Paramedics encounter growing numbers of people who self-harm and the authors identify that frequently these service-users report care and attitudes from healthcare staff as being unsatisfactory. However, it appears that paramedics and emergency care staff's role in these patients' care is under researched.
Previously, Rees et al (2014) have reported the findings of a systematic review of the quantitative literature on this topic, so this paper focuses on a review of qualitative research, exploring perceptions of paramedics and emergency care staff to patients who self-harm.
Using key search terms such as ‘self-harm’, ‘suicide’, ‘paramedic’, ‘emergency’, ‘overdose’, ‘pre-hospital’, ‘mental health’, ‘ambulance’, and ‘perceptions of care’, combined with processes of manual searching as well as searching electronic databases such as CINAHL®, OVID®, Psych INFO® and MEDLINE®, a total of 1 137 citations were identified. Having removed all duplicates, 734 papers remained.
Ultimately, 12 papers met the criteria for inclusion while 722 were excluded: 635 had no relevance to emergency or pre-hospital care; 52 did not focus on perceptions of care; 12 did not have relevant participants; five used quantitative methods; three focused on specialist mental healthcare workers; and the lead researcher was unable to retrieve a total of 15 papers.
The 12 studies were undertaken in either the UK, Australia, Sweden, USA or France and employed a variety of qualitative approaches involving methods such as observational field work; semi-structured or in-depth interviews; focus groups; and/or surveys. Participants included paramedics, doctors and nurses in different settings such as medical admissions, emergency department (ED) or the pre-hospital environment.
A brief review such as this one cannot do justice to the complexities of the analysis in this study, but this section of the paper makes for interesting reading should you get the opportunity. In summary, the analysis revealed four emergent metaphors which have been used to structure the presentation of the findings. The first metaphor—‘frustration, futility and legitimacy of care’—incorporates debate around the legitimacy of the need for care and the frustration experienced by some healthcare professionals when working with people who have inflicted injury on themselves as opposed to experiencing unsolicited medical emergencies. This was particularly evident when staff had to prioritise and/or triage patients according to need.
The second metaphor—‘first contact in the pre-hospital environment: talking, immediate and lasting implications of the moral agent’—identifies that paramedics are highly skilled at interacting in dynamic environments but, also, they frequently have responsibility for only one patient at a time, which may not be reflected in an ED environment. The patients themselves value this unique relationship seeing it as a beneficial component of the therapeutic encounter as opposed to being one of many patients in the ED.
The third metaphor—‘decision-making in self harm: balancing legislation, risk and autonomy’—includes accounts of paramedics feeling unsupported in the clinical setting in relation to managing patients with mental health issues, especially if the patient is refusing to attend hospital or other appropriate treatment pathways. Reports of the complexities encountered when making decisions relating to mental capacity were common, with a variety of strategies being employed informed by several factors such as previous experience, tacit knowledge and, in some cases, more formal education and training.
The final metaphor—‘paramedics' perceptions: harnessing professionalism and opportunities to contribute to the care of self-harm’—highlights a lack of education and training as a barrier to effectively helping mental health patients. No papers were found that only looked at paramedics' care and management of people who self-harm but, instead, self-harming was addressed in papers looking at management of patients' general mental health issues. In one study, paramedics felt they were being used to fill gaps in mental healthcare provision but, at the same time, they expressed concern that they had inadequate access to resources or appropriate referral pathways to do this effectively. Additionally, there was a feeling that other healthcare professionals do not always recognise or understand the paramedic's role and subsequently paramedics' potential contribution to the care and management of people who self-harm is not being exploited to its full potential. At the same time, some paramedics identified that they viewed mental health considerations as being secondary to their main priorities of managing medical emergencies and/or life-threatening conditions.
Limitations of the study included the lack of literature actually published in this area. The lead author also identifies that as he is a paramedic this may have influenced his interpretation of the papers, but surely this honesty and reflection should be seen as a strength in research? The paper is transparent in research processes and factors impacting on the researcher's decision-making, which subsequently enables readers to follow the audit trail related to this study, which is good practice in qualitative research.
The authors conclude that this area of health care is under researched and in order to improve the understanding of care and management of people who self-harm it is important to explore more fully the perceptions of care-givers. In particular, as ambulance staff are often the first point of contact for these patients, a targeted approach to research with this group of clinicians could be beneficial. Furthering our understanding of ambulance crews' experiences and their clinical decisions related to management of people who self-harm could usefully inform future policies pertaining to practice, as well as influencing development of appropriate educational interventions to support pre-hospital clinicians when working with this group of patients.