Over recent years, NHS England has increasingly focused on improving the outcomes and experiences of those with mental health problems. People can experience poor mental health at any time of life, as it affects all age groups. The Five Year Forward View for Mental Health (Mental Health Taskforce, 2016) acknowledges that, to improve the experiences and outcomes for those needing support, a wide-ranging approach is necessary, which includes better assessment and access to appropriate services in a timely manner.
Calls to emergency services because of mental health crises are increasing, with literature suggesting that at least 40% of calls are related to mental health (Ford-Jones and Chaufan, 2017). Indeed, Rees et al (2015) suggest that the UK has one of the highest incidences of self-harm in Europe, leading to a reason for hospitalisation. This presents significant challenges for prehospital staff, including paramedics, who are often faced with ambiguous patient presentations and a scarcity of any medical history for that person (Parsons and O'Brien, 2011). Despite Department of Health and Social Care (2014) recommendations for paramedics to be adequately equipped to carry out assessments and facilitate a joined-up approach to mental health care, gaps remain in their skills and knowledge. As this is compounded by deficiencies in community mental health services, providing high-quality care remains challenging (Rees et al, 2015; Ford-Jones and Chaufan, 2017).
As the role and scope of practice of paramedics develop, their involvement in the management of mental health issues continues to increase.
This article explores the views and experiences of student paramedics and factors that influence their decision making, specifically in the assessment of and response to calls relating to mental health issues.
Methodology
Qualitative methodology was employed to explore the views and experiences of paramedic students undertaking a diploma in higher education to become a qualified paramedic. This approach supports researchers to investigate situations and experiences of participants to achieve a better depth of understanding about the phenomena under investigation (Basit, 2010).
Data collection
Focus groups were conducted by two members of the research team who were academic members of staff. This was audio-recorded, anonymised and transcribed verbatim. A semi-structured approach was taken, with a schedule of questions agreed by all members of the research team.
Sample size and sampling
In total, fifteen student paramedics were recruited for the study, who were divided between three focus groups.
Purposive sampling was the basis for participant selection; specifically, three focus groups were facilitated with between four and six participants in each. Participants were student paramedics from both years one and two of the diploma programme, with many having substantial experience as technicians before enrolment at university.
Participants were given an information sheet with details of the study and all were invited to ask questions. Written consent was obtained before data collection began.
The study received ethical approval from the University's Research Ethics Committee (case number UREC 18/NAH/028).
Data analysis
Transcripts were read and re-read several times. This led to the creation of notes and ideas leading to the coding phase by each member of the research team. Researchers then searched for themes by combining different codes relevant to the aim of the research (Braun and Clarke, 2013). A thematic map was used to assist in linking themes and facilitating a relationship between them. Examples of narrative within the transcripts were then used to illustrate each theme.
Findings
Disparities between student paramedics' expectations of the role and the reality of paramedic practice were apparent throughout the data. Students perceived their role to be primarily one of attending emergency calls involving physical injury or healthcare needs. Preparation for practice included the understanding and ability to implement protocols and associated medical tasks.
However, the level of preparation for managing mental health issues was perceived as poor. While participants could clearly see the need for better mental health service provision, the lack of appropriate mental health support services in practice inevitably led to paramedics becoming involved and patients being transferred to accident and emergency (A&E) departments.
Findings from the focus groups highlight a need for education on mental health assessment and training to improve intervention.
Expectations versus reality
Paramedics deal with a significant number of mental health calls. One participant recalled that most calls related to mental health:
‘It's a huge problem.’
The impact of this on the paramedic student was evident:
‘I think it's quite draining, especially after a mental health job, you can sit on a job for four hours.’
This is further compounded by the worry that other people may need their intervention more urgently:
‘You're sat looking at your watch thinking ‘I know there's no vehicle for that cardiac arrest’ which, funnily enough, is what we do.’
Regarding mental health interventions, expectations are ambiguous. Participants acknowledged that mental health covers a wide variety of situations from depression to suicide and violent, acute episodes. However, the language used to assess the situation was equally ambiguous, with ‘mental health job’ being the point of reference. The response to such calls lacked a sense of purpose as there was little attempt to differentiate between presenting mental health symptoms or conditions:
‘You can train someone how to speak to a mental health patient but you can't teach them to deal with that person's immediate problem. No amount of training is going to be able to sort that person's problem out.’
When asked how this differed from physical illness, one participant said:
‘If you get there and sort of start the healing process … like when it's a broken leg or something, you can splint it.’
Participants seemed to have low expectations for their interaction with people needing mental health support and did not appear to link their initial response with an opportunity to influence patient recovery or affect clinical outcomes. Knowing how to communicate with people with mental health problems was acknowledged as important by various participants. However, they also recognised they were concerned about getting it wrong as responses to their interventions are difficult to predict:
‘I'm always scared of saying the wrong thing and making them feel worse.’
‘Annoying the patient even more.’
Both occupational therapists and nurses were thought to be better equipped to respond to mental health needs. However, it was acknowledged that, in response to suicide attempts, ambulances do have the necessary equipment to care for that person:
‘You've got at least a resuscitation kit available to do something about it.’
The focus here, however, is on the response to physical needs following a mental health episode. Ultimately, there was a level of frustration over the time paramedics spent with people needing mental health care because the necessary support was not available:
‘You've spent lots of time and feel like you've achieved nothing.’
Structure of mental health services
It appeared that the lack of options to support those with mental health issues was exacerbating the frustration experienced by the paramedics:
‘I don't particularly want to get on my soap box, but the provision of mental health first aid in this country is nothing short of shocking and, in some cases, third world.’
‘A&E isn't the right place for them, neither is a police custody suite and neither is the back of an ambulance.’
In response to this, participants felt a mental health response vehicle with a mental health practitioner would be more appropriate:
‘If we had a community referral like you can get out-of-hours GPs, you could get an out-of-hours mental health worker to the house within one hour … much more appropriate than taking the patient to hospital … but, again, that's funding. It's not going to change any time soon.’
It was recognised by participants that it is possible to improve the outcomes for those with mental health issues by providing more bespoke services and better education and training for paramedics in preparation for responding to mental health needs:
‘We should have better pathways to go down …our own mental health car.’
‘We need a mental health casualty … where there are experts in that particular field.’
Specifically, participants identified their concerns associated with attending to individuals at risk of suicide, and discussed the inappropriateness of A&E as a suitable environment for those people:
‘If you leave them at home and they kill themselves, you might as well tell [employer] to sack you—you might as well, when you get back to the station and find out they're dead, put your uniform in the bin and go home.’
Participants recognised some people at risk are not typical of mental health calls and therefore may be missed.
‘You could get like a 90-year-old lady who's severely depressed phoning an ambulance and they'll [111] say “well do you really need an ambulance?” and she'd go “It's OK, don't send me an ambulance, I'm fine” when she's not, she's really on the edge.’
Triaging as well as responding face to face to mental health calls can therefore be challenging.
Role of education and training
Participants referred to the lack of paramedic education and training specifically in mental health:
‘None of us are trained—none of us particularly know what to do with them.’
Calls to those with mental health issues appeared to carry a variety of risks to paramedics, ranging from their own personal safety to fear of litigation and job security, as well as patient safety concerns.
One participant recalled:
‘It got really charged … should have been contacting the police beforehand because then we got attacked by the person and, because of that, we had to retreat.’
The participant went on to describe the successful de-escalation that occurred once the police had arrived. This then led to an acknowledgment of how much better prepared the police service appeared to be in dealing with this type of event:
‘The police talking to them were brilliant, they were really good and really patient. It felt like they knew what to say and how to deal with it.’
One participant reported that the police were better than some paramedics at talking to people, appearing to use specific methods of engagement with those who had mental health issues:
‘They've got different techniques, different ways of talking to people.’
It was acknowledged by participants that paramedics would benefit from acquiring more techniques for dealing with such situations and there was some discussion about how education could help them, with one participant suggesting more training on specific conditions:
‘More training on actual conditions, ’cos they're all under one umbrella of mental health.’
However, another questioned the utility of this, given the variety of calls they are required to attend and the temporary nature of their contact with people:
‘You could say that about all the stuff we go to … We're here to patch things and get people to the right places.’
Mental health education and training were considered to be particularly important for those who enter the paramedic profession at a young age, so they would be prepared for dealing with challenging situations that might involve people with mental health issues:
‘You've got people with limited life experience. We have 18-year-olds on this course. You are going to ask them in two years, with no mental health training, to go to somebody who is either very, very down and needs them or does not want them to be there. I'm not saying 20s or 30s will be any better, but with some sort of life training of being in situations where you have to be a bit resilient.’
‘I think it's a bit of a frightening situation to put someone in.’
The need for people skills when attending to individuals at times of great stress was seen as important. Participants felt that school leavers would be less likely to have these skills.
Discussion
The Health and Social Care Act 2012 was intended to improve mental health services by giving mental health parity of esteem with physical health. However, data from this qualitative study of student experiences suggest that more ought to be done.
Participants in this study, despite being paramedics in training, had clear views on the need for improved mental health services and saw that gaps in these had a significant impact on their ability to, first, avoid unnecessary admissions to A&E and, second, provide a better patient experience with more suitable avenues for initial response and treatment. Fortunately, recent budget announcements include an injection of funds for mental health services to include better access to services on a 24-hour-a-day basis. Options include specialist ambulances to respond to calls and better support in A&E if admission is necessary (Gilburt, 2018).
While some of the problems experienced by paramedics relate to a lack of mental health services and therefore options for support, they can also be attributed to processes used by health professionals to make accurate clinical decisions.
Focusing on the process used by both paramedics and student paramedics to make clinical decisions, Jensen et al (2016) used the dual-process theory (Norman, 2009). This theory suggests there are two options: system 1, which is considered intuitive and rapid, influenced by experience; and system 2, which is deliberate, rational and based on knowledge. The systems may be used simultaneously.
In relation to paramedics and student paramedics, Jensen et al (2016) found that participants relied mainly on rational rather than intuitive decision making to achieve a provisional diagnosis. Recommendations from this suggest that paramedic education would benefit from including the process of clinical decision making with options such as case presentations with a ‘cognitive autopsy’ to focus on thinking strategies, or simulation with a ‘think aloud’ approach to facilitate exploration of the factors affecting clinical decision making (Jensen et al, 2016: 220). Key to the success of this approach, however, would be making a link between the knowledge base and the clinical decision arrived at. In relation to decision making for mental health calls, student paramedics would need additional education as participants suggested very little had so far been delivered.
Participants described a variety of situations that relate to mental health; in particular, some that require support from the police. When attending jointly with the police, some recalled how the police officers appeared to know how to handle the situation by having different ways of talking and de-escalation. The participants themselves highlighted how the techniques the police used would be beneficial to them.
The different approaches taken by the police in relation to their response to situations involving mental health issues appear to have been in place for a number of years, with the development of mobile crisis teams (MCTs). Some areas of the country have reported decreased activity in implementing criminal legislation with an emphasis on avoiding the criminal justice system. Officers benefited from engaging with the MCTs before deciding whether to detain people (Lancaster, 2016). It seems that access to such specialist support for frontline staff would also benefit the paramedic response, especially given the rational decision-making processes favoured by paramedics.
Paramedics can be the first point of contact in healthcare, regardless of the underlying rationale. As a result, paramedics are required to have a ‘hybrid skills set’ (Ford-Jones and Chaufan, 2017: 2). Findings from this study suggest that student paramedics would welcome more education about mental health, as participants indicated a significant level of concern for patient outcomes but felt their interactions were limited. Findings from a survey commissioned by the College of Paramedics are not dissimilar in that, while paramedics are aware of sections 135 and 136 of the Mental Health Act 1983, more education relating to mental health conditions would be beneficial, particularly around issues of patient safety (Berry, 2014).
Participants identified the need for resilience as a way of coping with challenging calls. Resilience is thought to be particularly important for health professionals because they work in a complex, stressful and emotionally challenging environment. Healthcare students in general report high levels of stress, poor or weak ability to cope, leading to difficulties in retaining (Sanderson and Brewer, 2016). There is also a correlation between resilience and the mental health of health professionals (Sanderson and Brewer, 2016). In addition, paramedic students on placement work in diverse and sometimes precarious environments, which adds to the stressful nature of prehospital care; this has led to calls for an enhanced level of resilience training (Kennedy et al, 2015).