Journal of Psychosomatic Research 78 (2015) 529535

Contents lists available at ScienceDirect

Journal of Psychosomatic Research

Review

Perceptions of paramedics and emergency staff about the care they

provide to people who self-harm: Constructivist metasynthesis of the
qualitative literature
Nigel Rees , Frances Rapport, Helen Snooks
Swansea University, Pre Hospital Emergency Research Unit, Welsh Ambulance Services NHS Trust, United Kingdom

a r t i c l e

i n f o

Article history:
Received 22 December 2014
Received in revised form 26 February 2015
Accepted 9 March 2015
Keywords:
Ambulance
Care
Emergency Self Harm Paramedic
Pre-hospital

a b s t r a c t
Objective: Presentations of self-harm to paramedic and emergency staff are increasing, and despite being the rst
professionals encountered, patients who self-harm report the quality of care and attitudes from these staff are
unsatisfactory. Understanding this care may provide opportunities to improve services. The aim of this study is to
enhance knowledge building and theory generation in order to develop practice and policy through a metasynthesis
of qualitative research relating to perceptions of paramedic and emergency care for people who self-harm.
Methods: The metasynthesis draws on Evolved Grounded Theory Methodology (EGTM). A search was undertaken
of CINAHL, MEDLINE, OVID and Psych INFO, and grey literature. Subject headings of self-harm were
used alongside key words suicide, paramedic emergency, overdose, pre-hospital mental health, ambulance,
perceptions of care, emergency.
Results: A total of 1103 papers were retrieved; 12 were nally included. No papers investigated paramedic care for
self-harm. The following metaphors emerged: (a) frustration, futility and legitimacy of care; (b) rst contact in
the pre-hospital environment: talking, immediate and lasting implications of the moral agent; (c) decision
making in self-harm: balancing legislation, risk and autonomy; (d) paramedics' perceptions: harnessing professionalism and opportunities to contribute to the care of self-harm.
Conclusion: Paramedics are often the rst health professional contact following self-harm, yet limited qualitative
literature has explored this encounter. Metaphors revealed in this paper highlight challenges in decision making
and legislation, also opportunities to improve care through professionalization and tailored education.
2015 Elsevier Inc. All rights reserved.

Introduction
The UK has one of the highest rates of self-harm in Europe at 400 per
100,000 of population [1], and it is among the ve top causes of acute
hospital admissions [2]. Yet this only represents a minority of those
who self-harm because most inict harm without the need for medical
intervention [3]; some studies nd only 1020% present to hospital [4,
5]. Service users report that care and attitudes from health staff are
unsatisfactory [3,68], and many avoid services [2]. Although paramedics and emergency staff are often the rst health professionals in
contact with those who self-harm, their contribution to care is under
researched.
A systematic review of the quantitative literature has been conducted
[9], and the following was found: training, policies and guidelines
improved staff knowledge and condence in caring for people who
self-harm, but access to such training is limited. Few departmental
Corresponding author at: Pre-hospital Emergency Research Unit, Welsh Ambulance
Service NHS Trust, Lansdowne Hospital, Sanatorium Road, Cardiff CF11 8UL, United
Kingdom.
E-mail address: nigel.rees5@wales.nhs.uk (N. Rees).

http://dx.doi.org/10.1016/j.jpsychores.2015.03.007
0022-3999/ 2015 Elsevier Inc. All rights reserved.

procedures to guide staff were also reported, and staff in acute settings
exhibited increased feelings of negativity, becoming less positive closer
to front line care. Recent studies reported positive attitudes amongst
emergency staff. Insights from qualitative research may therefore help
to place these ndings within a meaningful broader social context. The
aim of this research is to enhance knowledge building and theory generation in order to develop practice and policy through a metasynthesis of
qualitative research relating to perceptions of paramedic and emergency
care for people who self-harm.
Methodology
The epistemological basis of the study draws on the grounded theory
methodology (GTM) [10] and uses Noblit and Hare's (1988) procedural
guidelines [11], which were inspired by Finfgeld [12] and FinfgeldConnett [13]. A constructivist paradigm of inquiry is followed, where
the researcher is a passionate participant as facilitator of multi-voice
reconstruction (Lincoln & Guba 2005 p. 196) [14]. Such a position
strengthens the GTM by viewing data as narrative constructions, focusing on subjective meaning, and acknowledging that ndings are only
one possible interpretation of reality [15].

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N. Rees et al. / Journal of Psychosomatic Research 78 (2015) 529535

Unlike synthesis of quantitative research, qualitative metasynthesis

does not involve data aggregation or secondary analysis of raw data,
nor is it a type of meta-analysis [13]. It is quite different from accumulative logic averaging across studies. Rather, the goal is interpretive [16].
Whilst there are no universally agreed procedures for synthesising qualitative research [17] many methodologies have been recommended [11,
1820]. Sandelowski et al. (p. 366) [20], for example, dene qualitative
metasynthesis as
theories, grand narratives, generalizations, or interpretive translations produced from the integration or comparison of ndings from
qualitative studies.
When presenting metasynthesis research, validity is based on trustworthiness [21], which can be established through transparent data
collection, extraction, and analysis methods, clearly reported [13];
these are presented below. The rst author has been a practising paramedic for twenty 3 years, which is important as Noblit and Hare [11]
hold that metasynthesis reveals as much about the perspective of
the synthesiser as it does about the substance of the synthesis. The
audit trail in this study recognised the constructivist paradigm, the
researcher's past experiences, and is clear about putting to one side
the researcher's personal assumptions or subjective opinion during
both data collection and analysis. Finfgeld-Connett [13] points to the triangulation that occurs in metasynthesis through ndings from multiple
qualitative investigations comprising of multiple frameworks. In the
present study, the sample of papers included papers employing ethnography, grounded theory, hermeneutics and other methodologies.
Noblit and Hare [11] suggest synthesis is achieved by translation
which entails examining key concepts in relation to others in the original study and across studies; Noblit and Hare's (pp. 2629) [11] seven
steps of metasynthesis were followed.
Getting started (the search)
A search was undertaken of the databases CINAHL, MEDLINE,
OVID and Psych INFO. A broad search strategy was chosen that used
the subject heading of self-harm, and the key words included in the subheadings are as follows: suicide, paramedic emergency, overdose,
pre-hospital mental health, ambulance, perceptions of care and emergency. Manual searches of academic journals, grey literature, policy documents, procedures, clinical guidelines and government legislation
were conducted.
Conrming initial interest
Given limited paramedic and pre-hospital literature, all articles with
a paramedic focus were selected for review and manually scanned for
relevance and eligibility. The following criteria were used to select studies
for analysis:
a. The expressed a priori purpose of the study was to examine paramedic or emergency care for self-harm
or
b. A focus on education for paramedics
or
c. Studies including decision making in relation to mental health in the
pre-hospital environment
and
d. Data were gathered from paramedics or emergency care providers

Reading studies and extracting data

In order to eliminate publications that were clearly not reports
of qualitative research relevant to paramedics' and emergency staff
perceptions of care for people who self-harm, a review of each citation
title and abstract was conducted. Each study was subjected to a quality
critique form, based on Burns's [22].
Determining how studies are related
The concept-indicator model advocated by Strauss [23] was used in
order to identify common themes. Each paper was read; ndings were
highlighted and compared for similarities, differences and questions
regarding emergent phenomena.
Translating studies
An indicator refers to a word, phrase or sentence, a concept is a
label associated with that indicator. The concept-indicator model relies
on constant comparisons in the text. Indicators were grouped together
under concept headings, when another indicator did not generate new
insights to a concept, it was deemed theoretically saturated and thus
well grounded.
Synthesising translations
It was the intention to review studies that examined perceptions
of paramedic and emergency care personnel for those who self-harm;
however, no such studies were found to have been published. Therefore,
synthesis drew on a wide body of literature, which involved conceptualisations within studies and across contexts. Fresh insight into paramedics' and emergency staff perceptions of care for people who selfharm therefore emerged, along with its line of argument.
Expressing the synthesis
Theoretically saturated concepts were woven back together into the
narrative translation presented in results.
Results
A total of 734 papers were retrieved; a nal 12 met the inclusion criteria Fig. 1. No studies
were identied that specically studied paramedic care for self-harm. However, hospital
studies with emergency doctors and nurses were found that explored self-harm care.
Self-harm was also considered in studies exploring paramedic or emergency staff care
for patients within the wider context of mental health problems. Studies included are
presented in Table 1. The quality of studies included one low, six moderate and ve high.
The studies methodologies included ethnography, ethnomethodological, grounded theory,
narrative accounts, hermeneutics and thematic analysis. The methods included structured,
semi-structured and in-depth interviews, observational eld work and surveys. Participants and practice settings included emergency department (ED) and medical admissions
doctors and nurses, paramedics and pre-hospital nurses. Studies were carried out in the
UK, Sweden, USA, France and Australia.
Four interrelated metaphors emerged capturing perceptions of paramedic and emergency care personnel for people with mental problems including those who self-harm:
(a) frustration, futility and legitimacy of care; (b) rst contact in the pre-hospital environment: talking, immediate and lasting implications of the moral agent; (c) decision making
in self-harm: balancing legislation, risk and autonomy; (d) paramedics' perceptions:
harnessing professionalism and opportunities to contribute to the care of self-harm.
Frustration, futility and legitimacy of care
Caring for people who self-harm evokes experiences of frustration in practice, with a
sense of insubstantiality of interventions. This was articulated by a doctor in the study of
Anderson et al. [25] who said,
When you've got a department or ward full of severe athsma, meningitis,etc and
then you've got a couple of young girls who have taken a cocktail of things . . . They
cannot . . . with our current resources . . . be looked after in the same way.

and
e. The studies were conducted using qualitative methods.

Neither asthma nor meningitis is dealt with in the same way. Self-harm can be more
damaging to health than these conditions, yet it appears to be of less importance, and

Identification

N. Rees et al. / Journal of Psychosomatic Research 78 (2015) 529535

Records identified through

database searching
n=1103

531

Records identified through other sources n=34

Total number of citations identified n=1137

Screening

Full-text articles assessed

for eligibility n=26

Included

Records screened by title

and abstract n=734

Eligibility

Citations after duplicates removed n=734

Records excluded n=708

Reasons for exclusion:

No relevance to emergency care n= 631
No focus on perceptions of care n= 52
Not relevant participants n=12
Unable to retrieve n=13

Studies included in review

n= 12

Full-text articles excluded n= 14

Quantitative methodologies: n=5

Specialist mental health workers
included n=3
Unable to retrieve n=2
No relevance to pre hospital care n=4

Fig. 1. Moher et al. [24]. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.

there is a nuanced rationing of time and care. This was also found in Hopkins [26] where
one nurse participant said,
Sometimes it can be frustrating if it is busy because you feel you can't give patients the
time that is needed.

their role as preservers of life, and self-harm being viewed as the opposite, and thus
challenging the reasons they came into healthcare. One ED nurse reected,
I don't think they realise how potentially life potentially life threatening it is.
Anderson et al. [25] found the basis of frustration was the difcult feelings that whatever they do, nothing seems to work. Articulated by another nurse:

One girl often takes a lot of Paracetamol. When she comes in she has Parvolex treatment every timeyou know, the antidote. I mean, you are just doing the same thing
time and time again . . . working in here, I have become cynicalyou just get sick of it.
The studies in this metasynthesis presented a division between the deliberate nature
of self-harm and acute medical conditions, along with a distinction being drawn between
legitimate and illegitimate needs for care, with the former being viewed as having a greater
entitlement to care. This was evident in comments from the eld work of Nurok and
Henckes [27] in Paris and New York with pre-hospital emergency services. They observed
how social values and certain patient attributes inuenced how patients traverse medical
systems; calls were treated more slowly by paramedics on the assumption of legitimacy.
The following case was observed:
A call for a patient living in a housing project known to them, the team complains
about being given another lousy case and starts driving to the call without much conviction. On arrival they nd a patient almost unconscious. Upon seeing this, the paramedics pick up their pace rapidly administering Naloxone (a drug that reverses the
effects of overdose). The patient regains consciousness and starts breathing normally.
The team recognizes that the patient has probably overdosed on drugs and she is placed
in the ambulance and transferred to the hospital without any display of empathy.
Nurok and Henckes [27] recognised three phases: At rst the paramedics make a judgment of low social value and consequently show little interest. On arrival they recognize
the patient is in extremis, which they can treat, the case then takes on higher value. Once
lifesaving treatment has been successful, they focus on the overdose, which leads to a
devaluation of the case, demonstrated by a lack of empathy toward the patient. In these
three phases, they argue a transaction occurs between judgments about the patient as a
person and the technical dimension of enjoyable work.
Anderson et al. [25] found that nurses and doctors also maintained moral standards
toward the value of a person's life. The risky behaviour of self-harm was seen as a potential
waste of life, with young people having no respect for the dangers. Nurses and doctors saw

I nd it frustrating that I can't help . . . I know of kids that have been heremy
colleagues have said that have been regular attendersself-harmit's frustrating
I mean that is the frustrating part of it.
Such futility of care was also found in the work of Hopkins [26], where a nurse said,
Working in here, I have become cynicalyou just get sick of it.

First contact in the pre-hospital environment: the value of talking, immediate and lasting
implications of the moral agent
In the emergency department (ED), Anderson [25] found nurses and doctors wanted
to engage and listen to people who self-harm; however, the environment posed a nontherapeutic option, as articulated by one doctor,
This department isn't conducive to being able to talk to them in private.you have got
different priorities.
In contrast, Roberts and Henderson [28] conducted a study of the perceptions of
paramedics regarding their role, educational training and organisational culture when
attending suspected or known cases of mental illness. One participant paramedic noted,
I was criticised for being a social worker because I would actually sit down and talk to
them. I think it really depends on how the paramedic and society stereotypes
individuals.
The paramedic environment poses a stark contrast, with opportunities to talk in private
at the scene, or in the ambulance. Campeau [29] highlights this, nding how in contrast to
other healthcare providers, paramedics do not have predetermined work areas but accept

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N. Rees et al. / Journal of Psychosomatic Research 78 (2015) 529535

Table 1
Included studies
Study

Design

Method of data
collection

Method of data
analysis

Setting/clinician

Themes

Quality

Anderson
et al.
(2003)

GTM

Semi-structured
interview

GTM Charmaz (1995)

version

Experiences of frustration in practice

Strategies for relating to young people

Mod

Hopkins
(2002)

Ethnography

Observation and
semi-structured
interviews

Descriptive analysis
constant comparison
(Hammersley and
Atkinson 1983)

Nurses and doctors's E/D

paediatric medicine and
child and adolescent
mental health
Nurses on medical
admissions unit

The busy quality of such wards (busyness)

How this group of clients impede the busy quality
Strategies nurses use to cope with the difculties

Mod

Interviews

Shaban
(2005a)

Ethnographic and
ethnomethodological

Ethnographic and
discourse analysis.

Squires
and
Mason
(2004)
Machen
et al.
(2007)

Thematic analysis

Focus groups

Mixed methods

Qualitative
questionnaire
Semi-structured
interviews and focus
groups

Interpretive approach
(Denzin and Lincoln,
1998).

Nurses and paramedics

Cox et al.
(2006)

Qualitative focus
group interviews

Focus group
interviews

Content analysis
(Bowling, 2002).

Paramedics

Porter
et al.
(2007)

A qualitative study in
one large ambulance
service trust used
focus groups
Thematic analysis

Focus group
interviews

Thematic analysis

Paramedics
Pre-Hospital

Clinical database, a
survey and three
focus groups

Thematic analysis

Pre-Hospital
Paramedics

Grounded theory.

Interviews

Constant comparison

Ahl and
Nystrm
(2012)

Hermeneutic
philosophy of
Gadamer (1997)

In-depth interviews

Nurok and
Henckes
(2009)

Grounded theory

Observational
eldwork

EMS Canada Paramedics A theory was generated that describes how

from rural, suburban and paramedics coordinate key specic social processes
to establish space control at the scene.
urban settings
Five dialectic themes: Transportation or care,
acceptance or rejection, participation or exclusion,
giving oneself over or calling the care in question,
the emergency wardrelief or negative contrast
Pre-Hospital Paramedics Emergency work is shaped by a wide array of values
in New York and Paris
that are not identically prioritised and that compete
with each other in a framework that called a
uctuating economy.
Themes:

Roberts
and
Henderson
(2009)
Campeau
(2009)

Paramedics
Pre-hospital

Narrative explaining how the stories medics tell play Low

an important part in their tactical engagement with
the myriad relationships that structure their daily
lives in the organisation.
High
Categories of the mentally ill
Role of the paramedic Need for training Legislative,
policy and clinical practice conict
A mismatch between policy and practice in relation Mod
to non-conveyance decisions.

Tangherlini Narrative account

(2000)

Document review and

semi-structured
interviews
Thematic analysis

Constant comparison

Paramedics
Pre-Hospital
Pre-hospital
Paramedics

Patients were enthusiastic about being cared for at

home.
Involvement was a positive for staff.
Staff felt condent in managing calls effectively due
to knowledge and skills, and the quality of patient
care had been improved. Experienced increased job
satisfaction and skills development.
Perceptions of drivers for change; duty of care;
perceptions of professional image; role expansion;
preparedness for practice
Need to cover their backs in non-conveyance cases.
Crew members did not seem to be concerned about
the situation.
Role of paramedics managing mental illness.
Education and training, organisational culture and
interdisciplinary relationships.

the location where they nd a patient as their working area. Campeau [29] produced a
grounded theory explaining how scene management is a dynamic social activity which included sustaining social processes and antecedents of establishing a safety zone, trading off
patient care and scene safety. These elements can be observed in other studies relating to
paramedics and mental health, in Shaban (2005a) [30] one paramedic said:
I would have to say in my view most psychiatric patients I think would have been
identied loosely under a dreadful term as mad people and the police would have
been called.

There is a fear of mental stigma, because I don't need to bother, they can either call the
police, treat them as dangerous, and they don't particularly want to know.
The antecedents of establishing a safety zone and trading off patient care and scene
safety clearly come from a stated stigma toward mental health, and the perceived danger

Mod

Mod

Mod

High

High

High

High

Social value
Technical value: the priority of action
Medical and surgical value
Intellectual value: the attraction of complexity
Heroic value: the courage to fail
Perfection and competence value

mitigated by the social process of reducing uncertainty through social relations, and in this
case involvement of the police.
Ahl and Nystrm [31] found that the initial encounter with a pre-hospital care provider is of vital importance, with the potential for satisfaction as well as dissatisfaction with
care and outcomes. Participants initially regarded an ambulance as a means of transport
rather than a place for care, when treatment was felt to delay care, frustration and anger
emerged, with a patient telling,
I became frustrated . . . instead of taking me directly to the hospital they started xing
thing . . . so I told them to hurry up.
This illuminates the notion that the initial impression of pre-hospital care and caring
relations contains two different possibilities: acceptance or rejection. This is important in
self-harm, recognizing that the rst point of contact with those who self-harm is paramount, and one which will have a bearing on future acceptance of care and can sometimes
lead to avoiding emergency services (RCP 2010) [2].

N. Rees et al. / Journal of Psychosomatic Research 78 (2015) 529535

533

Feelings of safety often emerged in Ahl and Nystrm's paper [31], which highlighted
that on arrival of the ambulance staffed by pre-hospital nurses, a secure basis for trust
and condence was created. One pre-hospital nurse said,

There are ten of us in the room and obviously we have all got different ideas if the
patient meets the criteria.

Now you are my patient and to me you are the most important person in my life at the
moment as a caregiver.

Paramedic care for people who self-harm often involves on the spot decisions in
emergency situations and is clearly challenging. Wyatt [41] explored professional judgments made by paramedics faced with such unique and non-routine situations, nding
decision making to be associated with development of tacit knowledge. The relationship
of tacit knowledge with judgments made as part of expert practice was considered, nding
that paramedics utilised multiple sources of information when making judgments, and a rich
interplay of factors was revealed contributing to the development of judgment making,
including experience within a particular context, along with reversion to tried and trusted
rules or guidelines, and the capacity to play a hunch and trust in judgment.

This individual-oriented attitude of pre-hospital care was found to be in contrast to

other areas of the health care sector, with a patient saying,
In the ambulance I am the only one. At the hospital there are several of us.
This was the inverse to the frustration noted by a nurse in Anderson's work [25],
which stated, you feel you can't give patients the time that is needed because of competing demands.
Decision making in self-harm: balancing legislation, risk and autonomy
Shaban [30] examined paramedic accounts and constructs of judgment and decision
making of mental health patients. They found such patients to be categorised as presenting with violent, suicidal, drug-induced, or overtly psychotic behaviour. This is of importance because whilst this paper explores self-harm, the complexities of mental health
legislation and making the distinction between such mental health presentations appear
to be of concern to paramedics. UK guidelines call for support for paramedics [32,33],
which may include access to approved doctors and social workers when assessing mental
capacity and application of the Mental Capacities Act (MCA) [34] and Mental Health Act
[35]. However, this may not be happening in practice. Porter et al. [36] found in interviews
with paramedics that when patients declined to attend hospital, they struggled to get support. Social workers were so thin on the ground said one paramedic that trying to get hold
of one was a complete waste of time.
As for GPs,
The doctor doesn't want to know, usually. or we'll get in touch with the police If it's in
the patient's house, the police won't come out to the house, they won't come across
the threshold, very often.
Porter et al. [36] did not specically explore self-harm; however, insights into decision
making and mental capacity are of importance and were interpreted in the current paper
to articulate the challenge in dealing with people self-harm and refuse care. Paramedics in
the UK will involve police, social workers or doctors in attempts to apply the MHA [35].
Section 136 of the UK MHA [35] allows for a patient to be detained for their own safety
when in a public place; however, it is often inappropriately used in a patients home,
hence the tension that police will not come across the threshold. This tension was also
articulated by a paramedic in Shaban [30]:
I think both police and ambulance are in a very difcult position when the legalisation
asks them to make value judgment calls.
Roberts and Henderson [28] acknowledge that although the police no longer routinely
attend in mental illness cases in Australia, paramedics still call for their support in difcult
cases. Luck and Towsend [37] reported a case in Australia which highlights challenges the
police also face in dealing with self-harm. They attended a potentially suicidal man sitting
in a van with a vacuum hose from his exhaust pipe into his window. After talking with the
man and making inquiries, they assessed he was not at current risk of self-harm but was
rational and coherent and did not appear to be mentally ill. The man completed suicide
later that day in his car via carbon monoxide poisoning. The deceased's partner sued,
alleging the police were negligent and breeched their duty of care by not apprehending
him under s10 of the Mental Health Act 1986. The court decided in Stuart v KirklandVeenstra [2009] HCA 15 that a duty of care should not be imposed as the police ofcers
did not have the requisite control over the risk of harm to the deceased (in Luck and
Towsend [37]).
Porter et al. [36] also found a picture of anxiety and uncertainty about duty of care in
ambulance crews, exhibited in the following comments:

Paramedics' perceptions: harnessing professionalism and opportunities to contribute to the

care of self-harm
Studies of paramedics' perceptions of care have explored areas including expansion of
practice and myocardial infarction (MI) care [42,43]. One paramedic interviewed by Cox
et al. [42] perceived other healthcare workers to be unaware of paramedics' professional
responsibilities, telling how the general ward nurse and general ward doctor, I don't
think they completely understand what we do. Despite this, such opportunities are
being captured to improve health through a whole systems approach in other areas of
medicine. However, this opportunity is often overlooked, evident in Conlon and O'Tuathail's
paper [44] where it is argued that
nursing services are at the core of the ED, and are usually the rst healthcare professionals with whom a self harm patient comes into contact, providing triage, rst aid
and psychological support.
Whilst this might be correct, the health professional that gives care in the immediate
aftermath of self-harm is the paramedic. Shaban [40] recognises such an opportunity,
stating that
the roles of paramedics and contributions they can make to the care of the mentally ill
in the wider continuum of health care have not been fully recognised.
Tangherlini [45] noted that part of the working day of paramedics consisted of telling
stories about emergency responses. They found nurses and medics engaged in a bitter turf
war over the treatment of patients. One paramedic said, Nurses question the training and
abilities of medics, while medics deride the competence of nurses. Paramedics' perceptions of their care are thus vital. Whilst no studies were found on self-harm, studies in
other areas identify a commitment to development, based on the quality of the evidence,
ethical considerations and the unique opportunity to provide very early treatment [42,43].
The most common concern that emerged in Cox et al. [42] was lack of ownership, participants believed new procedures had been imposed without involving front line staff.
Some paramedics felt they were being used to achieve targets, and their views were
regarded as unimportant by policy makers. Squires and Mason 46] similarly reported
lack of ownership as a common nding in their study of attitudes to developing alternative
ambulance response schemes, which could also act as a barrier to change.
Paramedics identied attending to life-threatening conditions their rst priority,
dealing with the consequences of behaviour such as managing an overdose or physical
trauma, underlying mental illness was felt to be outside their skill level, as illustrated in
the paramedic quotes in Roberts and Henderson [28]:
Role of paramedic: to deal with any medical aspect of treatment to a patient who may
also have a mental illness Presentation of overdose, management of overdose,
management of any injury/self harm. Paramedics should not be for detention or
psychiatric counselling.
The paramedics' safety was vital, especially when dealing with unpredictable
behaviour:

If they say, I'm not going, we have no power to take them.We'd be done for
assault.Either way, you're screwed, you are.At the end of the day, they have a right,
their own rights, to refuse. Once they do, it's a mineeld for us, then.

I think safety is of paramount concern with mental illness, possibly more so than with
other complaints and certainly your preparation and awareness of potential or unpredictable situations is heightened when attending a case with mental health issues.

All of the studies surrounding paramedic management of mental health emergencies

are from Australia [28,30,3840]; however, there are signicant differences in paramedic
education and legislation. Despite this, there is similar detail of confusion revealed by
paramedics in Shaban [30]:

Paramedics felt the need to increase understanding and knowledge of different mental illnesses, treatment regimens available and focus training on what can be achieved in
the pre-hospital environment:

We are probably under equipped in so far as what we are doing under the Mental
Health Act is putting us into a legal realm as such, as we are grabbing people under
the Act, we may not do well if things actually went court.

Sessions available on specic mental health diseases and symptoms/management.

More information on risk assessment of suicide/aggression. Information on negotiation
with patient, while assessing to reduce the need for SAPOL section 23 [legal detention].

Whilst the MCA (2005) [34] and MHA [35] are explicit in their direction; however,
they still require enactment and interpretation to a given situation. Porter et al. [36]
found confusion of ambulance staff over the process of deciding whether or not someone
had the capacity to make the decision to refuse transport and treatment and problems
with its interpretation. One paramedic said,

Roberts and Henderson [28] argued that limited training, time constraints, frequent
yers and a perception of limited treatment options inuences the value placed on
treatment of mentally ill patients. Paramedics felt that they were lling in the gaps in
providing services for people that an under-resourced and under-funded mental health
system struggle to provide.

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N. Rees et al. / Journal of Psychosomatic Research 78 (2015) 529535

Discussion
Of those patients seeking health care services following self-harm,
many acknowledge negative experiences, hostile staff behaviour and
lack of staff knowledge [3,6,8]. This paper sought to present ndings
from a metasynthesis of qualitative research relating to perceptions of
paramedic and emergency care personnel for people who self-harm.
However, no qualitative papers specically investigated paramedic
care for self-harm. This may be inuenced by challenges in conducting
qualitative research in pre-hospital settings, as highlighted by Roberts
et al. [47]. They found such barriers to include ethical implications surrounding emergent, collaborative and participant-driven nature of
qualitative research, along with the need to assure research does not
impinge on staff time and workload. Despite this, the present study
has explored emerging concepts and theory from wider contextual
literature and synthesised them into a bigger whole in the narrative
form. Whilst rich descriptions that illuminate themes in the original
studies are lost, the metasynthesis offers a new story that identies
commonalities and metaphors across emergency care contexts and
cultures in the care of those who self-harm.
It emerged that emergency care professionals saw themselves as
preservers of life, and self-harm was counter to such professional motives. There was also a distinction made between legitimate and illegitimate needs for care, with medical cases taking a higher priority than
those who self-harm. This is also felt by patients who recalled being
told they were wasting time and resources [7]. Cook et al. [48] argued
that many self-harm patients nd themselves ignored by health professionals, not just because of negative attitudes toward them but also because they are perceived as difcult to deal with. This distinction may
inuence the rst contact with a patient who self-harms, with the potential for positive and negative outcomes, giving for a complex encounter, which involves moral decision making.
Paramedics in Roberts and Henderson's paper [28] felt criticised
for talking to patients. Despite this, assessment in which the views of
patients' who self-harm are taken seriously participate in decisions
about their care and treatment, are highly rated [7]. Above all, people
who self-harm want to be seen by empathetic health professionals
who are able to listen, be supportive and not judgemental [2,49,50].
Policy and guidelines advocate that ambulance staff should have
access to crisis resolution teams, approved doctors and social workers
regarding the assessment for those who self-harm [32,33,50]. However,
the reality is that paramedics crews nd difculties in decision making
around mental health legislation [30,36]. The rights of personal autonomy
for those who self-harm in the UK are enshrined in the MCA [34]. Despite
this, paramedics report anxieties over mental capacity [28,30,36].
Paramedic's likewise report difculties and anxieties application of the
MHA [35,28,30,36] even in Australia where paramedics have powers to
detain under their MHA [30]. Enactment of MCA [34] and MHA [35] can
therefore lead to a switch from respecting a patient's autonomy, to a
more paternalistic stance of acting in the patient's best interest. This has
implication for future care, as RCP [2] found that patients had avoided services for fear of being detained under the MHA [35] as the person's actions
might bring them to the attention of the police and to a place of safety.
Policy and guidelines highlight the professional responsibilities and
clinical opportunities of paramedics in the care of people who selfharm [6,32,33], and understanding the perceptions of paramedics
were deemed vital to harnessing this opportunity. There was a perception among paramedics' that healthcare workers were unaware of such
potential. However, such a lack of insight of the potential contribution of
paramedics in self-harm care maybe because paramedics only gained
professional registration in the UK 2001 [51]. Whilst the professional
responsibilities and clinical opportunities of paramedics are slowly
being recognised in managing self-harm, there appears to be fragility
to this recognition. Some paramedics perceive their primary role as
transportation, and attending to life-threatening conditions their rst
priority; mental health was viewed as a secondary consideration. This

is a signicant nding, as reconciling this position in light of current

and future policy and innovation, and the professional journey that
paramedics are undergoing needs further consideration.
The technical elements of physical care appear to take on a higher
value than dealing empathetically with the patient, and it was revealed
that this relates to the transaction of judgments made about the patient as
a person and legitimacy of care versus the technical dimensions. Future
policy and education would benet from recognising the perceived
primary role of paramedics in dealing with the physical consequences
of self-harm. Despite this, in Kilner [52], mental health education was
recognised to be of greater priority by paramedics than trauma and resuscitation. This is echoed by Shaban [30], and specically risk assessment of
suicide [28]. The content of such education may include patient centeredness, caring, empathic, valuing life, professionalism, non-judgemental
and non-discriminatory attributes, which also ranked in the top six
desirable qualities in the paramedic in a study by Kilner [51] and are
the very attributes suggested by policy and guidelines for self-harm
[2,53].
Limitations
This study employed systematic methods to identify and appraise
published research and has found limited literature related to paramedic
and emergency care. It therefore relied on synthesis of ndings across
practice and professional contexts. There was a possibility that as the
main researcher was a paramedic, interpretations were made through
a paramedic lens and might have an effect on the ndings. Despite
this, we believe we have been transparent about our methods and upheld
trustworthiness of data in order to enable researchers to follow our audit
trail.
Conclusion
A limited number of investigations have enquired about the patient's
perspective of self-harm care, yet despite dissatisfaction with this care,
few have sought to reveal the perspective of caregivers, and none
have investigated paramedic care. Whilst methods have been rigorously
applied, this study has relied on constructivist interpretations and translations of paramedic studies from a wide range of practice contexts.
It has revealed self-harm to be a common yet complex professional,
clinical and social interaction. The metaphors this paper has highlighted
reveal potential areas for development for paramedic and emergency
care, and this work will be used to evolve our understanding of potential
contributions to the care for those who self-harm and to inform practice,
including a tailored educational intervention for paramedics.
Acknowledgments
This study is supported by Swansea University, the Pre Hospital
Emergency Research Unit, Welsh Ambulance Services NHS Trust and
FALCK Foundation Research Grant. No conicts of interest exist.
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