The changes in mental health services in Australia during the early 1980s, which included the resettlement of long-term residential mental health patients into the community, had a profound impact on the roles and responsibilities of different frontline services (Australian Institute of Health and Welfare (AIHW), 2004). These reforms significantly altered the means by which mentally ill and mentally disordered patients come to access and receive ambulatory and emergency mental health care. The consequence of these changes has been the marked increase in mental health related presentations that paramedics are required to manage and treat (Shaban, 2004; Roberts and Henderson, 2009; Townsend and Luck, 2009).
Mental health in Australia
In Australia, mental health legislation varies from each state and territory, and while thes e laws promote the same fundamental principles, differences do exist in relation to the persons authorized to detain a person as an involuntary patient on the grounds of being mentally ill or mentally disordered. The extension of emergency provisions to paramedics in some Australian states and territories (New South Wales, Queensland, Northern Territory and Victoria) has meant that authorized paramedics are now being called to fulfil a role previously restricted to police officers or other accredited persons.
The granting of mental health legislative responsibilities to paramedics has herald a new era in not only the delivery of prehospital mental health care, but also in the way the community perceives the role and responsibility of paramedics.
While anecdotal reports suggest that the majority of mentally ill and mentally disordered patients are transported by paramedics to hospital voluntarily, a small proportion refuse treatment and transport and require short-term detention as involuntary patients under relevant mental health legislation.
In these circumstances, the purpose of temporarily removing a person's civil liberty is to ensure that patients who are assessed as ‘at risk’ are safely contained and conveyed to hospital for further assessment and treatment.
Historically, in situations that have necessitated the involuntary detention of an individual in the community, police have been called to enact police emergency powers under relevant mental health legislation and convey the person to hospital.
The main function of mental health legislation in Australia is to establish a legal framework in which involuntary, and to a lesser extend voluntary care, control and treatment should be provided for individuals with a mental illness (Mental Health Act, 2007). The overriding philosophy of mental health legislation is for an individual to receive the best possible care and treatment in the least restrictive environment, while at the same time protecting their civil liberties.
In relation to the involuntary detention of individuals, mental health legislation requires that an individual must meet the criteria of being either mentally ill or mentally disordered as defined by the American Psychiatric Association 2000 or the International Statistical Classification of Diseases and Related Health Problems (2007).
‘The extension of emergency provisions to paramedics in some Australian states and territories has meant that authorized paramedics are now being called to fulfil a role previously restricted to police officers or other accredited persons.’
Extending functions to paramedics
For the purpose of providing involuntary care and treatment, the two most critical areas of concern for health professionals typically relate to the serious likelihood of imminent danger to self or others, and the need for treatment (Mental Health Act, 2007).
The impetus behind extending these functions to paramedics should serve two distinct purposes. First, from a patient safety and clinical quality perspective, authorizing paramedics to enact mental health powers may significantly reduce police involvement in the transportation of mentally ill or mentally disordered patients, although relevant state and territory mental health legislation continues to uphold the recognition that police assistance is still necessary in situations that are deemed too high risk for paramedics to manage alone, thereby acknowledging that in some circumstances an inter-agency response is necessary in order to safely manage crisis situations.
Second, it could be argued that authorizing paramedics to enact mental health legislation by virtue promotes the idea that paramedics are an active part of the broader mental health discipline, and that mentally ill or mentally disordered patients should, where practicable, receive care and treatment by health professionals and paramedics and not by a law enforcement agency.
Defining a mental health emergency
A mental health emergency can be defined as a change in a person's mood or behaviour that is so disruptive as to require immediate attention. These can be grouped into a number of key categories that reflect the range of psychosocial and physiological characteristics that are typically observed across the spectrum of psychiatric presentations. A mental health emergency may occur in the context of a pre-existing mental illness, in response to a situational crisis; a result of organic complications; or following drug and alcohol intoxication, or trauma. Mental health emergencies are often associated with extreme levels of distress and a high risk of suicide (Yellowelees, 1998; Caroline, 2008; Grbich and O'Meara, 2008).
In the prehospital setting, paramedics are routinely required to manage mentally ill and mentally disordered patients in situations that are chaotic, uncontrollable and unpredictable. Consequently, the management of a mental health emergency in the community is often brief (Yellowelees, 1998) and involves limited back-up resources, particularly in non-metropolitan areas.
The purpose of this article is to examine the role of the paramedic with respect to mental illness, to explore what is known about paramedics' clinical decision-making practices and about the opportunities for future development of their scope of practice.
Method
An extensive literature search using CINAHL, MEDLINE, ERIC, PsychINFO and Google Scholar; entering key terms ‘paramedic clinical decision making’, ‘prehospital’, ‘ambulance’, ‘EMT’, ‘clinical reasoning’, ‘judgement’, ‘mental health emergency’ and ‘paramedic mental health care’; found only five recent Australian references that related to mental health care in paramedic practice (Shaban, 2004, 2005, 2006; Roberts and Henderson, 2009; Townsend and Luck, 2009). These documents were then used to source other relevant primary references. A number of Australian and international ambulance organizations were approached and voluntarily provided relevant organizational documents that relate to ambulance mental health care.
The search revealed that while the use of these powers by other health professionals has been examined in some research (Bower, 1993; Houlihan, 2000; Farrow et al, 2002), there is an absence of published literature that has examined paramedic use of legislative emergency mental health powers within their clinical judgment and decision-making of mental illness.
Findings
Emerging themes relevant to prehospital mental health care
An analysis of the literature identified two prominent themes with respect to paramedic mental health care. These relate to the quality of paramedic mental health education and training and the ability of paramedics to make competent and effective clinical decisions when responding to patients experiencing a mental health emergency. It will be postulated that the ultimate quality of these factors will determine whether paramedics apply mental health legislation in a justifiable and clinically appropriate manner.
‘A number of ambulance services have introduced specific mental health training programmes to equip paramedics with the necessary clinical skills to better manage mentally ill or mentally disordered patients’
Training needs of paramedics in managing mental health emergencies
In response to the inclusion of emergency powers for paramedics as part of the overhauling of mental health legislation, a number of ambulance services have introduced specific mental health training programmes (Shaban, 2004; Roberts and Henderson, 2009). These programmes were intended to equip paramedics with the necessary clinical skills to better manage mentally ill or mentally disordered patients and to prepare them to fulfil their legislative responsibilities.
Shaban (2004) argues that the degree of knowledge, training and skills required by paramedics to manage mentally ill or mentally disordered patients remains a contentious issue and a significant challenge for ambulance organizations. According to Shaban (2004), paramedic training courses have traditionally taken place within a competency-based training (CBT) framework, which restricts the ability of paramedics to undertake complex clinical decision-making in the real-life settings in which they are likely to occur.
Furthermore, a number of studies (Shaban, 2005, 2006; Roberts and Henderson, 2009; Townsend and Luck, 2009) have continued to reveal that even after receiving specific mental health training, many paramedics believe that they still lack the necessary attributes required to assess and respond appropriately to individuals with a mental illness. In a theoretical paper, Shaban (2005) found that paramedics have reported a perceived gap in their knowledge and skills in relation to mental health care, by expressing a need for further skill development in this area. Participants also felt that they would benefit if they had access to a specific tool to guide them in the better management of mental health patients, a view expressed by other frontline health professionals (Sands, 2009).
Similar findings were reported in a later study undertaken in South Australia by Roberts (2007). This study found that paramedics had reported a critical lack of appropriate mental health assessment skills and competencies to effectively respond to behaviourally disturbed patients, in particular, lacking effective de-escalation training that would assist them in managing potentially aggressive or violent situations.
Participants in this study had further expressed a sense of continuing frustration at working within a health system that was poorly equipped to meet the needs of mental health patients. Roberts and Henderson (2009) using a mixed methods descriptive study also investigated the perceptions of paramedics in relation to their perceived role and education and training when responding to patients experiencing a mental health emergency.
The main issues significant for paramedics
Roberts and Henderson (2009) identified four main issues that were significant for paramedics when providing mental health care. These key issues related to how paramedics perceive their workload in relation to mental health cases, ambulance mental health education and training, organizational culture in relation to the provision of mental health care, and their interagency relationships when providing prehospital mental health care.
In relation to their perceived role when attending to patients with a suspected mental health condition, participants felt that they were primarily focused on transportation rather than providing beneficial clinical care. For participants in this study, attending to any obvious physical injuries was the first priority rather than the emotional wellbeing of the patient.
Enhanced mental health education and training was reportedly welcomed by participants in this study, with a particular emphasis on improving their risk assessment skills and de-escalation techniques. The influence of ambulance organizational culture featured predominately in the study's finding, with participants revealing that they felt limited in what treatment options were available to them other than simply transporting patients to hospital for further assessment.
Some participants extended this argument, suggesting that the perceived value placed on the interventions that are available or sanctioned for use, were found to heavily influence how participants perceive their role in relation to patients experiencing a mental health emergency. The value placed on short time on scene, limited training and treatment options was found to negatively impact on how participants perceived their role in relation to mental health emergencies.
When considering the current organizational stance in relation to paramedic mental health training across Australia, Shaban (2005) pointed out that as the responsibilities of paramedics and other health professionals differ, so too do their training needs. He suggested that it seems unrealistic to expect paramedics to become an expert in all major health conditions including mental health care but rather emphasis should be aimed at ensuring paramedics have the clinical attributes necessary to competently manage a broad range of health conditions.
Roberts (2007) further argues that improving paramedics' training in relation to mental health care should not be seen as a means of addressing the problems associated with the broader health system, a point echoed by Sands (2009).
International studies
Several international studies have revealed widespread discontent in relation to the preparedness of other health professionals to effectively manage patients experiencing a mental health emergency, or for them to properly exercise similar emergency functions under mental health legislation. A study from the UK which explored the use of nurses' power to detain involuntary patients under the British Mental Health Act (1983) found that nurses felt uncomfortable with their new statutory powers and preferred instead to use the power of persuasion and de-escalation when responding the patients experiencing a mental health emergency (Bower, 1993; Houlihan, 2000). Similar findings were found in a study by Farrow et al (2002) which looked at the prescribing rights bestowed under mental health nurses in New Zealand.
It was assumed that the delivery of specific ambulance mental health training would correspond with enhanced clinical decision-making in relation to the provision of emergency mental health care. The other prominent issue emerging from the literature relates to the ability of paramedics to engage in effective and competent clinical decision-making when providing emergency mental health care.
Paramedic clinical decision-making and mental health emergencies
For paramedics providing emergency mental health care, a number of key areas concerning a patient presentation must be explored. These relate to the level of immediate risk of harm that each patient presents to themselves or others and a patients capacity to understand and make rational decisions about their current circumstance (Saunders, 2005; Caroline, 2008; Grbich and O'Meara, 2008). After assessing a patient's state of mental health, paramedics must be able to identify what, if any, the legal issues are regarding the patients situation. For example, ‘does this patient agree to come to hospital voluntarily or do they meet the criteria for being dealt with as an involuntary patient under relevant mental health legislation by refusing to come to hospital?’
The decision by paramedics to detain a patient under relevant mental health legislation should only take place when a patient's presenting behaviour is posing such a significant risk to themselves or others and where the patient is refusing to be transported to hospital voluntarily. Paramedics must be satisfied that their clinical decision to detain a patient is justifiable and that no other less restrictive measures could be deployed.
When enacted appropriately, mental health legislation promotes and encourages the need for clinicians (paramedics) to take an informed and balanced approach between protecting the rights of a patient to receive care and treatment against the patients general right to freedom.
This is illustrated in the Mental Health Act 2007 (NSW) which mandates that, as far as practicable, people with mental illness or a mental disorder should receive care and treatment in the least restrictive environment possible'. The challenge for paramedics in the prehospital setting is to ensure they possess a high level of clinical skills to competently assess a patients state of mental health, perform comprehensive and detailed risk assessments and formulate clinically appropriate and justifiable decisions.
Until recently, little attention has been given in research to understanding and conceptualizing paramedic clinical decision-making. However, the literature, from earlier non-peer reviewed sources (United States Department of Transportation, 1998; Saunders, 2005; Caroline, 2008) has provided a useful introductory basis for informing our understanding of the knowledge and skills required by paramedics to make effective patient care decisions in the pre-hospital setting.
Prior to the pioneering works of Spooren et al (1996); Yellowlees (1998); Shaban (2004); Roberts (2007); Alexander (2010), much of what was known about paramedic clinical decision-making in mental health care is derived from other disciplines. While these studies (Corcoran, 1986; Benner and Tanner, 1987; Tanner et al, 1987; Chapman and Sonnenberg, 2000) may in part be applicable to prehospital mental health care, in research terms there is limited evidence to suggest that their findings are transferable to, or can account for paramedic clinical practice.
Shaban (2004; 2005; 2006) has populated the literature, writing extensively around the issue of paramedic clinical practice in relation to mental health care. In his theorising, Shaban made a significant contribution to the field of prehospital mental health care by revealing the salient factors that account for how paramedics are expected to, and actually do, make clinical decisions. His studies have also offered some interesting insight into the situational and contextual nuances that have been found to influence paramedic clinical decision-making when providing prehospital mental health care.
The relationship between clinical decision-making and the role of intuition in paramedic practice has been examined by Wyatt (2003) using the intuitive humanistic perspective. Wyatt's studies have focused on exploring the subtle ways in which paramedics draw upon tacit knowledge (such as intuition), by applying what is often referred to as professional judgment when dealing with unique clinical situations. Wyatt postulates that for novice (intern) paramedics, clinical decisions are often mirrored and driven by organizational protocols and guidelines, and that with experiential learning, a degree of confidence and independence can been seen to emerge in their clinical abilities and their clinical decisions begin to extend beyond the boundaries of standard protocols and guidelines.
The role of experience
Wyatt's study (2003) also found that the role of experience significantly influenced a paramedic's clinical knowledge which, in turn, directly facilitated their abilities to formulate effective clinical decisions independent of organizational guidelines. While Wyatt's contributions have gone some way to improving our understanding of the clinical decision-making constructs used by paramedics, her theorizing has been unable to account for how a paramedic crew, consisting of two paramedics, engages in joint decision-making, i.e. whether the influence of the more experienced paramedic guides or influences the less experienced paramedic in the management of a patient.
What these studies have in common is that they continue to document that paramedics work in a climate of constant uncertainty, ambiguity and stress when managing mentally ill or mentally disordered patients.
To complement the findings purported by Wyatt (2003), Shaban's studies (2005; 2006) have also revealed similar findings to those derived from the field of nursing (Hammond et al, 1980; Benner and Tanner, 1987; Gerrity, 1987; Rew and Barrow, 1987) which indicate that intuition and prior experience were typically the only effective strategies paramedics could draw upon when managing behaviourally disturbed patients. Interestingly, paramedics in Shaban's studies reported that clinical decision-making in relation to mental health patients was often guided by the physical status of the patient rather than a patient's state of mental health, as described by Roberts (2007).
Shaban also found that the ambiguous nature of acute mental health presentations in the community often had a negative impact on the clinical decision-making process of paramedics, whereby the decision to transport mental health patients to hospital for further assessment was often more commonplace.
Education and training material
In 2003, Shaban conducted an analysis of Queensland Ambulance Service educational and training material, as well as operational clinical protocols and policies. His document analysis found that paramedics were not explicitly trained in performing comprehensive mental health assessments, and that there appeared a lack of specific training for paramedics in relation to how to engage in effective clinical decisionmaking when providing prehospital mental health.
A recent review of similar mental health resources in another ambulance service in Australia has found that while paramedics are provided with a list of key signs and symptoms to look for when providing emergency mental health care, key organizational documents that paramedics readily rely upon remain silent on the circumstances in which paramedics should invoke their Mental Health Act responsibilities.
Legislative issues
Moreover, Townsend and Luck (2009) raised concerns about the apparent misunderstanding in relation to the legal issues that surround the decision-making of paramedics when providing prehospital mental health care. They argued that with the expanding roles and responsibilities of paramedics, particularly in relation to mental health care, legal and ethical challenges are likely to add more confusion around this issue. Further, Shaban (2005) purported that such misunderstanding among paramedic in relation to when mental health legislative responsibilities should be exercised may in fact means that paramedics make less than sound clinical decisions in relation to patient management.
Townsend and Luck (2009) suggest that paramedics must have the necessary skills to make the correct clinical decisions when providing mental health care, otherwise it may ‘contribute to a breach in the paramedic's legal standard of care or may result in an assault being committed against a patient’.
Shaban (2005) also raised the possibility that, in exercising their mental health legislative responsibilities, paramedics may make a clinically inappropriate decision to enact these functions rather than face the potential of exposing themselves to future litigation. While mental health legislation provides protection to paramedics in such instances, the mere possibility (whether actual or perceived) of being liable to persecution may have a negative influence on paramedics decision-making process, whereby clinical decisions are taken from a more cautionary standpoint when managing behaviourally disturbed patients.
Shaban (2005) touched on this issue, finding that often clinical decision-making processes were compounded by the fear of prosecution from patients who were not transported to hospital. Sands (2009) investigated mental health triage practices among mental health clinicians, and found that uncertainty in relation to the potential to misdiagnose a patient was a key concern among mental health nurses and influenced their clinical decisions.
Opinion and percieved judgement of other colleagues
The opinion and perceived judgment of other colleagues has also been found to influence clinical decision-making in relation to emergency mental health care. In a study conducted by Shaban (2005), not transporting patients to hospital was viewed negatively among paramedics; that is, the act of transporting a patient to hospital for assessment was viewed as providing care and treatment, whereas not transporting a patient to hospital was viewed as a failure to treat the patient.
Conversely, mental health nurses who participated in Sands' study described feeling significantly concerned about what other mental health nurses would say if a patient who was not considered psychiatrically ‘unwell enough’ was referred for admission (Sands, 2009).
Whereas the practice of transporting all patients to hospital is viewed positively among paramedics, mental health nurses, who took this action were judged by other colleagues (or ‘gate-keepers’) to be making ‘soft decisions’ (Sands, 2009) and were often perceived as being unable to competently manage the risks associated with the triage role.
For mental health triage nurses in Sands' study (2009), the decision not to admit low acuity patients (such as those patients with known personality disorders or in situational crisis) was often viewed more favourably among other mental health nurses.
Organizational protocols and clinical guidelines
Furthermore, Shaban's study (2005) found that organizational protocols and clinical guidelines around the management of mental health patients often meant that paramedics were required to transport all patients to hospital regardless of their presentation, a claim also put forward by Townsend and Luck (2009). For patients not presenting with actual or threatened self-harm, existing policy guidelines provide no guidance to paramedics on leaving a patient at the scene, or the option of referring a patient to more appropriate services such as the local community mental health services for follow-up. Porter (2007) conducted a study in the UK which examined the issue of paramedic decision-making in relation to not transporting non-urgent patients to hospital. Porter found that for patients who were judged as incapable for making informed decisions about their situation, ambulance organizational protocols mandated that paramedics could only leave a patient in the care of another appropriate professional.
For paramedics in these circumstances, the availability of an appropriate person was often found to be limited to the scarce availability of social workers or GPs. What this study reinforced was the notion that the decision-making processes involved in relation to the non-transport of patients to hospital by paramedics was considerably more complex than existing ambulance protocols accounted for.
Cheney et al (2008), sought to evaluate the overall effectiveness and safety of introducing an ambulance triage protocol that afforded paramedics the option of transporting patients directly to mental health services instead of the emergency department. Results from this study revealed that introducing such a protocol could be used by paramedics as an effective tool to screen patients with primary psychiatric conditions for other medical conditions.
Paramedics who had used the protocol were able to transport those patients not assessed as having an underlying medical condition directly to the mental health service without accessing the emergency department.
Limitations
While offering significant theoretical contributions to the field of prehospital mental health care, shortcomings in relation to these studies and the non-peer reviewed literature have been identified. For example, the literature has not been able to account for the actual decision-making processes paramedics draw upon and use when deciding to enact their mental health legislative responsibilities, nor do they offer any indications of how legislative obligations may ultimately influence, prejudice or even dictate specific clinical decision-making outcomes.
By drawing upon previous studies and literature, future research is now needed to explore how paramedics perceive and make sense of their readiness and preparedness to take on legal responsibilities in relation to prehospital mental health care, and to identify the factors that influence clinical decision-making processes in relation paramedics exercising these responsibilities.
In doing so, this will build upon and contribute to the limited studies which have sought to examine and make known the complex and often ambiguous role of paramedics in relation to prehospital mental health care. By placing prehospital mental health care into the research agenda, future research is likely to identify key areas where enhancements can be made to paramedic mental health training, and may inform the development of future ambulance resources which support and guide paramedics in their decision-making in relation to the use of mental health legislation.
As an adjunct to these issues, further advancements to the professionalization (Williams et al, 2009) of the paramedic discipline can only be benefited by increasing the theoretical and research base and creating an evidenced based discipline specific body of knowledge (Williams et al, 2009). Until this occurs, advocating for change to government policy in relation to a professional status for paramedics is likely to remain a challenging pursuit.
Conclusion
This article has shown how global reforms to mental health services have had a significant impact on how mental health emergencies are dealt with by frontline emergency workers. Furthermore, that the continuing expansion in the role of paramedics in relation to emergency mental health care has now made it necessary to generate a research base that is able to underpin claims that such reforms have resulted in improved mental health services for patients in the community setting.
More specifically, the implication for not examining the impact that the introduction of legislative responsibilities for paramedics has had on how they respond to mental health emergencies means that claims that paramedics receive adequate training and skill development which prepares them to take on these responsibilities remains unsubstantiated and lacks suitable scientific rigour.
While the literature relating to mental health and clinical decision-making in health care is vast, much of what is known is confined to the fields of medicine, nursing and psychiatry. With specific reference to paramedic clinical decision-making, the literature is much more limited, there is only a scarce amount focused on paramedic practice in relation to mental health care (Wyatt, 2003; Shaban, 2005).
The studies described herein have revealed salient factors such as intuition and prior experience as being heavily involved in effective prehospital mental health care. These studies have also consistently found that despite specific mental health training and organizational protocols and clinical guidelines, paramedics continue to perceive a lack of adequate mental health skills, competencies and tools to effectively manage mental health emergencies. This article concludes by proposing a continued warrant for further research into the field of prehospital mental health care.