to individuals needing mental health care. Patients that present with complex needs require extended scene time and care provision and do not fit the traditional mould of emergency care which is forcing organisational and structural changes. These changes include a move to becoming a profession, university based training, electronic documentation and further training both at graduate and post graduate levels. This thesis explores the culture of paramedic work when identifying, assessing and managing individuals with changes in behaviour attributed to mental health concerns (psychiatric presentations) in the community. As the link between pre-hospital and further care, paramedics have a vital role to play, but to date paramedics' 'on-road' experiences and culture when attending psychiatric presentation has not been widely researched. This ethnographic account of paramedic actions and beliefs, their culture, is based in the theory of symbolic interactionism and social constructivism which asserts that human interaction is central to how individuals construct meaning and knowledge. The data was collected over an eleven month period from 2009-2010 at a tertiary public hospital in South Australia. The ethnographic methods used were observation of the ambulance arrival and emergency department triage areas, interviews with paramedics and emergency department staff, and document analysis. Using thematic analysis based on cultural domains, the findings follow a linear case history, beginning from dispatch and arrival, paramedics' first impressions and their approach, assessment, and finally to handover and reporting. This demonstrates how paramedics are caught between the provision of traditional acute care and extended scene times and management of complex presentations such as mental illness. It outlines how the changing expectations and demands place paramedics in a conflicting position and challenges the concept of their role and their identity. Key findings include the paramedics' reliance on their first impressions and 'on-road' experience due to the limited information they receive from dispatch when attending psychiatric presentations. Findings explore how organisational structures such as the communication system (dispatch), documentation, and handover shape their approach and subsequent assessment. This includes the importance of their role as emergency clinicians and the high priority placed on risk, safety, and caution. The heightened perception of risk and the need to control the unpredictable through strategies which assume control tends to promote actions which focus on transport to further care and compliance. The thesis explores the limited care paramedics feel they can provide due to the nature of the environment, their scope of practice, their limited education and professional development in mental health, and associated patient comorbidities. This leaves paramedics dealing with the consequences of the patient's behaviour, such as self-harm while aiming to meet their duty of care by transporting the patient safely to further care, usually the emergency department (ED). These cultural considerations placed an emphasis on the paramedics overriding duty of care, generated feelings of frustration with the patient and the mental health system, and created a situation where paramedics were forced to practice between their traditional role of acute care and managing those needing complex care. Documenting the nature of paramedic work with patients suffering a mental illness assists with identifying the structural, educational, policy, and resource needs required to make operating in this environment more tenable leading to better patient care and outcomes.

Keywords: paramedics,mental health,ethnogrphy

Subject: Nursing and Midwifery thesis

Thesis type: Doctor of Philosophy
Completed: 2013
School: School of Nursing & Midwifery
Supervisor: Professor Eimear Muir-Cochrane