Non-conveyance and autonomy: How organisational contexts influence ambulance clinicians’ practice in mental health crises – A qualitative study
Nina Øye Thorvaldsen, Anne Kristine Bergem, Jorun Rugkåsa, Kristin HäikiöBackground
Ambulance services increasingly attend mental health crises, where safe non-conveyance is appropriate but inconsistently achieved. Training gaps and organisational constraints, e.g. unclear guidance, limited referral pathways, and weak interagency collaboration, constrain practice and foster a risk-averse culture that defaults to conveyance in ways that might undermine patient autonomy.
Aim
This study aimed to explore key challenges faced by ambulance clinicians when managing people in mental health crises within the current Norwegian healthcare system.
Methods
We conducted eight semi-structured group interviews across three of four Regional Health Trusts in Norway. Key themes were identified using Braun and Clarke's Reflexive Thematic Analysis (2022) and interpreted in light of Schein and Schein's (2017) theory of organisational culture within a critical realist perspective.
Results
A total of 48 ambulance clinicians participated. Participants reported gaps in formal mental health education and training, lack of guidelines and templates, and limited referral options, which often made conveyance the perceived safer, more straightforward option. This can have consequences for on-scene practices and further care trajectories for patients who do not want the healthcare offered or whose decision-making capacity is in question, and/or there is fear of adverse outcomes if patients are not conveyed. In such situations, the above factors can lead to an over-reliance on conveyance to specialist clinicians, preferably a physician, and also potentially limit patients’ autonomy to remain on-scene when appropriate.
Conclusion
The findings highlight how organisational culture, particularly weak managerial support and risk-averse norms, are experienced to directly influence conveyance practices. This might indirectly impact the extent to which patients’ autonomy is upheld. Strengthening training, referral pathways, inter-agency agreement and managerial support might help shift current practice towards person-centred care.