Exploring the lived experience of paramedics responding to individuals experiencing a mental health crisis in the community: A phenomenological study

Abstract

Aim

This phenomenological study explored the lived experience of paramedics attending to individuals experiencing a mental health crisis in the community.

Background

In recent years, paramedicine has evolved significantly, becoming a distinct discipline within the health sector with transformed roles and practices. Simultaneously, mental healthcare has transitioned for most consumers to community-based models of care. However, limited services have led individuals to rely on emergency departments and ambulance services as their primary, albeit last resort, during a crisis. Consequently, paramedics have become crucial providers of unscheduled mental healthcare, offering assessment and support to individuals experiencing a mental health crisis.

Method

This study utilised descriptive phenomenology, following the tradition of Husserl, to capture detailed descriptions of the phenomenon under study. Eighteen Australian paramedics employed by a Jurisdictional Ambulance Services took part in the study. Unstructured recorded interviews were conducted with each participant, ranging from 25 to 95 min. Data analysis was carried out using Colaizzi's seven-step method.

Results

The study revealed four central themes experienced by paramedics: (a) the clinical interaction; (b) the barriers to accessing care for mental health consumers in a one-size-fits-all system; (c) It's just all a little bit grey – paramedic education and training in mental health presentations; and (d) the paramedic, the clinician and the person. Structural and non-structural barriers, including personal, professional and organisational factors influenced care delivery. Limited specialised services and referral networks further complicate optimal care delivery.

Conclusion

The study highlights paramedics’ challenges in caring for individuals experiencing a mental health crisis. Participants noted their limitations due to inadequate education, training and on-site support, leading to frustration with a system focused on episodic rather than holistic care. Additionally, limited access to specialised services and referral networks complicated their efforts to provide optimal care.

Keywords

paramedic consumer ambulance service mental health paramedicine descriptive phenomenology Husserl

Background

Paramedics find themselves increasingly accountable for the care of individuals experiencing a mental health crisis in the community.^1–3 The expanding responsibilities of paramedics have sparked debate within the profession, with some asserting that the assessment and management of individuals experiencing a mental health crisis fall outside their scope of practice.^4,5 This perspective may stem from a limited 20th-century view of paramedicine, overlooking its historical role in transporting individuals with conditions such as leprosy and psychiatric, once deemed incurable, who now benefit from effective treatments and community integration.⁶ This contention highlights the complexity of a rapidly evolving and often challenging landscape of modern paramedicine, where the boundaries of clinical practice and responsibility are constantly being redefined. Despite significant advances, mental health practice in paramedicine has not evolved as rapidly or comprehensively as practice addressing physical health presentations.^7–9 This is despite the significant prevalence of mental health disorders in Australia, affecting approximately 20% of adults and 15% of young people each year,¹⁰ with the World Health Organization in 2019 estimating that, globally, 11.6% of people are currently experiencing a mental health condition.^11,12 To effectively integrate mental healthcare into modern paramedicine, it is essential to understand the demands placed on paramedics, the profession itself and ambulance services.^13–19 A clear understanding of paramedics’ experiences in this setting will provide an evidence base to guide the reform of models of care and referral pathways. This includes developing and integrating care models to support assessing and identifying the most appropriate care at the initial point of contact, establishing effective referral pathways and leveraging technology to minimise reliance on involuntary assessment provisions.^15–20

Methodology and methods

Aim

This phenomenological study aimed to delve into the lived experiences of paramedics caring for individuals experiencing a mental health crisis residing in the community. Articulating these genuine experiences contributes valuable insights to the existing body of knowledge in paramedicine. To enhance clarity and promote transparency, the reporting of the study was guided by the Standards for Reporting Qualitative Research.²¹

Methodology and paradigm

This study employed a Husserlian descriptive phenomenological research design, focusing on describing the human experience in the ‘lifeworld’, as it is directly given in consciousness.²² Phenomenology, situated in the qualitative paradigm, acknowledges that individuals have a unique and personal understanding of the world, influenced by their perspectives, beliefs, values and experiences, which cannot be distilled into quantitative metrics. Phenomenology posits that knowledge is created by exploring and describing people's lived experiences with a particular phenomenon. By adopting the phenomenological approach, the researcher explored and gained an understanding of the world from the participants’ perspective, enabling a rigorous examination of the phenomenon of the lived experience²³ of paramedics attending individuals experiencing a mental health crisis in the community. This approach allowed for the exploration and comprehension of the intricate dynamics and perspectives surrounding paramedics delivering mental healthcare,²⁴ thereby developing new knowledge that cannot be derived from external observation or objective measurement.

Setting

The setting for this study was paramedicine in Australia, specifically within jurisdictional ambulance services (JAS). JAS, in the Australian context, refers to the state or territory ambulance services responsible for responding to emergency calls, of which there is a single service in each of the eight states or territories. Paramedics in these services are nationally registered with the Paramedicine Board of Australia and are graduates of Board-approved paramedicine programmes, including vocational diploma and undergraduate bachelor's degree programmes. They practice in adherence to clinical practice guidelines with high levels of autonomy and, in the mental health context, work within their respective mental healthcare legislation that enables them to work within an involuntary care paradigm when necessary.

Participants and recruitment

The study was open to all Australian paramedics working in JASs, provided they had a minimum of three years of clinical practice experience. Purposive sampling was employed as this non-random method of selection allowed²⁵ the selection of participants with the lived experience of the phenomenon under study.²⁶ Recruitment was facilitated through the Australasian College of Paramedicine (ACP), which promoted the study to its membership through its social media platforms and email. The advertisement directed potential participants to a video outlining the study, participant information sheet, consent form and expression of interest form.

Data collection

Data were collected through unstructured one-on-one online interviews,²⁵ between April and May 2022. At the beginning of the interview, the study's purpose, nature and aims were explained to the participants, and verbal consent was obtained for the interview to proceed and be recorded. In adherence to the Husserlian phenomenological method, the interviews were unstructured to encourage participants to freely express their thoughts and feelings in their own words.²⁷ This approach empowered participants to explore their personal experiences in-depth. It facilitated the capture of rich firsthand narratives essential for Colaizzi's data analysis techniques,²⁸ ensuring that the fundamental structure of the phenomenon was revealed. This approach began with the initial open-ended question, allowing participants to share their experiences authentically and without constraint.²⁹

The principal researcher undertook all the interviews, ranging from 25 to 95 min. Online interviews offered several advantages, including access to paramedics from across Australia, minimised risks to the health of participants due to the pandemic, and enabled data collection from participants who were in COVID isolation. Videoconferencing allowed for the capture of vocal nuances, facial expressions and body language cues.^28,30 This visual medium facilitated the detection of non-verbal cues, aiding in recursive questioning and enhancing the depth of understanding regarding participants’ experiences.²⁸

Interview process^28,30

Interviews commenced with the question:

‘Could you please share with me, in as much detail as you can, your experiences as a paramedic caring for individuals with mental health challenges in the community?’

Additional questions or prompts that guided the interview process included:

Tell me more about that.

How does what you are talking about relate to your experiences?

Please give me examples of what you are describing.

The unstructured approach was chosen over a semi-structured one to allow for a deeper, more authentic exploration of participants’ lived experiences. Unlike semi-structured interviews, which follow a predetermined set of questions, unstructured interviews offer flexibility, enabling participants to freely share their stories and insights without the constraints of a fixed framework. This method aligns with the phenomenological approach by prioritising the understanding of human experiences from the participants’ perspectives, capturing the richness and complexity of their narratives, and allowing the conversation to evolve naturally. This flexibility supports the phenomenological aim of setting aside researchers’ biases and immersing fully in participants’ authentic viewpoints, leading to a more holistic understanding of the phenomenon.

Throughout data collection, the research team held multiple meetings and discussions about the interview process, utilising insights and reviewing both the interview process and coding. The primary researcher used comments and notes from their reflective journal to identify enablers, barriers or concerns that had arisen during the interviews and to facilitate any necessary adjustments. For instance, when participants paused, the primary researcher reflected on whether 15–20 seconds was an appropriate amount of time for self-reflection.

Interviews were recorded digitally using Microsoft Teams, except for two instances where telephone interviews were necessary due to internet issues. Verbatim transcription followed a two-step process. First, digital files were uploaded to NVivo Transcription^®, an automated platform that converts audio or video recordings into English text transcripts. To ensure participant anonymity, only the principal researcher had access to the NVivo Transcription^® platform.³¹ In the second stage, the principal researcher reviewed and edited the transcripts while listening to the recordings.³² Each transcript was assigned a random pseudonym to further reduce the risk of participant identification – these have been used when attributing quotes.

Data analysis

This phenomenological study utilised Colaizzi's data analysis method, a qualitative research approach aimed at uncovering the essences of lived experiences.³³ After the verbatim transcription, the transcript was emailed to the participant for review. This process, known as member checking³⁴ allowed participants to verify their transcripts and accurately captured their lived experiences with the phenomenon. Participants could modify their transcripts, clarify statements, add context and redact portions. Of the 18 interview transcripts, 5 were returned with amendments.

The primary researcher immersed themselves in the data, thoroughly engaging with interview transcripts and recordings. They conducted a secondary review of the interview transcripts, listened to the interview recordings at least three times, and performed a line-by-line analysis of the transcripts while watching the video recordings.^35,36 Significant statements were identified and extracted, with formulated meanings developed and theme clusters created.^35,36 These theme clusters were then developed into central themes.^35,36 An exhaustive description of the phenomenon was developed, followed by a description of the fundamental structure of the phenomenon.^35,36

Throughout data analysis, the primary researcher and research team reviewed coding, significant statements, formulated meanings, theme clusters, central themes, exhaustive descriptions and the fundamental structure of the phenomenon. This process led to further reflection and refinement of the analysis. Once the data analysis was complete, participants were emailed the exhaustive description to assess whether it accurately reflected their experiences. The feedback from participants indicated that the exhaustive descriptions aligned well and resonated with their lived experiences.^24,37

Throughout the study, the primary researcher employed bracketing strategies, a core element of descriptive phenomenology, to identify and mitigate personal biases, preconceptions, perceptions, thoughts and feelings that could influence data collection and analysis. Various bracketing methods were utilised, including annotation, memoing, interview field notes and a reflective journal. The researcher's commitment to bracketing enhanced the interpretation and reporting of findings by promoting objectivity, supporting thorough exploration, encouraging reflective practice and ensuring transparency. These practices collectively contributed to a more rigorous and nuanced analysis of the investigated phenomenon,^25,38 ensuring the research remained grounded in the data and accurately represented the participants’ experiences.²²

Ethical considerations

Ethics approval was granted by the Western Sydney University Human Research Ethics Committee, approval number H14516. This study used typical case sampling to mitigate potential harm to participants and the researcher by avoiding a focus on significant or sentinel events.^39,40 When a participant recounted a significant event, a welfare check was conducted, and the participant was asked if they felt safe to continue.⁴¹ At the end of the interview, the researcher checked in on the participant's wellbeing and reminded them of the support services listed in the Participant Information Sheet (PIS).

Results

Recruitment resulted in 28 expressions of interest in participating in the study. After applying the inclusion criteria, 21 paramedics were deemed eligible, while 7 participants were excluded based on predefined exclusion criteria. The 21 eligible participants were emailed a PIS and consent form. Ultimately, 18 participants returned completed consent forms and participated in interviews, with none withdrawing their consent. Participants had between 5 and over 30 years of experience and had been employed by one or more Australian JAS. The group included 12 male and 6 female participants.

Fundamental structure

The fundamental structure of the lived experience of paramedics caring for individuals experiencing a mental health crisis is multifaceted and complex clinical interactions (Figure 1). Each clinical interaction shapes the paramedic's experience and influences their future interactions. Significant role conflict emerged between the expectations and reality of paramedicine, particularly regarding the care of individuals experiencing a mental health crisis. Paramedics felt ill-prepared for clinical interactions due to insufficient resources, inadequate training and a lack of education. As a result, paramedics navigated these complex interactions with a mindset of self-preservation to avoid blame, which can potentially compromise patient-centred care. This study identified four central themes (Figure 2), highlighting how each interaction with individuals experiencing a mental health crisis contributed to paramedics’ evolving perspectives, commitment to mental healthcare, and approach to future interactions. The fragmentation of the mental health system further hindered paramedics’ ability to deliver patient-centred care, often leaving them feeling undervalued and trapped in a cycle of repetitive care with limited meaningful outcomes.

Figure 1.

Fundamental structure of the phenomenon.

Figure 2.

Central themes and theme clusters.

Theme 1 – ‘Are we ready for this?’ The paramedic and patient interaction

Participants identified several challenges in delivering mental healthcare, which were primarily attributed to limited resources, incomplete information, and insufficient support. While recognising that the care of individuals experiencing a mental health crisis is an integral part of paramedicine, many participants identified notable gaps in JASs preparedness to do so. Two theme clusters emerged, ‘Delivering care in a fragmented and under-resourced system’ and ‘The transfer of care is a road well-travelled, yet the system still fails everyone’. These theme clusters underscore the struggles paramedics faced during clinical interactions with individuals experiencing a mental health crisis, revealing systemic deficiencies in cohesion and resources within the healthcare system.

Cluster 1.1 - Delivering care in a fragmented and under-resourced system

Participants highlighted significant obstacles in delivering mental healthcare, primarily due to the fragmented structure of community and hospital-based services. This fragmentation was exacerbated by public and private providers working independently, leading to information silos and poor coordination of patient care. The lack of integration posed significant challenges in achieving optimal outcomes.

Participants also noted the challenge of delivering patient-centred care due to the compartmentalisation of clinical information and restricted access, particularly outside standard business hours. This limitation increased the potential for paramedics to inadvertently make suboptimal decisions, which could lead to adverse effects for patients and missed opportunities for early intervention and coordinated care. As Danny described, ‘if you don’t know a bit of the backstory, then how are we supposed to be prepared for that? We can’t, you know, and I know the police have a better system and [they] know everything that's going on and [that} … , they’ve been to them 10 times this month for the same issue’.

Paramedics’ interactions with community treatment teams often revealed a perception that these teams focused on chronic, predictable and scheduled care, typically involving very low-risk consumers. This resulted in the community teams being unprepared to deliver unscheduled care or assist in acute crises, instead leaving emergency services to respond. As Simone recounted, ‘They [community mental health teams] often pick people up to get their “depot” [medication] and drop them home and all that sort of stuff. But I don’t think they have a very big input into their clients at times of crisis. That always sort of falls back onto emergency services. Paramedics see this as an abdication of responsibility, putting paramedics in harm['s] way’.

Participants also raised concerns about the contemporary approach to mental health, with Alvin highlighting, ‘You only have to look internationally at the research to find that some of the things that we do in statutory services in Australia and some of the things that we do inside the [state] service are not entirely consistent with the accepted best practice’. Additionally, Garry's experiences underscored the limitations of JAS Clinical Practice Guidelines (CPGs) for mental health, noting, ‘There's always a conclusion the way the guideline is written. But in reality, I don’t think there's always a conclusion for every single case’.

While participants acknowledged that a standardised approach aligns with the risk appetite of JAS, they felt it significantly limited paramedics’ ability to provide nuanced, patient-centred care. Several participants echoed Garry's perspective, feeling that CPGs pushed them to transport patients – something some perceived as a way of mitigating ‘organisational risk’ by transferring the risk to another healthcare service. Participants advocated for more flexible, adaptable, and personalised care options. Adrian emphasised that contemporary paramedic practice should ‘… encourage clinicians to make decisions and carry the level of risk they’re comfortable with and if something goes wrong instead of being [punished] the case would be reviewed … [in] a positive process, a learning process’.

Cluster 1.2 – The transfer of care is a road well-travelled, yet the system still fails the consumer

Participants expressed frustration with the ongoing challenges of providing care, particularly within the constraints of a 24-h ambulance service. They felt that their efforts were hindered by a mental health system that is not accessible 24/7. Tina summarised these challenges, ‘It's two o'clock in the morning on a Saturday. Nobody else is going to do this. Nobody else is going to help. Nobody else is going to find a solution’.

A common concern was limited patient options, often restricted to Emergency Departments (EDs). Despite developing referral pathways to enable paramedics to direct low and sub-acute presentations away from EDs, these pathways often failed to meet their intended goals. As paramedic referrals to these services exceeded initial projections, the services adjusted their screening protocols, resulting in patients being directed to EDs, raising concerns about patient care quality and autonomy. Garry noted, ‘But this thing has been such a success that, anecdotally, what I’m hearing from my colleagues, who know some of the staff, is that when [clinicians] are questioning patients, [they] are almost asking the leading questions as to whether they have any plan to harm themselves or do you feel like smashing things up … because if they do that, that place cannot cope [with] them, so they [have] go to the hospital’.

Participants also highlighted the inadequacies of the triage system, which often relied heavily on ED observations, disregarding events before arrival. This contrasts with physical presentations, where on-scene information informs the triage process. Alvin emphasised the frustration, saying, ‘Notwithstanding what's happened outside the hospital, once we get to a hospital, we don’t have a consistently good system for making sure that our clinical peers from other health professions really understand exactly what's happened before [we arrived at the hospital] and why we’re at the place that we’re at now’.

Of the few reported positive experiences with mental health referral pathways, the advantages of integrated response models were highlighted. Adrian provided insight into co-responder models, offering valuable perspectives on their implementation and effectiveness. ‘Anecdotally, from my experience, we’re leaving probably 75 to 80 per cent of the patients that we see at home, and they’re being mainly referred to community services’. Similarly, Gary noted the introduction of mental health referral pathways that bypass the ED under specific parameters, enabled appropriate care ‘mental health referral pathways that bypass the emergency department under certain parameters, enabling the patient to get a medical clearance and medical assessment. In the context of ambulance work and aligning closely with the mental health clinician [scope], this opens up [non-ED] pathways for that patient, I think is a tremendous step forward to good mental healthcare’.

The inherent complexity of the mental health system means effective care transitions rely on clear communication and seamless exchange of critical information among clinicians and care teams. However, participants noted that delivering care remains challenging, particularly outside regular business hours and in overburdened healthcare facilities.

Theme 2 – The barriers to accessing care for mental health consumers in a one-size-fits-all system

Participants’ narratives provided a comprehensive perspective on the diverse barriers patients encounter when seeking healthcare within the standardised healthcare system. They emphasised the frustration and helplessness felt by both patients and paramedics due to inadequate access to appropriate care. The scarcity of services resulted in limited options, extended wait times, and an overreliance on EDs. Rural residents faced additional hurdles, such as distance and financial strain. Stigma and bias further impede access to care, leading to instances of refusal and discontinuity in treatment. This theme also highlighted the intersection of mental health with aged care and disability services, adding layers of complexity. The system's dependence on ambulances and EDs exposed systemic flaws and shortcomings in the accessibility and continuity of community-based care.

Cluster 2.1 – Access to healthcare

Participants highlighted the significant financial burden associated with accessing mental health services. Graham identified, ‘You get 10 visits from Medicare under the mental health plan, … [but] there would still be a gap of nearly $100 [for each visit]’. After accessing care and receiving a diagnosis, the cost of medications led vulnerable consumers to make decisions about basic necessities and medication. Tina described, ‘the doctor refused to do a telehealth appointment and told him he had to come in. So, he couldn’t take a day off work because he's earning the minimum wage, and he's only just making enough to pay his rent for himself’.

The inability to afford medication, prolonged waiting periods, and a lack of access to community-based services and primary healthcare contributed to the deterioration of patients’ conditions. Many participants shared experiences of patients becoming chronically unwell, sometimes resulting in acute crises. Consequently, individuals would reluctantly resort to ambulance services as a last option during a crisis.

Cluster 2.2 – The patient's experience of mental healthcare

The patient experience within the mental health system is a complex mosaic shaped by multiple factors, including diagnosis, attitudes of healthcare professionals, cultural influences and the healthcare system. Participants identified that previous interactions with mental health services shaped patients’ expectations of future interactions. As described by Glen ‘There's often a negative perception there, whether they had poor care in the hospital, or they didn’t receive the help they wanted, or they felt like nothing really changed. That's what I’ve experienced mostly with a lot of patients with mental health conditions’.

Participants recounted instances where healthcare professionals overtly or covertly declined to provide essential care, significantly hindering consumers’ access to services. The pervasive stigma and biases surrounding mental health further exacerbated these issues. For example, paramedics frequently encounter patients who have been turned away by other health professionals or denied necessary treatment and medication.

Paramedics frequently encountered patients with limited health literacy, having received poor education and support, resulting in discontinuation of their treatment plan and deterioration. Danny shared, ‘They don’t want to take their medication because they’re feeling good. But then we go to them again because now they’re at that low point again. They say, because I decided I feel good, I don’t need my medication anymore’.

Virtual mental health assessments were designed to improve access to care, reduce reliance on EDs, and reduce ambulance ramping. However, they were not without their challenges. Participants felt they inadvertently delayed care. Laurance noted, ‘you wait for them to ring you back. By the time that's happened, it's been 40–50 min, and you think I could have been pretty much at [regional city] hospital, you know, in 10 min from now’.

Participants’ accounts illustrate the intricate and diverse challenges experienced by patients. These narratives reveal a landscape marked by disparities and challenges that significantly hinder paramedics’ efforts to facilitate timely and effective access to care.

Theme 3 – ‘It’s just all a little bit grey’ Paramedic education and training in mental health presentations

Participants’ insights and experiences regarding their education and training in mental health focused on two main themes: emergency mental health education and organisational culture.

Cluster 3.1 – Mental health education

Participants consistently expressed dissatisfaction with their initial mental health education, describing it as inadequate preparation for addressing the needs of people experiencing a mental health crisis. Criticism was directed both at JAS and university education. Participants characterised employer training as reactive rather than proactive, often neglecting essential skills. University education was viewed as overly theoretical, lacking sufficient exposure to real-world situations.

Participants frequently compared mental health education unfavourably to that provided for physical health conditions such as trauma and medical presentations. Rather than offering nuanced approaches, mental health education tended to be oversimplified and distilled into an acronym. They noted a lack of depth and failure to address the complexities of mental healthcare. Laurence encapsulated this view, stating education; ‘was mainly focused on what your legal responsibilities were and how to “cover your ass” if something happened as opposed to how to provide the most effective support to somebody in crisis’.

While some training touched on de-escalation, it was often delivered superficially, without thorough practical application. This theory-practice gap left participants feeling underprepared and lacking essential skills for managing people experiencing a mental health crisis.

Cluster 3.2 – Organisational culture

Participants highlighted how organisational culture shaped mental healthcare delivery. They observed that JAS prioritised avoiding blame and mitigating legal concerns over providing comprehensive care. Key performance indicators (KPIs), such as response times, time on scene and documentation completion, were emphasised at the expense of patient-centred care. Anne described this challenge, saying, ‘my assessment, you know, to do a thorough assessment and to have a chat with the patient, know what's going on and to talk about the situation, especially should they go or should they stay. Mental health, you can’t do that in 20 min’.

This culture of rapid task completion created a reactive system where responsibility was shifted to EDs instead of seizing the opportunity to support people experiencing a mental health crisis in the community. Malcolm summarised this sentiment, ‘It's almost like the ambulance service [is saying] we don’t care what you do with them as long as we are not the last ones to handle the ball … this is something that needs to change, encapsulates the participants’ general sentiment regarding the approach of ambulance services to mental health patients’. The risk-averse culture in JAS constrained paramedics’ professional judgement, fostering a fear of consequences that adversely affected patient outcomes, perpetuating a cycle of reactive care.

Participants advocated for comprehensive education and training reform to equip paramedics with the knowledge, skills and confidence necessary to deliver high-quality care to persons in crisis. Addressing these gaps could significantly improve patient care and mitigate the challenges in this area of clinical practice.

Theme 4 – The paramedic, the clinician and the person

Participants identified that paramedicine, both as a healthcare and academic discipline, is rapidly evolving, driving continuous changes in the role of paramedics. The swift evolution has led to significant role conflict, primarily from the disparity between expected patient cohorts and the reality of contemporary paramedicine. Jordan captured this shift, stating, ‘If you have trouble looking after people who are homeless, vulnerable or at risk [and] have some sort of dependency, whether alcohol, drugs or whatever, [you are] probably not even suited to the role because there's such a core function’.

A notable point of contention within the discipline is whether mental health calls should be classified as emergencies and whether they fall within the paramedic's scope of responsibility. This debate highlights how participants’ attitudes and experiences vary.

Cognitive biases, often unconsciously shaped by personal backgrounds, experiences, and societal stigmas, were consistently identified as influential factors in paramedic attitudes toward people experiencing a mental health crisis. These biases and attitudes significantly impact team culture, patient interactions, and clinical outcomes. Glen illustrated this, stating, ‘I’ve seen paramedics treat patients with mental health conditions poorly, which has made them hesitant to receive care in hospital or further along down the track. This obviously negatively impacts their overall wellbeing and future’.

Although only a minority of participants reported unprofessional conduct, these incidents had profound implications. They included deliberately escalating patients, making inappropriate comments or treating patients harshly. Jack highlighted unprofessionalism, sharing an account of a colleague ‘I’ve been in so many fights with patients this year’, and [I am] like there's a common denominator here you know, you're starting fights and this same ambo happened to be [tall] and [well built, so [they] liked ending fights … and [they] would attend to a mental health patient, and [their] attitude would be just to yell at them until they acted up and then knock them out [punching]’.

As discussed in Theme 3, organisational culture is crucial in establishing the overall atmosphere and accepted standards guiding clinical interactions and patient outcomes. Many participants felt that JAS view mental health presentations differently from physical health presentations, evidenced by mental health cases often remaining in pending incident queues for long periods. Feeling inadequately prepared, paramedics are questioning their ability to provide appropriate, adequate and evidence-informed care to this patient cohort.

Despite these challenges, many participants had taken the initiative to address their knowledge gap in mental health through targeted professional development. However, they emphasised that future training programmes should delve deeper into diagnoses, communication and decision-making skills. They also emphasised the need for real-time support and 24/7 access to mental health services for appropriate assessment, referral and care.

The emotional and mental fatigue reported by participants stemmed from a perceived cycle of futility in mental healthcare, which diminished job satisfaction. Their inability to deliver effective care mirrored the patients’ experiences of the patients themselves, further contributing to a reactive model of care. Adrian encapsulated these frustrations, ‘Hang on a minute. This is the eighth time this week that we’ve been talking to you. And whilst I don’t mind being here to support you, it's also frustrating … . Your cup of empathy has run empty at this point given the context of what we do. So I would say that that is a really big challenge for paramedics to not let that context infiltrate and transfer to patient care’.

Discussion

The 21st century has witnessed both rapid evolution in paramedicine and evolving consumer demands⁴² for Australian JAS, as identified by Makrides.⁴³ In Australia, the Queensland Mental Health Act 2000⁴⁴ marked a pivotal moment, introducing increased responsibilities and accountabilities for paramedics caring for people experiencing a mental health crisis. As identified by Shaban, this marked the first time Australian paramedics employed by a JAS were granted involuntary powers for treatment and transport powers.⁴⁴ Successive states and territories followed suit,^45–48 with Victoria being the latest jurisdiction to include these provisions in its 2022 Mental Health Act,⁴⁹ though they have yet to be enacted. However, as of 2025, paramedics in the Northern Territory and Western Australia lack such legislative powers.^50–52

Participants’ experiences echoed the findings by Finn et al.,¹⁸ revealing ongoing pressures from increasing consumer demand for JAS, particularly from non-traditional clinical presentations such as mental health^53–55 and low-acuity^56,57 presentations. Many participants stated that without urgent reforms, paramedics would continue to navigate this ‘new normal’ with ambiguous clinical boundaries, a concern previously raised by Taraves.^58–60 Despite paramedics’ historical involvement in delivering care to individuals with mental ill health, participants expressed their frustration over other services abdicating responsibility for these patients, particularly to inadequate mental health services,^61,62 especially outside standard business hours.^61,62 This has resulted in considerable variability across JAS regarding whether paramedics are the appropriate response for persons experiencing a mental health crisis.^63,64

Participants perceived that the organisational culture within JAS has struggled to adapt to these evolving demands, resonating with Shaban's findings.⁶⁵ This lag in adaptation has led to a portion of the workforce viewing their roles and responsibilities through the lens of the 20th-century perspective,^66,67 focusing predominantly on life-threatening and physical health presentations^58–60 as identified by McCann.⁴ Participants identified key performance indicators,^68,69 such as response time, time on scene, and transfer of care times, further reinforcing this focus on high-acuity cases.^68,70 While JAS focus on high-acuity responses due to associated mortality risks,⁷¹ they risk neglecting the needs of other patient populations and society's health goals.⁷²

Participants reported a perception that JAS often fail to adequately address mental health presentations, leaving paramedics feeling unprepared to provide evidence-based care, as previously reported by McCann et al.,⁴ and disadvantaged even before an interaction occurs. Unlike their preparation for physical clinical presentations, paramedics reported feeling disadvantaged when responding to person with a mental health crisis. This aligns with the findings by Duncan et al.,⁷³ which suggest that JAS underestimate the potential impact paramedics can have in reducing morbidity and mortality among persons presenting with a mental health crisis. Clinical practice guidelines (CPGs) primarily focus on treatment guidance for persons with a high-acuity mental health crisis,^74–76 emphasising de-escalation, chemical and mechanical restraint, and legislative powers.³ While these CPGs are crucial, they risk perpetuating stereotypes of individuals experiencing a mental health crisis as dangerous or violent. Furthermore, this focus may prime the dynamic risk assessment, leading to unnecessary police involvement, reinforcing stigma and criminalising mental health.⁷⁷

Participants highlighted a lack of guidance for ‘lower acuity’ mental health presentation, compounded by the scarcity of point-of-care clinical options. Delays inherent in integrated care models exacerbate these issues, causing internal conflict among practitioners striving to deliver timely and effective care to individuals experiencing a mental health crisis. Some participants expressed concerns that ambulance services might take over the role of ‘street corner psychologists’, a label originally applied to police by Teplin⁷⁸ in the 20th century. This risk sees ambulance services becoming another ‘revolving door’, perpetuating the systemic inadequacies of mental healthcare.

Participants’ experiences aligned with Keefe et al.'s study, recognising the historical role of paramedics in responding to people experiencing a mental health crisis.⁸ However, they highlighted that interactions with people experiencing a mental health crisis often require a hands-off approach, focusing on active listening, rapport building, empathy and patience. While ‘de-escalation’ was frequently mentioned, they reported insufficient education on practical implementation, highlighting a critical gap in mental health crisis training.

Participants also identified the need for interdisciplinary relationships. However, integrating paramedicine into the clinical practice of mental health has faced challenges. Rather than adopting established practices, some ambulance services are modifying evidence-based practices and assessment tools. These practices result in paramedics conducting and reporting mental health assessments in a different ‘dialect’, seeing the introduction of ‘noise’ during clinical handover. The noise is a direct result of the receiving clinicians having to receive ambulance-specific acronyms and then decode them into the mental state examination framework, which may undermine their confidence in the paramedic's clinical and risk assessments of the mental health patient.

A small proportion of participants had experience with virtual mental health assessment platforms and reported mixed results.^79,80 While these platforms provide access to specialised care, the outcome for people experiencing a mental health crisis not transported remained unchanged – they were still in the community with limited access to ongoing care. Others found significant delays in accessing virtual care services, hindering timely interventions as they required transport and were another barrier to accessing care. Participants also raised ethical, safety and confidentiality issues regarding telemedicine in the ambulance context.

Participants emphasised that failing to address these discrepancies within paramedicine and JAS has resulted in a disenfranchised workforce.⁸¹ Hence, there was an essential need for a targeted initiative to recalibrate the depiction of paramedicine and the workload associated with being a paramedic in a JAS. The inclusion of attending to people experiencing a mental health crisis as a significant facet of paramedics’ responsibilities is now widely acknowledged as an inherent aspect of their profession. Participants identified significant disparities in their preparedness to deliver mental healthcare compared to physical and medical clinical interactions. Paramedics have emphasised the point that without an organisational cultural shift elevating mental healthcare to a level commensurate with physical health presentations, where it becomes ‘a core aspect of paramedic practice’, the ongoing emotional and mental strain endured by paramedics will continue. This dynamic has been leaving paramedics feeling trapped in a cycle of persistent mental healthcare that participants reported is providing minimal progress for the consumer. Consequently, paramedics have been feeling deflated, grappling with a sense of inadequacy in delivering care to people experiencing a mental health crisis.

Limitations

This study has some limitations, and readers will need to assess the transferability of themes, concepts and findings from this study to their respective settings. To facilitate transferability, a thick description with extensive detail of data collection and analysis has been provided. The study was limited to paramedics currently working with Australian JASs, meaning that interactions and care delivery in private ambulance services was not explored. Readers should therefore assess the study setting to determine whether the results are transferable to their context. Future studies should explore other settings or involve international participant cohorts.

Purposive sampling carries the risk of producing a non-representative sample due to its selective nature based on predetermined criteria. Prospective participants were excluded if they did not work for a JAS, had less than three years of clinical practice, held dual health qualifications, or were supervised by the researcher in their workplace. While purposive sampling may limit the sample's representativeness, it aligns with the goal of descriptive phenomenology, which is to deeply explore and describe individuals’ lived experiences.

The phenomenological approach was appropriate for this study, as it aimed to explore the complex, nuanced and subjective lived experiences of paramedics providing care to individuals experiencing a mental health crisis. As a practising paramedic, the primary researcher was attentive to maintaining a neutral stance throughout the interviews and data analysis. The researcher consciously set aside their perspectives and listened with the objectivity required, ensuring that the participants’ voices were authentically represented. The research reinforced trustworthiness through unstructured interviews, recursive questioning, member checks, and reflexive journaling. Detailed contextual descriptions enhanced transferability, while bracketing and phenomenological reduction supported objectivity, ensuring the participants’ experiences were captured and represented.

The COVID-19 pandemic imposed limitations on this research project, including a shift from in-person to virtual data collection, which could have impacted the depth and richness of the data due to reduced access to non-verbal cues and potential technical disruptions. Ethical and practical concerns also arose, particularly regarding participant privacy in virtual environments. To address these challenges, video conferencing was used as the primary method for data collection, enabling the observation of non-verbal cues. Privacy was managed by advising participants to undertake interviews in a private, non-work setting.

Conclusion

The study shed light on the lived experience of Australian paramedics delivering mental healthcare in the community, revealing complex clinical interactions for which they currently feel ill-prepared. The need for enhanced education at the university level and during employment was emphasised to ensure paramedics are ready for the diversity and complexities inherent in the spectrum of mental health diagnoses and presentations. Adequate preparation is essential for effectively responding to, assessing, and treating people experiencing a mental health crisis. Paramedics see the adoption of assessment tools and language used by their colleagues in mental health as necessary and advocate for refraining from creating paramedic-centric tools. Improving education and aligning assessments with those used by mental health specialists will enable paramedics to provide a more empathetic response, comprehensive assessment, and better transfer of care when providing care to people experiencing a mental health crisis.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Paul Simpson is a member of the editorial board of Paramedicine. They had no involvement in the editorial flow or decision making for this paper, and all editorial and review processes were double-blinded in adherence to the journal’s policy.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Paul Simpson

Liz Thyer

Matthew Simpson

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