The care of patients assessed as not in need of emergency ambulance care – Registered nurses’ lived experiences

https://doi.org/10.1016/j.ienj.2018.01.007Get rights and content

Highlights

  • The care is a struggle between competing demands of different expectations.

  • A high workload of non-acuity patients leads to a risk of losing empathy.

  • Formal directives and support are needed in the care of non-acuity patients.

Abstract

Aim

The aim of this study was to describe the care of patients assessed as not in need of emergency ambulance care, from Registered Nurse’s lived experiences.

Background

Non-emergency patients in need of ambulance care are described as vulnerable and patients in ambulance care have earlier been found to be dependent on the Registered Nurse. However, little is known about the care of non-emergency patients in the ambulance setting, from the perspective of Registered Nurses.

Methods

A reflective lifeworld research design was chosen. Five Registered Nurses with experience of ambulance care were individually interviewed.

Results

The result reveals the essence of the phenomenon as a desire to provide good care in an on-going struggle between one’s own and others’ expectations. Three meaning constituents emerged in the description; Being in a struggle between different expectations, Being in a questioned professional role, and Being in lack of support and formal directives.

Conclusion

Registered Nurses’ care for patients assessed as not in need of emergency ambulance care, is a complex struggle between different expectations. This may be related to the encounter between the nurse’s and the patient’s lifeworld.

Introduction

The Emergency Medical Service (EMS) provides advanced medical care to out-of-hospital patients [1], within or in direct connection to an ambulance vehicle. In Sweden the assessment of patients’ need of EMS is made by the medical dispatch centres, using three priority levels: 1) acute life threatening conditions or accidents, 2) acute but non life-threatening conditions, and 3) other conditions requiring advanced care where it is judged that a longer response time will not negatively influence the patient’s condition [2]. In 2014 the emergency medical dispatch centres in Sweden assessed approximately 1.2 million ambulance calls. These comprised 41% Priority 1, 48% Priority 2, 11% Priority 3 [3]. The EMS professional’s assessment at the scene may change the initial priority level of the patient [4]. Some ambulance patients are not transported to a hospital after assessment [5], e.g. they may be left at the scene or transferred to primary care [6].

Ambulance transportation to hospital among patients with low-acuity conditions is found to be associated with vulnerable population categories (e.g. older age, psychiatric disease, homelessness) [7]. Non-emergency patients in the EMS are described as being in a state of insecurity and vulnerability due to not knowing what is wrong with them [5]. Hence while not being able to handle the illness, patients perceive that there is no other option than to call for an ambulance [8] and are thus dependent on the EMS professionals [9]. Furthermore, vulnerability in the emergency care setting may be seen as complex, involving psychological, social and/or physical aspects [10]. The caring professionals in EMS internationally are often paramedics and/or emergency medical technicians. However, in Sweden there is a requirement for at least one RN in each ambulance, with an overall responsibility for the care [11]. Usually a Swedish EMS team consists of two Registered Nurses (RNs) or one RN and one Emergency Medical Technician, with different level of training from the RN. Registered Nurses in the Swedish EMS experience their foremost responsibility as focusing on emergency medical assessment and treatment [12]. Initially RNs have to exclude life-threating and/or urgent medical conditions before assessing patients as not being in need of emergency ambulance care [6]. In addition the RNs have to perform medical assessment simultaneously while holistically assessing the patient’s unique and subjective situation [12], [13], which is also stressed by Swedish EMS managers as essential knowledge in pre-hospital care [14]. This demands the competence to autonomously initiate, perform and evaluate nursing care [15]. Taken together the RNs in the EMS have to assess the patient’s need of care based on complex needs, and not only focused on medical care and treatment.

Patients’ experiences of ambulance care have earlier been found to involve more than just medical treatment and to be related to the encounter with the RN [16]. Hence, care in the EMS may be understood as the establishment of a trustful and caring relationship with the patient [17], acknowledging his/her whole life-situation [12]. Thus, care may be described as incorporating medical care with an existential perspective on the patient [18]. This may be a challenge in the EMS setting, requiring the RNs to balance their medical assessment and the assessment of the patient’s unique situation [17]. The challenges of accurate pre-hospital assessments have earlier been found to be related to both life-threatening and non-life-threatening conditions [19], [20], [21]. In addition ambulance care is characterized by the ambition to reduce time on scene [22] in order to increase patient survival from serious medical conditions [23].

Taken together the RNs in the EMS have to assess and care for a variety of complex patients’ needs. Patients with low-acuity conditions assessed as not in need of emergency medical care form part of the EMS responsibility. These patients have earlier been described as vulnerable, seeing themselves as not being taken seriously by the EMS personnel. Thus RNs have an overall responsibility for the care of the patient in the Swedish EMS, and not only focus on life-threatening conditions. This requires the ability to assess and care for patients’ medical needs as well as their psychological, social and existential needs, covering both acute and non-acute patients. Earlier studies have focused on patients’ experiences of non-emergency ambulance care and there is a lack of knowledge based on RNs’ perspectives. This knowledge is important in order to both understand the non-emergency care and the role of RNs in the EMS setting.

Section snippets

Aim

The aim was to describe the care for patients assessed as not in need of emergency ambulance care, from RNs’ lived experiences.

Design

In accordance with the aim a reflective lifeworld research design was chosen [24]. This method is based on the epistemological foundation as described by Husserl [25] and aims to illuminate and describe meanings of phenomena [24].

Participants and setting

The setting for the study was a Swedish EMS organisation covering a population of approximately 17.000 inhabitants. Contact was established with RNs at the EMS department using a convenient sample. The inclusion criteria required at least five years’ of experience

Results

The essence of the studied phenomenon is a desire to provide good care in an ongoing struggle between different expectations. This struggle means weariness and a risk of losing empathy for the patient, being torn between the patient's expectations and one’s own expectation of care, and the formal responsibility of being an EMS professional. At the same time, this is balanced with a desire to care for the patient in an unprejudiced way. However, the lack of support and guidelines when assessing

Discussion

The findings reveal that the care of patients assessed as not in need of emergency ambulance care, is experienced by the RNs as competing demands of different expectations. On the one hand this may be related to the encounter between the patient’s and the RN’s different lifeworlds. The patient’s lifeworld may be understood in the light of their illness as an interruption to their daily lives [28] a feeling of inadequacy that they cannot handle the situation on their own [5], [9]. Hence, the

Methodological considerations

In assessing the trustworthiness of this study we have considered credibility, dependability, confirmability and transferability [41]. One limitation in the present might be the low number of participants. However, five participants is suggested as sufficient in lifeworld research [24] as earlier reported in similar studies [12], [42]. In addition the interviews were judged to be rich in variation, which is described as more essential in lifeworld research than the number of participants [24].

Conclusion

The care of patients assessed as not in need of emergency ambulance care involves a struggle between competing demands of different expectations. A high workload of patients not assessed as having acute emergency needs increases fatigue, frustration, bitterness and the risk of losing empathy. This is related to the RNs views, opinions and expectation of ambulance care as foremost emergency medical care. The RNs also experienced a lack of support and formal directives when having to make

Funding

No funding was received for this study.

Acknowledgements

The authors would like to thank all the RNs that participated in the study and Dr. Anders Bremer (Linneaus University) for his efforts providing us with a critical revision of the draft.

Authors’ contribution

Both authors were involved in the study’s concept and design. Christian Barrientos collected and analysed the data and Mats Holmberg supervised the process. Both authors drafted the manuscript and approved the final version.

References (42)

  • Socialstyrelsen. SOSFS 2009:10 Ambulanssjukvård m.m;...
  • A. Bremer

    Dagens ambulanssjukvård [Ambulance care of today]

  • A. Rantala et al.

    The meaning of being triaged to non-emergency ambulance care as experienced by patients

    Int Emergency Nurs

    (2015)
  • E. Durant et al.

    Factors Associated with Ambulance Use Among Patients with Low-Acuity Conditions

    Prehosp Emergency Care

    (2012)
  • M. Holmberg et al.

    To surrender in dependence of another: the relationship with the ambulance clinicians as experienced by patients

    Scand J Caring Sci

    (2014)
  • Andrew Scanlon et al.

    The use of the term vulnerability in acute care: Why does it differ and what does it mean?

    Aust J Adv Nurs

    (2007)
  • B-O. Suserud

    A new profession in the pre-hospital care field – the ambulance nurse

    Nurs Crit Care

    (2005)
  • M. Holmberg et al.

    The encounter with the unknown: nurses lived experiences of their responsibility for the care of the patient in the Swedish ambulance service

    Int J Qual Stud Health Well-Being

    (2010)
  • M. Holmberg et al.

    Ambulance clinicians’ experiences of relationships with patients and significant others

    Nurs Crit Care

    (2016)
  • K.T. Galvin et al.

    Embodying nursing openheartedness: an existential perspective

    J Holistic Nurs

    (2009)
  • J. Tärnqvist et al.

    On-scene and final assessments and their interrelationship among patients who use the ems on multiple occasions

    Prehospital Disaster Med

    (2017)
  • Cited by (15)

    • Implementing a person centred collaborative health care model – A qualitative study on patient experiences

      2021, International Emergency Nursing
      Citation Excerpt :

      However, some persons, especially frail and persons with multiple diseases, have difficulties with transfer to a primary health care center and often call for an ambulance instead [6]. Professionals find it difficult to prioritize the emergency calls in the dispatch center [7] and sense a struggle between different expectations in the care of patients assessed not being in need of emergency ambulance care [8], results in patients being both over- and under prioritized [7]. Difficulties to prioritize emergency calls may lead to high emergency ambulance services use for provision of care associated with ACSC.

    • Inequalities and short-term outcome among patients assessed as non-urgent in a Swedish ambulance service setting

      2021, International Emergency Nursing
      Citation Excerpt :

      Patient safety within the AS is likely to be compromised by poor clinical reasoning and inadequate decision-making, as it is suggested that the undertriage rate is between 9% and 29% due to ACs’ decisions about the medical necessity of ambulance transport [16]. However, it is argued that patients now request ambulance transport for more trivial symptoms than was previously the case and that the number of patients assessed as not needing emergency ambulance care is increasing [17–19]. Based on previous research and due to the lack of guidelines regarding the assessment of non-urgent patients, it is important to analyse current referral patterns and short-term outcomes for non-urgent patients as a foundation for the future development of guidelines.

    • Lecturers’ lived experiences of guiding reflective seminars during nursing education

      2018, Nurse Education in Practice
      Citation Excerpt :

      The aim of RLR is to increase the understanding of the human experience by reflecting upon things that are taken for granted and by illuminating the implicit and tacit dimensions of the lifeworld (Dahlberg et al., 2008). RLR was developed over time, and it is used in a broad range of fields, including research studies focusing on nurse education (Holst et al., 2017), elderly care (Van Wijngaarden et al., 2015) and ambulance care (Barrientos and Holmberg, 2018). The interviews as well as the data analysis have been carried out with openness and a reflective attitude in order to allow the phenomenon under study to be revealed.

    View all citing articles on Scopus
    View full text