Patients waiting in ambulances outside emergency departments (EDs)—known as ambulance ramping or access blocking (Cameron and Campbell, 2003; Forero et al, 2011)—is a public-facing issue for the NHS in England and Wales. This is fuelled by increasing demand and an ageing population that requires more complex care. Minimising the number of unnecessary conveyances to hospital is a strategy to reduce delays and overcrowding (O'Cathain et al, 2018). The potential for paramedics delivering patient care away from the ED has been recognised (Auditor General for Wales, 2013). However, this requires appropriate use of ambulance resources (Snooks et al, 1998; Dejean et al, 2016) and the delivery of enhanced patient care at scene (NHS England, 2015).
Inappropriate use of ambulance services in rural areas is of particular concern (Gunnarsson et al, 2007). Longer distances to the nearest hospital could leave a community without an emergency resource (Public and Corporate Economic Consultants, 2017) compared to an urban setting. Furthermore, larger populations and therefore greater use of ambulance services mean that predicting and planning demand is easier in urban areas than in rural, sparsely-populated areas (Norton et al, 2012).
Following an external review (McClelland, 2013), the Welsh Ambulance Services NHS Trust (WAST) changed its response to 999 calls. Clinical condition codes were recategorised to better reflect different response categories (Table 1). Condition codes and call categories remain an indicator of the care required, but this can be determined only following an assessment of the patient by a paramedic.
| Category of call | Overview |
|---|---|
| Red | Immediately life-threatening, e.g. cardiac arrest or choking. Subject to clinical indicators such as return of spontaneous circulation (ROSC) rates, as well as time-based standard requiring minimum attendance at 65% of these calls within 8 minutes |
| Amber | Serious but not life-threatening calls, e.g. most medical and trauma cases such as chest pain and fractures |
| Green | Neither serious nor life-threatening, e.g. ear ache or minor injuries. Ideally suited to management via secondary telephone triage |
Decision making about conveyance for patients in the ‘amber’ category (those in a serious but not life-threatening condition) is complex. Paramedics may need to trade off the clinical need of the patient against other factors such as the availability of alternative community resources to refer patients to (O'Hara et al, 2015) or patients' unwillingness to go to hospital because of long distances (O'Cathain et al, 2018). WAST does not have a published standard for conveyance decision making for amber calls, and there is little assurance that decisions are made consistently.
Relatively little is known from the literature about how paramedics working in rural settings make these conveyance decisions. The majority of the literature considers urban or combined urban and rural areas. Studies have identified six factors influencing conveyance-related decision making regarding calls in non-life-threatening circumstances: paramedics' perception of their role (O'Hara et al, 2015; Simpson et al, 2017); extent of organisational support for non-conveyance decisions (Porter et al, 2007; O'Hara et al, 2015; Simpson et al, 2017); training and education undertaken (O'Hara et al, 2015; Simpson et al, 2017); availability of resources at the time of decision making (Porter et al, 2007; O'Hara et al, 2015); usefulness of decision support aids (Porter et al, 2007; O'Hara et al, 2015); and individual patient factors (Porter et al, 2007). With the exception of one study (O'Hara et al, 2015), rural findings were not made explicit. Therefore, results are mostly generalised across urban and rural areas, and only an indication of factors affecting decision making in rural areas is provided.
This article aims to address this knowledge gap by exploring perceptions of paramedics in a rural setting about how they make decisions regarding conveyance and non-conveyance for patients categorised as amber.
Methods
The study explored the experiences of paramedics working in rural areas. A qualitative design was used to provide depth and richness. Data were analysed through inductive thematic analysis (Braun and Clarke, 2006).
Ethical approval
The article is based on work undertaken as part of the lead author's (CI) dissertation for an MSc in Health Sciences at the University of Warwick. The study received ethical approval by the University of Warwick Biomedical Sciences Research Ethics Committee, and was approved by WAST's Virtual Research Risk Review Group as a service evaluation study.
Setting
WAST serves seven health board areas. The study setting was the most sparsely-populated health board area, with a population of approximately 130 000 and a density of 25 people/km2 in the 5181 km2 land mass. The area has no acute hospital and relies upon bordering trusts and health boards for acute services. Consequently, the distance to travel for acute care is a problem, with the average travel time being nearly 45 minutes.
There were 12 ambulance stations in the area with 54 NHS band 5 paramedics with a mix of higher education and vocational paramedic training, supported by emergency medical technicians and urgent care service staff, and led by team leaders and locality managers. At the time of the study, band 5 employees formed the largest staff group, and responded to nearly all 999 calls. The study focused on this band 5 paramedic participant population.
Data collection and data analysis
Sampling
Purposive sampling ensured representation across the area and sufficient depth to capture the range in education and experience of band 5 paramedics. Poster invitations were put up in all ambulance stations in the area. All participants received a participant information leaflet, attended a briefing before the study, and gave consent.
The majority of participants were stationed in the south of the area, but paramedics were expected to provide cover in other station areas. Furthermore, some ambulance stations classified as being in the south area could also be described as ‘mid’ and provided cover in the north of the area. An overview of participant characteristics is shown in Table 2.
| North (n=2) | South (n=15) | |
|---|---|---|
| Core paramedic qualification | ||
| Institute of Healthcare Development (IHCD) paramedic award | 2 | 10 |
| DipHE paramedic science | 5 | |
| BSc prehospital care | ||
| MSc enhanced paramedic practice/prehospital care | (one IHCD qualified paramedics working towards this) | (one Dip HE qualified paramedic working towards this) |
| Job role | ||
| Paramedic | 1 | 11 |
| Team Leader | 1 | 4 |
| Number of years paramedic experience | ||
| 0–5 | 4 | |
| 6–10 | 2 | |
| 11–20 | 2 | 3 |
| >20 years | 6 | |
| Sex | ||
| Male | 2 | 12 |
| Female | 3 | |
Data collection
Draft interview questions were tested with two senior paramedics who no longer worked in the area. Following minor amendments, final interview questions were developed and are available from the authors.
A pragmatic approach to sample size was taken (Saldaña, 2016), which took the time available to complete the study into account. The sample size of 17 is within the range of similar studies (Lamont, 2005; Price et al, 2005; Dejean et al, 2016; Murphy-Jones and Timmons, 2016). Semi-structured interviews lasted between 13 and 40 minutes, and were carried out over a 6-week period during March and April 2017.
Interviews were conducted by the lead author in the ambulance station offices, with one held in a coffee shop and one over the telephone. Interviews were audio-recorded, then transcribed by a third party. Field notes were made by the interviewer.
Analysis
The analysis was divided into three parts: coding; categorising; and thematic analysis.
Throughout the analysis, the authors held regular meetings to discuss and review progress and themes, and to clarify ambiguities and uncertainties. Transcripts were first read and checked against the audio recording, then sections of text deemed significant were coded using open coding (Saldaña, 2016). Initial impressions and thoughts were recorded in an analytic memo. Coding was supported by NVivo qualitative software version 11.4.2.
Codes were grouped into categories or decision-making factors considered by paramedics in the decision-making process, and were constantly compared with associated codes and raw interview data (Corbin and Strauss, 2015). At this stage, a visual representation was developed, which provided a clearer understanding of relationships, overlap and where comparisons could be made.
Member checking (Cooper and Endacott, 2007; Saldaña, 2016) of categories based on a synthesis of all 17 interviews was undertaken with seven paramedics. This resulted in similar categories being re-grouped and in refinements being made to names of categories.
Results
The main study finding can be summarised under a high-level theme of ‘Hospitals are perceived as a place of safety (for patients and paramedics)’. The analysis suggests that paramedics make difficult (i.e. amber category) conveyance decisions in uncertainty, based on a perception that hospitals are a place of safety, which they trade off with their awareness that the ED may not be the most appropriate place for the patient. Safety in this context means two things: psychological safety; and patient safety.
Psychological safety (Edmondson and Lei, 2014) concerns individuals' perceptions about the consequences of taking interpersonal risks. In this study, the paramedics' perceived level of psychological safety was influenced by the culture of the organisation, the confidence of the paramedic, and individual perceptions of what the role of the paramedic is. For paramedics who experience low psychological safety, taking patients to hospital can provide the sense of safety they need.
Hospitals can also be perceived as a safe place for patients in situations of uncertainty. This perception is influenced by a feeling of responsibility and accountability for the patient under their care, and the perceived availability (or lack) of support and resources in the community. When paramedics are worried about their patient because of these factors, they will more likely take the patient to hospital.
Psychological safety
Culture
A lack of trust in their organisation should something go wrong following a non-conveyance decision can influence some paramedics.
This can sometimes lead to practitioners deliberately not acting in what might be the best interest of the patient or the most appropriate use of ambulance resources in order to protect themselves.
While sometimes practitioners might act this way because they lack confidence in their own decision making, the paramedic quoted below suggests that a punitive organisational attitude influences their decision to take patients to hospital to stay on the safe side:
‘There's the old adage which was always said, for many years, that you can be criticised for taking somebody into hospital, but you can't be sacked. Whereas if you didn't take somebody to hospital you'd be sacked, never mind being criticised. So, it's better to be criticised than be sacked.’
Confidence
Good decision making during uncertainty requires confidence. Paramedics described feelings of uncertainty and ambiguity, as well as a lack of confidence, which made them more likely to take patients to hospital. Lack of confidence can be related to experience (number of years in the service), but can also be down to limitations in the role of paramedics and the circumstances under which decisions have to be taken.
One paramedic describes this thought process, and suggests that the safest path was to seek advice or take the patient to hospital:
‘It's all very much linked to the limited things that we can do in the ambulance. The training that we've got. The examinations. The history of it. And sometimes, it's in your head. You're flitting back and forth so it's probably this but what if it's that? You know. I think most people in that situation would err on the side of caution and either seek advice from the GP or convey them in to be assessed.’
Perception of paramedic role
There was variation in how paramedics perceived their role, which can influence their level of psychological safety and therefore decision making.
Traditionally, the paramedic role was strongly focused on conveyance but, more recently, this has changed, in particular with the introduction of postgraduate education opportunities. For some paramedics, this can create additional uncertainty, and leave them feeling insecure, while others fully embrace this new vision of the paramedic role.
Below, a paramedic from a traditional background reflects on these challenges, and acknowledges that they have not been trained to leave people at home:
‘I'm not sure if it's an argument or the debate about paramedics leaving people at home. As I say, I'm from an IHCD [Institute of Healthcare Development] background, so I have not been qualified. I've not been trained in leaving people at home. You know, back then, it wasn't, our job was basically to stabilise, take people into hospital. And now the role of paramedicine has changed, especially over the last 2–3 years.’
Patient safety
Responsibility for the patient
Paramedics expressed strong feelings that the safety of the patient was a key consideration when making conveyance decisions. Paramedics use their subjective assessment of the particular needs of the patient to make decisions during uncertainty. When paramedics were worried about the patient, a decision to convey to hospital was highly likely.
The feeling of being worried can result from insufficient patient information being available at the time of the paramedic assessment, e.g. a lack of information about blood results or medication history. This increases uncertainty and inhibits paramedics' making an informed judgment about the patient's clinical need.
In addition, the patient's social situation can be perceived as a complicating influencing factor. For example, a paramedic explains that they are aware of the trade-off between taking a patient to hospital and thereby contributing to overcrowding, and leaving them at home where they will potentially be at risk. In these situations, being worried about a patient acts as an overriding concern and triggers the decision to convey:
‘People who maybe live on their own or not coping, they end up going in as well and causing bed-blocking … the social aspect also comes into play as part of your decision making and whether an individual is safe to be left. Because that's what it all comes down to. A patient has got to be safe.”
Lack of community support
Paramedics described a general lack of alternative healthcare resources in the area compared to urban areas. This can be frustrating because it conflicts with the care paramedics want to provide for patients, and can lead to decisions to convey patients to hospital even though this might be inappropriate.
Mental health patients and frail elderly people were two patient groups mentioned most frequently where trade-offs are made between what is best for the patient and what appropriate resource options were available. Below, a paramedic describes the case of a patient who had experienced a fall, and how the lack of appropriate resources in the community led them to take the patient to hospital:
‘If you leave them, they could fall again. They may well sustain an injury. So, sometimes, due to a lack of social care in the area and capacity of district nursing as well that time of day, sometimes it is the only option to convey that patient to a district general hospital.’
Discussion
Decisions about conveying patients to hospital should be based on clinical need. However, in rural areas, and for patients with uncertain clinical needs, paramedics consider a range of factors when making a trade-off between taking a patient to hospital inappropriately or leaving the patient at home, thereby exposing patients and the paramedics themselves to a degree of risk.
The findings of the present study suggest that this trade-off is frequently resolved by the perception of hospitals as places of safety—for paramedics as well as patients.
Psychological safety describes the degree to which people perceive their work environment as being supportive of interpersonally risky behaviours (Edmondson et al, 2016) such as making trade-offs (Sujan et al, 2015) or reporting problems. Psychological safety can support staff and organisations in learning behaviours and improved performance, because staff are less likely to focus on self-protection.
Research on incident reporting and organisational learning in healthcare suggest that, in environments that fail to provide psychological safety or in blame cultures, staff are less likely to speak up about problems they experience in everyday clinical work (Tucker and Edmondson, 2003; Sujan, 2015; Sujan et al, 2017).
Psychological safety can be increased by open leadership behaviours, actively seeking and valuing staff input and acknowledging fallibility (Edmondson et al, 2016). The present study suggests that, for some paramedics at least, the level of psychological safety was low, which influences their decision making and leads to patients being taken to hospital when they might not need to be there. This is in line with other studies, which suggest that safety culture in ambulance services might benefit from further consideration and improvement (Fisher et al, 2015; Simpson et al, 2017).
Inadequate or unavailable resources in the community frequently trigger decisions to convey patients to hospital where there is not necessarily a significant clinical need for this. This reduces the availability of emergency ambulances because of long travel distances in rural areas and contributes to ED pressures. It could also cause unnecessary inconvenience to patients (O'Cathain et al, 2018) in addition to the risks of being in hospital.
A lack of alternative resources in the community was identified by O'Hara et al (2015), and has been recognised as a wider system issue (Welsh Government, 2010). However, findings suggest that resolution of this important issue is not yet in sight.
The paramedic role continues to evolve, and this might be one way of addressing the need for advanced clinical skills. At the time of the study, WAST was undergoing a period of workforce changes to match paramedic capability and capacity with clinical demand, so improvement in this area has started. However, without clarity on what is expected of paramedics and a shared understanding of the role, the risk remains that the default position to convey patients to hospital, even if this is inappropriate, may remain. This tension between traditional cultures and organisational control has also been recognised in other ambulance trusts (Wankhade et al, 2018).
Limitations
The majority of participants held the IHCD paramedic award and had more than 5 years of experience. This might not be representative of other ambulance services, where the numbers of more recently qualified paramedics might be higher, and the educational profile of paramedics might tend towards university-level qualifications such as the recently introduced advanced practice postgraduate degrees. The views expressed might, therefore, not necessarily be representative of other ambulance services.
Results of this qualitative study are subject to bias regarding both participants' perceptions and the authors' ability to interpret these. Interviews were conducted by the lead author, who was employed by WAST as a project manager at the time of the study, but had no direct relationship with the paramedic participants. Some potential for bias was recognised on a personal level, as the lead author lives in the study setting and has experienced rural healthcare challenges.
The validity of the findings was strengthened through critical reflection throughout the study process, and through member checking of the analysis results. The findings are based on data collected in one specific rural region, and might not generalise to other areas or settings.
Conclusions
Paramedics working in rural areas perceive hospitals as places of safety for themselves and for patients. Lower levels of psychological safety (e.g. because of a blame culture in the organisation) and perceived increased risks to patient safety (e.g. because of a lack of health resources in the community) influence paramedic decision making towards conveying patients to hospital. This can add to already rising pressures on EDs.
Ambulance services should work towards a non-punitive culture of safety where paramedics feel they can make decisions based on their experience and expertise rather than to protect themselves.
Further potential levers for improvement are around the introduction of advanced practice roles, consistency in the interpretation of the paramedic role, and new support models in the community.