Introduction

Paramedics frequently care for patients who have mental health and/or alcohol and other drug (AOD) problems, which represent a substantial part of their workload [1–3]. For instance, in the state of New South Wales in 2013, NSW Ambulance attended more than 60,000 calls classified at the call-taking stage as mental health or psychiatric [4]. However, there is limited research on how paramedics feel about providing care to patients with non-medical emergency-related mental health and/or AOD problems, and what they believe their role is or should be in this context [5]. This is an important consideration because perceptions of what practices are within, or beyond, paramedics’ scope of practice are likely to influence the nature and extent of the care provided.

The relatively small body of literature on paramedics’ perception of their role in relation to patients with non-medical emergency-related mental health and/or AOD problems provide some tentative clues. Roberts and Henderson [6] conducted a mixed method study (survey (n = 74) & 3 focus groups of paramedics; ambulance service clinical database) with South Australian Ambulance to examine workforce perspectives about attending patients with known or suspected mental illness. The results indicated that paramedics viewed their role as primarily one of transportation in this situation, they felt ill-prepared to manage and care for these patients, and needed tailored education. The authors argued that de-institutionalisation of mental health care and under-investment in community services in places like Australia for people with mental health and/or AOD problems has positioned paramedics as frontline community care providers.

A qualitative study (observations and interviews) by Prener and Lincoln [2] in the US found that urban paramedics and emergency medical technicians were frustrated by what they perceived as “filling the gaps for other health care and social services” in attending to patients with mental health and/or AOD problems. Similarly, studies have documented a perception amongst paramedics that non-medical emergency-related mental health and/or AOD presentations divert resources and attention away from the ‘real’ medical emergency work that paramedics believe should be the primary focus of their work [2, 6].

A range of initiatives have been undertaken to build the capacity of paramedics to perform extended and advanced care roles, including providing preventative care [7] and more holistic care [8]. While these efforts have had some impact on paramedics’ roles [7], they do not appear to have extended to mental health and/or AOD care. For instance, like Prener and Lincoln [2], Roberts and Henderson’s [6] study of paramedics in South Australia found that paramedics overwhelmingly (n = 73, 98.6%) reported transportation of patients to emergency care as a key part of their role when faced with mental health presentations. In part, this may be influenced by clinical practice guidelines and legislative responsibilities that sanction/encourage involuntary mental health care (and thus transportation) in instances where patients are deemed to pose an immediate threat to themselves or others [5, 9], and a lack of availability of alternative referral options for patients with mental health and/or AOD problems. However, other potential functions, such as communicating with the patient, mediation, providing treatment, or referral to services are reported less frequently [6].

Rees, Rapport and Snooks [10] conducted a constructivist meta-synthesis of 12 qualitative studies of paramedics and emergency department staffs’ perceptions about caring for patients who self-harmed. They reported that although none of the studies focused specifically on self-harm, paramedics perceived their primary role was to provide medical care and preserve life, and patients requiring medical care were considered a higher priority than those who self-harm. They also had difficulty and anxiety about the application of mental health acts in their practice, and there was a dichotomy between policies and guidelines advocating a potential for a paramedic role with patients who self-harm and paramedics’ awareness of such potential.

Several other contextual factors beyond paramedics’ individual attitudes have also been identified as potentially shaping their work practices in caring for patients with mental health and/or AOD problems. For instance, high work pressures and limited mental health training may constrain the ability of paramedics to respond to the needs of patients with these problems beyond transportation [2, 5, 9, 11–14]. Alternatively, organisational cultures in ambulance services that promote a medical emergency care focus can, potentially, reinforce the idea of responding to non-medical emergency-related mental health and/or AOD presentations as being a less important aspect of paramedics’ role [2, 6]. Furthermore, such ideas may be reinforced and/or reflect the broader stigmatisation of people with these problems [2, 15, 16].

While the small body of literature on paramedics’ perception of their role in caring for patients with non-medical emergency-related mental health and/or AOD problems provide some useful insights, there are several gaps that are worth noting. First, most empirical studies have focused on particular locations or states within a country, which limits the applicability of their findings beyond those settings. Second, few have been sensitive to differences in perceptions or experiences of paramedic role between different groups of paramedics, such as those from rural or metropolitan areas. Third, few have documented perceptions around whether paramedics feel that their scope of practice should be extended. In light of these gaps, and the need for further research on the role of paramedics in providing mental health care [5], the aims of this paper are to explore the experiences of paramedics across Australia in caring for patients with non-medical emergency-related mental health and/or AOD problems, understand their perceptions of scope of practice in caring for these patients, and ascertain if their practice should be extended to incorporate education with this cohort of patients.

Methods

The qualitative findings presented in this paper were part of a larger mixed method study involving an online survey and qualitative interviews with paramedics across Australia. The online survey examined paramedics’ attitudes toward men who presented to ambulance services with mental health and/or substance use problems; and assessed the barriers, facilitators and professional development needs of paramedics in providing support to men with these problems. A separate part of the study involved qualitative interviews with men who had presented to these services with these issues.

Results

Participant characteristics

In total, 73 paramedics, with a mean age of 43.9 years, participated (Table 1). Almost two-thirds were male. Participants worked in 6 of the 8 Australian states and territories. Just over 40% worked in metropolitan cities, while the remainder worked in regional and rural centres, and, to a lesser extent, remote areas.

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Table 1. Paramedic participants’ sociodemographic and workplace details (N = 73).

https://doi.org/10.1371/journal.pone.0208391.t001

Discussion

The aims of this paper were to examine paramedics’ experience of caring for patients with non-medical emergency-related mental health and AOD problems, ascertain their beliefs about scope of practice in caring for these patients, and establish if they believed that their practice should be extended to include an educative role with these patients. Three interconnected themes were abstracted from the data illustrating participants’ experiences and, at times, contrasting views about caring for patients with these problems.

The first theme highlighted that, in contrast to historical experiences, caring for patients with non-medical emergency-related mental health and/or AOD problems is now a routine part of paramedics’ work. This finding is consistent with those of other studies reporting that paramedics frequently care for patients with mental health and/or AOD problems and transport them to emergency departments [1–3]. Possible explanations for this situation are that the de-institutionalisation of mental health care and under-investment in community services in developed countries, such as Australia, for people with mental health and/or AOD problems have made it increasingly difficult for these individuals to access specialised care and treatment [6]. Another explanation for the increase in AOD presentations is liberalisation of the alcohol market [26], and drugs that cause greater harm are more likely to lead to an emergency call for ambulance services (e.g., methamphetamine, synthetic drugs, overdoses related to prescription opioids) [1]. A consequence of this situation is that many people with mental health and/or AOD problems turn to paramedic services for help and to transport them to emergency departments, which is an indirect way of accessing specialised services.

Another consequence of this situation is that it has led to an extension of paramedics’ routine work to include caring for and transporting patients with mental health and/or AOD problems [3]. In the present study, there was also recognition of the limitations of the current generic model of practice, whereby paramedics responded to call-outs to people with a broad spectrum of medical, mental health and/or AODs problems. There were calls for the introduction of alternative models of practice, including a mental health and/or AOD specific model, which may have particular merit in jurisdictions experiencing high demand for this type of service, such as in metropolitan centres. A proof of concept of this type of model was undertaken in Sydney, incorporating an outreach team comprising a paramedic and a mental health nurse [27]. Initial findings indicated that almost 70% of patients with mental health and/or AOD problems were not transported to emergency departments, just over 45% were brought directly to a mental health facility, and almost 22% were not transported. A variant of this type of model is the use of mental health clinicians working in call-taking and dispatch. Limitations of this type of model employing mental health clinicians, however, are it may result in under-utilisation of these personnel and reinforce a perception among some paramedics that dealing with patients with non-medical emergency-related mental health and/or AOD problems is not within their scope of practice.

The second theme indicated that there were contrasting perspectives about scope of practice in caring for patients with non-medical emergency-related mental health and/or AOD problems. Some paramedics perceived their scope of practice as incorporating the care of patients with these problems in their day-to-day practice, and these individuals were as deserving of care as those with medical conditions. Family and personal experience, and the influence of training experiences with professional role models (educational and clinical), contributed to this broader perception of their scope of practice. In contrast, other participants considered that caring for individuals with these problems was beyond their scope of practice, and that these individuals were difficult to deal with and less deserving of paramedic care than patients with acute medical problems. One explanation for this finding is public stigma towards people with mental health and/or AOD problems contributed to paramedics’ reluctance to broaden their scope of practice in this context. Paramedics reside in the broader community in which they work, and their attitudes are reinforced by, and reflective of, such communities, where public stigmatisation of people with people with mental health and/or AOD problems occurs routinely [2, 15, 16].

Another explanation for this finding is that inadequate undergraduate and in-service mental health education and training constrained paramedics’ confidence, ability and willingness to engage therapeutically with patients with mental health and/or AOD problems [2, 5, 9, 11–14]. A third explanation is high workloads and pressure from paramedic services to be available to respond to waiting cases precluded a desire to broaden their existing scope of practice.

The third theme highlighted that there were competing perspectives about whether paramedics’ scope of practice should be extended to incorporate education to patients with non-medical emergency-related mental health and/or AOD problems, and that there should be increased options for alternative treatment pathways for these patients. One group of participants emphasised that their practice should be extended to encompass education in this circumstance. Extending their scope of practice could be interpreted as an acknowledgment, in this and other studies [1–3], that an increasing proportion of paramedics’ day-to-day practice involves caring for patients with these problems. Therefore, extending their practice in this context could be interpreted as a natural extension of paramedics’ existing educative role with patients with medical problems who are not transported to hospital. In light of the level of unmet needs of people with non-medical emergency-related mental health and/or AOD problems in the community, there may also be scope to introduce and evaluate rigorously a second alternative model of practice, this time incorporating an adapted form of existing community paramedicine practice.

Community paramedicine, originally introduced in the US, but also operating now in other countries, such as Canada, the UK and Australia, is where paramedics (mostly) are trained to provide assessments and interventions in the community but normally do not provide acute transport [28, 29]. Generally, community paramedicine programs focus on social support, wellness, prevention, care of people with chronic illness and increasing medical adherence [28]. Within the context of the present study, there is scope to broaden community paramedicine roles to include people with non-medical emergency-related mental health and/or AOD problems who do not require transportation to emergency departments, mental health or AOD services. Instead, they would be managed in their homes, followed up and/or referred to, for example, a GP, mental health or AOD service.

Another group of participants in the present study indicated that their existing emergency medical care-oriented scope of practice should be maintained and not extended into an educational role with patients with non-medical emergency-related mental health and/or AOD problems. This finding is consistent with those of other studies, where paramedics claim that their primary role with patients with these problems is to transport them safely to hospital emergency care departments [2, 6]. Lack of access to, and availability of, specialised care and treatment services for people with non-medical emergency-related mental health and/or AOD problems, means that paramedics have to meet this shortfall, and is one explanation for their preference to maintain their existing medical-oriented role.

Roggenkamp et al. [3], in an analysis of mental health-related presentations to emergency medical services in the state of Victoria, Australia, reported that one-in-ten presentations to these services were mental health-related and, of these, most were transported without any treatment from paramedics. The authors highlighted the need to provide alternative models of care which improved access to specialised mental health services for these patients. Lack of service access, along with stigma, can reinforce a perception that having to deal with patients with these problems diverts resources and attention from, what paramedics believe should be the main focus of their work, caring for patients with acute medical problems [2, 30]. Furthermore, and in line with the findings of the present study, paramedic service policies and clinical practice guidelines, which are informed by legislation that enables involuntary mental health care and transportation of patients considered an immediate threat to themselves or others [5, 9], may also reinforce paramedics’ perception that their role in this situation is primarily to provide transportation.

Other explanations for maintaining their current emergency medical-oriented scope of practice are, overall, a lack of undergraduate and in-service education and training about the care of patients with mental health and/or AOD problems, and ambulance organisational cultures and discourses that reinforce a medically-oriented primary focus [2, 6, 30]. Perpetuating this focus could also be interpreted as a means of enhancing the professionalisation of paramedic services, something that is less likely to be achieved by broadening their scope of practice to include an educative and non-transportation role with patients with mental health and AOD problems. Paradoxically, broadening their scope of practice to be able to independently manage patients with non-medical emergency-related mental health and/or AOD problems in their homes (instead of primarily being a transportation service), could be conceived as a way of increasing the professionalisation of paramedic services.

Supporting information

Acknowledgments

We are grateful to the paramedics who participated in the study for openly sharing their views and experiences. We are also grateful to the following ambulance service representatives for their valuable contribution to the project: Kevin McLaughlin and Dr. Rosemary Carney, Ambulance Service of New South Wales; Alex Wilson, Ambulance Tasmania; Melanie Thorrowgood, South Australia Ambulance Service; Michael McKay and Sue-Ellen Skinner, St John Ambulance Northern Territory. Our thanks also to Emma Sandral, Turning Point/Eastern Health, for her contribution to data coding. Finally, our sincere thanks to the Project Steering Committee members for their valuable guidance in the project.