Paramedics spend about 1.8 million hours per year (the equivalent of 75 000 days) managing patients with mental health issues (National Institute for Health and Care Research Applied Research Collaboration East Midlands (NIHR ARCEM, 2024). England's ambulance services received 524 485 999 calls in 2018--2019, which increased to 652 720 in 2021-2022—a rise of 24% (NIHR ARCEM, 2024). The National Audit Office (2023) reported in February last year that 1.2 million people were waiting to receive care and treatment from NHS community mental health services.
Before the Covid-19 pandemic, rates of mental illness in England were steadily rising, according to the British Medical Association (BMA, 2024). The prevalence of common mental health disorders (such as anxiety or depression) among adults aged 16-64 years had increased from 17.5% in 2000 to 18.9% in 2014. The BMA (2024) added that Covid-19 accelerated this trend, generating an increase in the number of people who are in contact with secondary mental health services. Mental health services in England received a record 4.6 million referrals during 2022 (up 22% from 2019). Nearly half (43.4%) of adults (24.5 million in England) think they have had a diagnosable mental health condition at some point in their life (NHS Digital, 2016), with prevalence of depression increasing during pandemic years (Office for National Statistics, 2021).
Adding to the demand on ambulance services is the introduction of the new National Partnership Agreement: Right Care, Right Person (Department of Health and Social Care (DHSC), 2024), which has led to a further increase in calls made to the ambulance service for patients experiencing mental health crises. This is intended to ensure the right agency deals with health-related calls, instead of the police being the default first responder as had been the case in most areas. However, in the UK, paramedics do not have the authority to detain an individual to a place of safety from a public place—only the police have this authority—which can cause delays for all parties involved.
Conversely, in Queensland, Australia, an emergency examination authority allows an individual to be detained and transported by a police officer or ambulance officer without their consent, using the force that is necessary and reasonable in the circumstances (Clough et al, 2023).
The limited amount of research that has explored this area in paramedic practice has found that paramedics say there is an increasing need for further education (Rolfe et al, 2020). There is no consistent or standard education delivery requirements for ambulances services in terms of supporting paramedics in how they manage patients with mental health issues, and more educational support may be needed (Rolfe, 2018). A scoping review by Emond et al, 2019) added that education and training, organisational factors and clinical decision-making contribute to how paramedics manage this patient group, with the authors recommending further research to address these areas as high-quality evidence will support planning in this complex area of healthcare delivery.
There is no educational or competence standard across paramedic preregistration curricula in England around managing mental health. The recent publication of Mental Health in Paramedic Practice (Rolfe and Partlow, 2022) and the publication of new mental health clinical guidelines via the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and Association of Ambulance Chief Executives (AACE) (2023) has provided some additional resources to staff.
The Covid-19 pandemic worldwide and the introduction in the UK of policies, such as the national partnership agreement (DHSC, 2024) and the NHS Mental Health Implementation Plan 2019/2020-2023/2024 (NHS, 2019) have had implications. These have influenced updates to clinical guidelines (JRCALC and AACE, 2023) and the sixth edition of the paramedic curriculum (College of Paramedics, 2024), highlighting how the context of paramedic delivery of healthcare to patients experiencing mental health problems has changed.
This scoping review will follow on from Emond et al's (2019) review, acknowledging this changing context, and therefore aims to explore the updated literature associated with paramedic management of patients with mental health issues.
Methods
The purpose of a scoping review is to consider as comprehensive a range of data as possible, with less emphasis on quality. This allows research areas requiring further study to be identified and provides a broad context in relation to the research question (Arksey and O'Malley, 2005).
Using the Arksey and O'Malley (2005) scoping review framework, five stages were followed.
Stage one sought to develop the research question. This was based upon an updated literature review of previous work by Emond et al (2019). The research question was: ‘How do paramedics manage patients with mental health issues?’ Keyword searching was conducted systematically so that relevant studies could be identified and selected. Data were charted, collated and summarised, and subject experts included in the research team to allow further understanding and consultation.
Stage two was developing the search strategy. Key words (Table 1) were used to systematically search databases. Where available, filters were used to limit results to 2018-2024 (since the last relevant review by Emond et al (2019)). English language and ‘review or research article’ were selected to retrieve the most relevant results. The number of results from each database and databases searched using a single search tool are presented in Table 2. All other searches were conducted on the database's platform. Appropriate databases were selected via consultation with an academic support librarian to achieve a thorough search.
| Key word | Search terms—combined with AND |
|---|---|
| Paramedic | Paramedic* OR “ambulance clinician*” OR “ambulance technician*” OR “emergency medical technician*” OR EMT* OR “emergency responder*” |
| Ambulance | Ambulance OR “Emergency service*” OR “emergency medical service*” OR “emergency care service” OR prehospital OR pre-hospital |
| Mental Health | “Mental Health” OR “Mental health condition*” OR “Mental health issue*” OR “mental health disorder*” OR suicid* OR “self-harm” OR “mental health illness*” OR “mental illness*” OR “mental health disorder*” OR “mental disorder*” OR depress* OR anxiety OR anxious OR “panic attack*” OR “panic disorder*” |
| Database searched | Date of search | Number of results |
|---|---|---|
| Academic Search Ultimate | 31 January 2024 | 905* |
| BestBETs | 31 January 2024 | 0 |
| CINAHL Complete | 31 January 2024 | 905* |
| Cochrane Library (Embase and PubMed) | 31 January 2024 | 26 |
| EBSCOhost Databases | 31 January 2024 | 905* |
| Elsevier eLibrary | 1 February 2024 | 0 |
| Epistemonikos | 31 January 2024 | 58 |
| F1000Research | 31 January 2024 | 0 |
| Journals@Ovid | 31 January 2024 | 0 |
| Medline Complete | 31 January 2024 | 905* |
| PILOTS | 1 February 2024 | 0 |
| PsycArticles | 31 January 2024 | 905* |
| PsycBooks | 31 January 2024 | 905* |
| PsycInfo | 31 January 2024 | 905* |
| PubMed | 31 January 2024 | 311 |
| ScienceDirect | 1 February 2024 | 609 |
| Scopus | 1 February 2024 | 273 |
| SocINDEX with Full Text | 31 January 2024 | 905* |
| Web of Science | 1 February 2024 | 311 |
| ProQuest Ebook Central | 1 February 2024 | 0 |
| Embase | 1 February 2024 | 121 |
Stage three was selecting relevant studies. The manual screening process was duplicated by researchers (AE and PP), and results compared to increase rigour of the methods. Exclusion criteria (Box 1) were collaboratively discussed throughout the process to ensure relevance of records included.
Box 1. Exclusion criteria
Mental health of clinician
Hospital setting
Non comparable country (not the UK, the United States, Australia or Europe)
Other emergency services handling mental health calls
Organisational focus
Specific treatment interventions
Violence or domestic abuse
COVID-19
Physical health focus
Public health
Medical education
Overdose with no mental health care focus
Dementia, delirium and disability
Drug or alcohol intoxication
End-of-life or palliative care
Suicide (not related to this review)
Other
Nurse led
Duplicates
Language: not published in English
Stage four was to chart the selected studies. The selected studies were divided between all authors and charted into a table to allow themes to be identified from the reported outcomes. During the charting process, two further records were removed because they were not relevant.
Stage five was to collate and summarise the findings. All literature considered was qualitative; the themes identified across the sample were summarised and reported. All authors discussed the themes to reach consensus.
Results
A total of 2303 results were identified using the search strategy; there were 1391 after duplicates were removed. These were screened as shown in the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) diagram (Figure 1) (Tricco et al, 2018). Article titles were then assessed against exclusion criteria (Box 1), resulting in 63 results to be assessed by abstract and full text. Seventeen sources were included in the review, which was reduced to 15 during the process of charting and collaboration among the research group; two were removed because they were not relevant, as mentioned above.
These studies are presented in Table 3, which shows the authors and year, location, aims, study population, methodology and findings (McCann et al, 2018; Rees et al, 2018; Duncan et al, 2019; Ferguson et al, 2019; Ford-Jones and Daly, 2020; Genziani et al, 2020; Keefe et al, 2020; Rolfe et al, 2020; Briggs et al, 2021; Emond et al, 2021; Ford-Jones and Daly, 2022; Gee et al, 2022; King et al, 2022; Ford-Jones, 2023; Hammarbäck et al, 2023).
| Authors (year) | Country/ location | Aims | Study population | Methodology | Main findings |
|---|---|---|---|---|---|
| McCann et al (2018) | Australia, multiple states/territories | To explore paramedics’ experience of caring for patients with non-medical, emergency-related mental health and/or alcohol or drug problems, understand their perceptions of their scope of practice in caring for them, and ascertain if their practice should be extended to incorporate education about these patients | Paramedics (n=73) | Semi-structured telephone interviews |
Three themes: caring for these patients is a routine part of paramedic work; contrasting views about scope of practice in relation to these patients; competing perspectives about extending education about this group of patients |
| Rees et al (2018) | UK | To explore paramedics’ perceptions of caring for people who self-harm using evolved grounded theory methodology | Purposive sampling |
Evolved grounded theory semi-structured interviews | Basic social process: decision-making in the context of risk. |
| Duncan et al (2019) | Scotland | Describe mental health patient characteristics, volume, case mix, outcomes and care pathways following ambulance attendance relating to mental health emergency or self-harm | All patients attended by Scottish Ambulance Service in 2011 with codes relating to mental health emergency or self-harm | The cohort was followed via linked records for at least 1 year to the end of 2012 |
Ambulance service and emergency departments are missing opportunities to provide better care to this population and in potentially avoidable mortality, morbidity and service burden. Developing and testing interventions for these patients in prehospital and emergency departments could reduce suicide, patient distress and service usage |
| Ferguson et al (2019) | Australia, multiple states/ territories | What factors impact on the perceived quality of ambulance care according to men who access ambulance services with mental health and/or alcohol or drug problems? | Men aged >18 years old who had used the ambulance service following a mental health or alcohol/drug problem (n=30) | Semi-structured interviews over the telephone |
Three themes: professionalism and compassion—displays or does not display compassion; communication—language used and how patients were spoken to; handover—how patients were transferred to ED staff (positive or negative) |
| Ford-Jones and Daly (2020) | Canada | To analyse the fit between paramedicine pedagogy, patient needs and the conditions for paramedics’ skill development | Paramedics in Ontario (n=46) | Ethnography: ˜90 hours of observations 46 interviews with paramedics | Insufficiencies in training in mental health; mental health is not prioritised/valued in training |
| Genziani et al (2020) | UK | To explore the experiences of emergency workers dealing with incidents in which section 136 of the Mental Health Act 1983 is invoked by the police | Four individuals from a police force and three from an ambulance complex in a London locality | Police officers (n=4) and ambulance workers (n=3), not known to each other, participated in separate interviews (data were collected between 2012 and 2014. In keeping with the interpretative phenomenological analysis approach, open-ended questions were used inviting participants to tell their stories in their own words, with prompts where necessary | Participants felt they were the first port of call and that training should be improved to help them deal with people experiencing mental health crises in the community. Police workers noted time pressures trying to gain patient trust and said section 136 detention sometimes felt like a betrayal of the individual. Most participants had negative experiences of admissions to 136 suites; several suggested ways of improving the admissions system. Some went beyond their expected duties to ensure distressed patients were supported before accessing mental healthcare services |
| Keefe et al (2020) | United States | Aimed to address a significant gap in the literature on paramedics’ ability to respond to the needs of individuals experiencing behavioural health crises | 23 paramedics at two large ambulance companies in Boston, Massachusetts: 14 men, nine women; 22 white, one Hispanic/black | Telephone interviews; digital recordings transcribed verbatim by professional transcription service |
Three themes: paramedics work frequently with patients having a behavioural health crisis; paramedics report inadequate behavioural health training; experiential learning and strong interpersonal skills are critical |
| Rolfe et al (2020) | England | To observe and explain how paramedics respond to and manage patients experiencing mental health issues | 21 paramedics at one ambulance trust, and 20 patients with mental illness and their carers/family | Ethnography: observation |
Two themes: paramedics perform on two levels—front- and back-stage acting; paramedics use coping mechanisms to deal with demands of this role—humour, stereotyping and nostalgia |
| Briggs et al (2021) | Wales | To explore the thoughts, feelings and educational requirements of paramedics and nurses working on emergency medical services clinical desks, focusing on mental health-related calls and the triage tools used | 41 staff on clinical desks at the Welsh Ambulance Services NHS Trust's clinical contact centres in June 2019 | Service evaluation: a questionnaire was developed and distributed | Of the 41 employees, 26 (63%) responded. Low levels of confidence were reported in managing mental health calls, along with inadequate detail in the mental health elements of their triage algorithm and deficiencies in referral pathways |
| Emond et al (2021) | Australia | To describe the perceived confidence and preparedness of paramedics in managing mental health presentations | Paramedics across Australia (n=1140) | Online survey developed for study. Questions related to confidence and preparedness | Differences in confidence and preparedness by sex (women less confident) and region (less confidence within rural areas) |
| Ford-Jones and Daly (2022) | Canada | This study qualitatively explores to what extent there are promising practices to be learned from paramedic services that are connecting patients to mental health and psychosocial programmes | Frontline paramedics (n=31), paramedic services management (n=5), educators at paramedic college programmes (n=5) and base hospital physicians/directors (n=5) in Ontario | Interviews were conducted. Work observations were performed in three paramedic services, with multiple crews in different shifts (˜90 hours) |
Benefits of diversion programmes that transfer patients to a destination other than the emergency department; crisis response teams that attend calls involving mental health; and community paramedicine programmes including those for referral to alternate services. Implementing specific programming for mental health-related calls in paramedic services is beneficial, as is reaching beyond the prehospital and mental healthcare system to comprehensively and preventively address mental health needs |
| Gee et al (2022) | England | Explore young people's experience of ambulance service care during mental health crisis | Ten participants aged 16-25 years: eight women; one man; one preferred not to say. |
Face-to-face interview (n=1) |
Main theme: inconsistency in quality of care |
| King et al (2022) | Australia | To examine the mental health literacy of Australian paramedic students, and the training and experiential factors associated with this | Paramedic students across Australia (n=94) | Cross-sectional online survey | Low stigmatising attitudes towards mental health |
| Ford-Jones (2023) | Canada | Explore the tensions between frontline paramedics’ considerations for managing safety and violence when attending calls for those with mental distress and the violence and safety concerns frequently faced by those with mental health needs | Three paramedic services in Ontario: one urban (including some suburban and rural communities), one rural; and one suburban and rural | Single qualitative, ethnographic case study. 46 interviews (20-60 minutes). Frontline paramedics (n=31), paramedic services management (n=5), paramedic college educators (n=5) and base hospital physicians and directors (n=5). |
Main theme: violence and safety |
| Hammarbäck et al (2023) | Sweden | To describe ambulance clinicians’ conceptions of responsibility when encountering patients in a suicidal process | Ambulance clinicians in south Sweden. Purposive sampling to cover ages and levels of experience (n=27) | In-person semi-structured interviews |
Three different descriptions of encounters: conventional responsibility—responses linking care to traditional emergency care; conditional responsibility—responses that acknowledged mental health assessment requirement but with limited emphasis; ethical responsibility—treating patients as fellow humans, establishing a relationship prioritised. Role of training in supporting clinicians to do this |
As limited research has been conducted in this topic domain, it was decided to conduct a scoping review instead of a systematic review so no studies were excluded based on quality as part of a critical appraisal (Munn et al, 2018). A critical appraisal was not required for this scoping review, which aims to scope the breadth of literature and synthesise the evidence associated with paramedic management of patients with mental health issues. Nonetheless, the researchers acknowledge the importance of the quality and relevance of data, so reviewed the relevance of the sources of evidence, discussing together any papers deemed potentially outside of the scope of this review.
Charting these studies revealed five themes: communication skills; lack of education and training; call triage and inter-service collaboration; perceptions and expectations; and assessment and evidence-based interventions. Table 4 shows how these themes are mapped to the studies included, with lack of education and training being the most frequently reported.
| Communication skills | Lack of education and training | Call triage and inter-service collaboration | Perceptions and expectations | Assessment and evidence-based interventions |
|---|---|---|---|---|
| Ferguson et al (2019) | McCann et al (2018) | Genziani et al (2020) | McCann et al (2018) | Duncan et al (2019) |
| Keefe et al (2020) | Rees et al (2018) | Gee et al (2022) | Keefe et al (2020) | Ford-Jones and Daly (2022) |
| Hammarbäck et al (2023) | Ferguson et al (2019) | Ford-Jones (2023) | Ford-Jones (2023) | |
| Ford-Jones and Daly (2020) | ||||
| Genziani et al (2020) | ||||
| Keefe et al (2020) | ||||
| Rolfe et al (2020) | ||||
| Briggs et al (2021) | ||||
| Emond et al (2021) | ||||
| Gee et al (2022) | ||||
| King et al (2022) | ||||
| Hammarbäck et al (2023) |
Discussion
The five themes—lack of education and training, communication skills, inter-service collaboration, perceptions and expectations, and assessment and evidence-based interventions—are discussed in more detail here.
Lack of education and training
Papers in this review highlighted how ambulance staff across multiple countries felt unprepared to manage patients presenting with mental health conditions and felt they needed more training and education (Rees et al, 2018; Ford-Jones and Daly, 2020; Genziani et al, 2020; Keefe et al, 2020; Rolfe et al, 2020; Hammarbäck et al, 2023). Ambulance staff reported that the cause of their lack of confidence in managing mental health presentations was a lack of specific education and training, in both undergraduate curricula and training within employment (Rees et al, 2018; Ford-Jones and Daly, 2020; Genziani et al, 2020; Keefe et al, 2020; Hammarbäck et al, 2023).
Parent et al (2020) carried out a scoping review looking at mental health teaching on paramedicine undergraduate curricula across Australia. They found that students felt unprepared in managing mental health conditions, and the cause of this was a lack of formal education on this topic. They reported wide variations in content and approaches to mental health education and found that students visited mental health content only once within their curriculum with no practical learning. They highlighted how this created an unequal minimum standard for paramedic management of mental health conditions, and that greater consistency was needed across institutions.
In another Australian study, a pre- and post-subject questionnaire was conducted for final-year student paramedics undertaking a specific mental health module (Emond et al, 2021). The authors found that before the module was taught, student paramedics felt unprepared for managing mental health conditions and held many misconceptions about mental health management. Additionally, they lacked awareness of common presentations and their paramedic management.
However, while there is consensus within the literature that focusing on education and training for paramedic students and staff would improve their confidence and ability to manage mental health presentations, there is an alternative view that rejects the notion that this should be the role of the paramedic.
Participants in Emond et al's (2021) study had differing views on the core role of paramedics. This study had 1140 Australian paramedic participants; some paramedics acknowledged that mental health presentations were a routine type of call to ambulance services, and it was incumbent on the system and individual practitioners to be able to competently assess and manage this type of presentation. Others saw their role as primarily managing physical health presentations, and that managing mental health presentations was outside their scope. This was linked to participant sex, experience and geographical region of work, with rural female paramedics reporting the lowest confidence in responding to mental health emergencies.
These views of paramedic practice reflect a wider conversation about the role identity of paramedics, and what a paramedic should and should not be attending to.
Williams et al (2021) highlighted how it is difficult to define a paramedic, and that the dominant identity of paramedics is still bound up in managing life-threatening emergencies, which is no longer the reality of ambulance work (Phillips and Trenoweth, 2023); this appears to be reflected here concerning paramedic management of mental health presentations.
These issues are also bound up in the design of paramedic curricula, which are often unbalanced in favour of emphasising traditional, life-threatening emergencies with less of an emphasis on the importance of mental health presentations. This is sometimes reinforced by the hidden curriculum—the hidden messaging to students by educators about the perceived importance of different aspects of the curriculum (Phillips and Trenoweth, 2023).
The 6th edition of the paramedic curriculum (College of Paramedics, 2024) and the new mental health guidelines (JRCALC and AACE, 2023) are steps in the right direction in the UK to address gaps in education and training for paramedics managing patients with mental health problems. However, as both are considered guidance and not protocol, questions remain regarding educational inconsistency, variable uptake by higher education institutes and uncertainty around competence.
Communication skills
Communication skills were highlighted as important factors in paramedic management of mental health presentations. Hammarbäck et al (2023) identified a range of clinician attitudes towards suicidal ideation. They concluded that practitioners who viewed this presentation with ethical responsibility, seeing the patient as a human, social being, were able to communicate effectively. This enabled them to understand patients’ stories and have therapeutic conversations about suicidal ideation.
Ferguson et al (2019) found benefits to effective communication from the patient's perspective. They identified that patients reporting positive interactions with paramedics were recipients of positive communication that included careful use of language and tone of voice.
The opposite was true of bad experiences and poor communication. Keefe et al (2020) also found that paramedics valued good-quality communication skills in managing mental health presentations. They highlighted that this included verbal and non-verbal communication, as well as types of language and tone of voice. It enabled paramedics to demonstrate their empathy and compassion to patients which they felt improved their management of the presentation. Their findings support those of Hammarbäck et al (2023) in that good communication can effectively de-escalate potentially violent situations.
Communication is widely seen as an important skill in the management of mental health presentations.
Patterson et al (2008) identified communication as a core skill for newly qualified mental health nurses. Mental health nurses in their study highlighted that communication is a complex skill that operates on different levels, and a variety of communication skills are required for different situations.
Ellis and Philip (2010) also emphasised the importance of communication skills in their study of generalists in Australia. Following a training programme, participants reported improvements in communication skills. They specifically pointed to the ability to read non-verbal cues and better listening skills. This increased their confidence in approaching patients who were potentially volatile.
Ditton-Phare et al (2015) supported the emphasis on communication as a core skill in mental health, with effective communication leading to better outcomes for patients and clinicians. They report that there are often deficiencies in the quality of communication, and that advanced communication is a skill that can be taught to trainees.
The wider evidence supports the findings of this review that communication is an important skill in managing mental health presentations. Future education and training packages for paramedics need to address this core area of mental health management.
Call triage and inter-service collaboration
A study by Jones et al (2024) reinforced the need for collaboration between specialist services and ambulance trusts. In the UK, many ambulance services are attempting to address this by employing mental health professionals in various capacities. Ambulance services in England have also included specialist mental health response vehicles and mental health professionals in emergency operations centres to address the increased demand on paramedics and ambulances (Knowles et al, 2020).
One ambulance service reported that employing mental health professionals to help manage mental health calls reduced response times and resulted in fewer additional resources being deployed (Knowles et al, 2020). Additionally, the ‘mental health street triage’ collaboration between paramedics, mental health professionals and police responding on a dedicated response vehicle reportedly reduced emergency department (ED) admissions (Knowles et al, 2020). However, although the national partnershp agreement (DHSC, 2024) is intended to ensure patients are seen by the appropriate agencies, the burden of this on ambulances services and the impact on those experiencing mental health crises is yet to be evaluated.
Gee et al (2022) supported the notion of further collaboration in their study by identifying inconsistency in care quality and the importance of retaining agency as well as highlighting the need for mental health training for ambulance clinicians. They concluded that, in the absence of mandatory high-quality mental health training and evidence-based protocols, the quality of care appears largely dependent on the qualities and experience of individual ambulance clinicians. Therefore, they suggested inter-service collaboration is required to improve consistency of patient experience.
In the study by Genziani et al (2020), which included the collaboration of police and ambulance staff, participants felt training should be improved. Police participants particularly noted time pressures and negative experiences of admissions to 136 suites (places of safety to where police in the UK can use emergency powers to take people who are having a mental health crisis in a public place). Paramedic and police participants spoke less favourably of their experiences of trying to get individuals admitted into the suites, especially around the welfare of detainees where there were delays. The study recommended improving training of emergency workers, and that this would also help improve care on discharge. Learning identified from the participants’ experiences lent support to collaboration between emergency and mental health services—an important step towards improving the section 136 process so detainees can access help without unnecessary delay (Genziani et al, 2020).
Perceptions and expectations
Despite the prevalence of mental ill health, with one in eight people worldwide living with a mental health disorder (World Health Organization, 2022), perceptions and expectations about mental ill health and how it is managed remain points of concern for paramedics and patients alike.
In an earlier study by McCann et al (2018), paramedics’ experiences of caring for patients with mental health and/or alcohol and other drug problems and perceptions of their scope of practice in caring for these patients revealed paramedics needed more undergraduate and in-service education. They were concerned about extending their scope of practice to include education with these patients. McCann et al (2018) recommended introducing alternative models of paramedic practice, such as community paramedicine, with a focus on supporting people in the community with mental health problems. They also believe there is a need for a change in workplace and organisational culture about scope of practice in caring for patients with these problems. Extending paramedics’ role could, potentially, benefit these patients by improving care quality, reducing the need for transportation to EDs and decreasing clinicians’ workloads in these units.
The literature on the perceptions and experiences of paramedics responding to behavioural health emergencies in the United States is limited. Keefe et al (2020), highlighted that there is a significant gap in paramedic training, a recurrent theme throughout this review. Keefe et al (2020) suggested additional training to respond to and work with individuals experiencing behavioural health emergencies will better serve those in crisis, as well as paramedics and other emergency providers. This recommendation from the US is also consistent with those in the UK and Australia (Rolfe et al, 2020; Emond et al, 2021). Keefe et al (2020) concluded that further investigation into the perceptions of paramedic students to enhance understanding to better prepare them to respond to behavioural health crises in the field was also needed.
King et al (2022) proposed that some paramedics in Australia held negative attitudes towards the use of emergency services to provide care for mental health patients. The study's participants—paramedic students—felt they had poor mental health first aid intentions despite good recognition of mental health disorders and good knowledge about mental health. They demonstrated low stigmatising attitudes towards mental illness; however, they expressed a lack of willingness to interact with a person experiencing mental illness (King et al, 2022). As with other studies in this review, King et al (2022) proposed a combination of work-based experience and specific mental health first aid training, which may help paramedic students improve care.
Stigma was further highlighted by Ford-Jones (2023), who looked at themes linked to violent encounters and safety concerns. These concerns are particularly linked to paramedics attending mental health and substance use calls. Their findings include success with de-escalation of those in distress, and paramedics challenging the notion that all individuals with mental distress are violent. Ford-Jones (2023) also explored tensions between attention to care providers’ and care recipients’ safety, the contexts in which this care takes place, and equity concerns related to managing mental health emergencies appropriately. Paramedics’ insights into the ways in which these calls are perceived are valuable findings, showing an ongoing heightened expectation of violence is present with these calls.
Assessment and evidence-based interventions
Assessment and how to complete a safe, evidence-based management plan for those experiencing mental health issues are the final themes of this review.
In the UK, the recently published JRCALC mental health clinical guidelines (JRCALC and AACE, 2023) are completely revised guidance with new information around mental health services provision and treatment. However, research continues to show paramedics still need further support and education in how to manage this patient group. Clinical guidelines provide a starting platform, but further integrated education and knowledge evaluation are needed.
Duncan et al (2019) added that ambulance services and EDs are missing opportunities to provide better care to those with mental health issues, alleviating an avoidable mortality, morbidity and service burden. Developing and testing interventions for these patients in prehospital and ED settings could lead to reductions in suicide, patient distress and service use (Duncan et al, 2019).
Ford-Jones and Daly (2022) analysed the relationship between paramedicine pedagogy, patient needs and the conditions for paramedics’ skill development. Tensions were explored in relation to the pedagogy of paramedicine and the conditions of work experienced by paramedics in Canada. The authors highlighted insufficient training in mental health, and mental health not being prioritised or valued in training. They recommended more comprehensive didactic training, including: the social determinants of health; scenario training; practical placements in mental health or social services; collaboration with mental health and social services to further develop relevant curricula; and inclusion of service users (Ford-Jones and Daly, 2022).
Few studies have considered the perspectives and capability of practitioners in assessing patients over the phone. Briggs et al (2021) explored the thoughts, feelings and educational requirements of paramedics and nurses working on emergency medical service clinical desks, focusing on mental health-related calls and the triage tools used. Low levels of confidence were reported in managing mental health calls, along with inadequate detail in the mental health elements of their triage algorithm and deficiencies in referral pathways. Briggs et al (2021) concluded that more attention should be paid to the education and training of clinical desk professionals and the decision support tools available in ambulance services.
Limitations
The widely accepted framework of Arksey and O'Malley (2005) increases rigour of review; however, this structure is designed to identify breadth of research without critically considering quality of evidence (Tricco et al, 2018).
Because of limited resources for translation, articles published in languages other than English were excluded, which also affected geographical regions that could have contributed to this review.
The authors also acknowledge that, by definition, a scoping review may have missed relevant studies.
Key Points
Conclusion
This scoping review found several factors affect how paramedics are able to manage patients with mental health presentations. Paramedics appear to feel that there are deficiencies in their education around these presentations, which affect their communication skills as well as their expectations about managing this group of patients.
From a system perspective, inter-service collaboration was found to be an issue that affects how well paramedics feel they can address the needs of these patients.
There is a need for effective evidence-based education and training for paramedics in the management of patients presenting with mental health issues. This should address communication skills, attitudes and perceptions, as well as the expectations of other services to optimise management.