Paramedic experiences of interacting with residential aged-care staff: A descriptive phenomenological study

Abstract

Introduction

Paramedics routinely respond to residential aged care facilities (RACF) for health issues. Paramedics then interact with RACF staff to obtain information regarding the resident and the health issue. There are few studies investigating the paramedic perspective of attending RACF and interacting with staff. Our study focuses on the Australian paramedic perspective of the inter-professional relationship and its potential influence on decision-making and resident outcomes.

Methods

Seven paramedics, employed by four different Australian jurisdictional ambulance services, were interviewed online. Using a descriptive phenomenological methodology, the essential structure of the phenomenon was developed using the method described by Giorgi and Giorgi.

Results

The paramedic experiences of attending RACF are predicated on a preconception of an ideal encounter. This includes expectations of a valid reason for the call, that staff appropriately manage acute health issues and that handover of resident information was timely and accurate. Interactions not meeting these standards resulted in a loss of professional trust and sometimes a default decision to hospital transport, irrespective of clinical need. Extrinsic and intrinsic factors influenced paramedic decision-making, including other stakeholders wishes and an avoidance of conflict. Greater professional experience and training led to an adjustment of the ideal concept and a more positive experience.

Conclusion

The inter-professional relationship that paramedics have with RACF staff is influenced by preconceived expectations that dictate what should happen during any interaction. This imagined ideal has a negative effect on the relationship and potentially impacts paramedic decision-making and, by extension, the outcomes of the resident.

Keywords

paramedic interprofessional aged care nursing home qualitative

Introduction

The lived experience of Australian paramedics attending residential aged care facilities (RACF), and how those experiences influence their decision-making, remains a largely unknown phenomenon, yet paramedics employed in jurisdictional emergency ambulance services, managed and funded by the separate Australian state and territory governments, routinely attend to residents living in RACF.¹ This relationship is unique to this context and differs from paramedic attendance of older people in a community setting. The data regarding calls from RACF to emergency ambulance services is reported, both nationally and internationally, using various methods. This makes direct comparison unreliable however; in Australia, rates have been reported to be as high as 770 per 1000 people per year whilst in the United Kingdom (UK), calls to care homes accounted for approximately 16% of calls to people >75 years^2,3 More than 95% of people from RACF arrive at an emergency department (ED) via ambulance, with annual rates of care home residents in the ED reported to vary from 1.9% to 3.3%.⁴ Residential aged care refers to the provision of accommodation, personal care and nursing services to an older person within a facility. Common synonyms found in the research literature include nursing homes, aged care homes or care homes and may be used interchangeably.⁵

Studies by Ng et al. (2020) and Lind et al. (2020) have found that residents living in RACF, care homes or nursing homes are older and have increasingly complex care needs, including circulatory diseases, dementia, multiple other co-morbid health conditions and polypharmacy.^6,7 Hendin et al.⁸ found that older patients with low-acuity triage scores presenting to an ED were many times more likely to be admitted to hospital than younger people and had longer hospital stays with poorer outcomes. Hospitalisation for acute care in people over 65 years was described by Loyd et al. as ‘a sentinel event leading to older adult disability’.⁹^(p2) Other iatrogenic harms from hospital admission include delirium, falls, infections and pressure injuries that often reduce quality of life and hasten mortality.¹⁰ This population are complex patients with different goals and ceilings of care to a younger, less frail cohort and it is essential that the provision of patient-centred care recognises these specific challenges.

A 2023 scoping review examined the research on reducing emergency ambulance transports from long-term care homes to hospitals and included 90 studies that assessed interventions within six categories; enhanced usual care and comprehensive care, palliative and end-of-life care, advance care planning, care in place for acute, subacute or uncontrolled chronic conditions and transitional care.¹¹ The latter category was the only one that looked at situations in which an ambulance or paramedics had been called for a resident. Translational care included 11 different intervention studies, with just one of these focused on an intervention assessing the outcomes of introducing extended care paramedics in a Canadian province.¹² The apparent exclusion of such a key link in the chain of health care for this patient cohort does a disservice to any program attempting to address the issue of preventable hospital admission from RACF.

The reasons that RACF staff call for an ambulance have been previously reported in the literature and have found both clinical and non-clinical reasons for those calls.^13–15 Some key factors include RACF protocols, expectations or pressure from family members and insufficient, or insufficiently qualified, staff who are unable to provide appropriate levels of clinical care.¹⁶ This study was initiated in response to the handing down of significantly negative findings from the Royal Commission in Aged Care Quality and Safety in 2020. An aspect of the commission’s findings reflected on issues such as emergency and unplanned care provision in RACF and the large percentage of residents being avoidably transported to hospital EDs.¹

Three studies specifically examine the role of paramedics responding to RACF. Murphy-Jones and Timmons¹⁷ explored the experiences of paramedics responding to residents and making decisions regarding end-of-life care in the UK. This phenomenologically influenced study of six paramedics from an English NHS Ambulance Trust found that paramedics’ decisions to transfer residents to hospital were influenced by factors such as lack of information about a resident's wishes, difficulty negotiating with other stakeholders involved in the process and the weight of making a decision in the best interest of a resident who may lack capacity. Pulst et al., in their qualitative focus group study, examined the perspectives of 18 paramedics in Germany regarding resident transfers to hospital. Their study found that paramedics faced complex issues when responding to RACF residents and had concerns regarding systems issues related to the RACF along with inter-professional issues with staff regarding poorly organised clinical handover and potentially avoidable transfers.¹⁸

Similarly to Murphy-Jones et al., Laparidou et al.¹⁹ interviewed UK ambulance staff regarding their perceptions of care provision quality when attending RACF. They identified the complexity of shared-decision making and effective communication as key elements in providing high-quality care and stressed that care homes should address perceived shortcomings in staff training and knowledge to better provide high-quality care in place. It is apparent that, when compared with the body of research that examines prevention of unnecessary resident transfers to hospital EDs, the presence of paramedics within the chain of care in this context is understudied and often absent. Another recent study from the Swedish context examined paramedic interprofessional collaboration with multiple actors when caring for older people with complex care needs.²⁰ However, there are key differences in the systems of prehospital care between Sweden and Australia and this limits its transferability to our context. This dearth of literature, and the importance of better understanding the paramedic influence on decision-making and resident outcomes, led us to ask what the experiences are of paramedics when interacting with aged care staff during the potential transfer of a resident to hospital? This research aimed to understand paramedics lived experiences of interacting with aged-care staff during transfers of care in RACF.

Methods

Study design

Our study used the descriptive phenomenological method described by Giorgi and Giorgi.²¹ Descriptive phenomenology was chosen for this research as it has a rich history of examining experiences, thoughts, behaviours and feelings of a specific phenomenon, in this case the interaction of paramedics with aged care staff. The researcher's positionality and its potential influence on the analysis were recognised, with reflexive strategies employed to mediate such influence. This particular methodology is grounded in the belief that the human experience of being in the world can be interrogated, understood and communicated in an open and scientific manner whilst remaining true to its ontological and epistemological origins.²². This methodology facilitated a deeper understanding of the participants’ feelings and thoughts about the inter-professional relationship with aged-care staff. Participants were asked to respond to the question: ‘Please tell me about your experiences of interacting with aged care staff’.

Participants and setting

Australian emergency ambulance services utilise a system that provides a dual paramedic team for each ambulance. This system does not include physicians or nurses as part of the dual crews routinely and is structured around the Anglo-American model of out-of-hospital care.²³ Paramedics employed by the state and territory-based ambulance services are predominantly qualified via tertiary undergraduate degrees and then registered by the Australian Health Practitioner Agency (Ahpra) as the regulating body for health professionals.²⁴ In Australia, only a jurisdictional ambulance service can respond to aged-care facilities via the national emergency response network.

Participants were paramedics currently employed with an Australian jurisdictional ambulance service, irrespective of clinical level or length of employment. Only those paramedics who were concurrently or previously registered as a nurse or who worked in an aged-care facility were excluded. See Table 1 for full participant demographic data.

Table 1.

Individual participant demographic data.

Participant	Age range	State/Territory^a	Geographical region^b
P1	35–39	NSW	RRMA 1
P2	60–64	Qld	RRMA 2
P3	30–34	NT	RRMA 1
P4	25–29	NSW	RRMA 1
P5	30–34	NSW	RRMA 1
P6	30–34	NSW	RRMA 1
P7	35–39	Tas	RRMA 1

NSW: New South Wales; Qld: Queensland; NT: Northern Territory; Tas: Tasmania. ^bAustralian Government Rural, Remote and Metropolitan Area Classification (RRMA): Metropolitan zone (RRMA 1–2); Rural Zone (RRMA 3–5); Remote Zone (RRMA 6–7).

The Australian RACF workforce includes personal care workers, a mix of nursing roles including registered nurses (RNs), enrolled nurses, nurse practitioners, allied health staff (e.g. physiotherapists, speech therapists, podiatrists, pharmacists and dieticians), as well as administration and ancillary care workers.²⁵ RNs and nurse practitioners have the highest qualifications and responsibilities, with enrolled nurses working under their supervision, to provide specialised nursing care, health assessments and medication management. Personal care workers and assistants in nursing provide assistance for activities of daily living including limited healthcare interventions and social care.^26,27

Recruitment and sampling

Purposive sampling from the Australian paramedic work force was undertaken online via the peak professional body for the profession, the Australasian College of Paramedicine (ACP). Snowball sampling occurred via word of mouth and various social media. Determining the sample size for a descriptive phenomenological approach is an iterative process; therefore, an a priori sample size was not set as it would not have remained true to the theory or methodology of descriptive phenomenology, however data collection was stopped after seven interviews as sufficient description of the phenomenon had been obtained to commence a robust analysis.²⁸

Data collection

Interviews were scheduled as per participant request and were undertaken consecutively by the female primary researcher between 26 September and the 21 October 2022. Verbal consent was obtained from each participant who was interviewed on a single occasion via Zoom using an open interview format. The average duration of the interviews was 63 min, with the longest being 96 min and the shortest 48 min and analysis was commenced only at the completion of data collection.

Demographic information was collected for participants age range, state or territory of employment, and the geographical region of employment. This was determined according to the Australian Government Rural, Remote and Metropolitan Classification. Participants were asked to describe their experiences of interacting with aged-care staff throughout the potential transfer of a resident. Extension questions were dependent on the individual conversation and care was taken not to lead or direct the conversation.

The audio recordings of the interviews were transcribed verbatim using Rev^TM – a Zoom^TM affiliated service. Each participant had an alphanumeric code assigned to their transcript and all written material was de-identified of any individual or location information. NVivo^TM was utilised to provide a structured and unambiguous analysis.

Data analysis

A key tenet of the descriptive phenomenological method retains a version of the philosophical step of reduction.²⁹ The researcher must set aside their preconceptions and pre-understandings of the experience under analysis and approach their data with openness and reflexivity. The primary researcher is a paramedic who had extensive experience of the phenomenon under study; therefore a consistent and conscientious effort was made to account for this positionality via journalling, with the process beginning several months prior to the data being collected and continuing throughout the collection and the analysis phases. The objective of journalling was to make explicit any assumptions that were borne from the researcher's own professional experiences of the phenomenon being examined. It was crucial that, in making these factors known, they could be examined and set aside to appreciate the description of the participant's experiences with an open mind.

This study applied the four analytical steps, articulated by Giorgi and Giorgi, to the data.²¹ It was chosen to provide a rigorous, structured and logical sequence of analysis as a structured approach underpins qualitative research methods with validity and rigour.³⁰ This essential structure is fully elucidated in the results of the study. The researcher begins with listening to the interview audio recordings, providing a general sense of the cadence and tone of the participant's ways of describing their experiences, followed by reading the transcriptions. There is no analysis performed at this stage. The researcher then dissects the text into ‘meaning’ units, denoted using a back slash. This allows the large body of text to be broken down into its meaningful parts and is a practical application rather than a theoretical one. Figure 1 provides a worked example of this process extracted from the transcript of the interview with a participant. The left-hand column shows the process of breaking down the text into meaning units.

Figure 1.

Example of text dissection.

The third and fourth steps reconstruct the everyday language into psychologically grounded meaning. The right-hand column of Figure 1 demonstrates how this was achieved in practice.

The researcher becomes the narrator for the participant by utilising the implications and significance of the described experiences. Analysis ends when the truly invariant meanings are identified as they relate to the structure of the experience. The ultimate objective of this method is to generate a description of the essential structure consisting of the identified elements of the phenomenon. The results are expressed as a paragraph that fluently incorporates the elements of the phenomenon that make it explicit.

Ethics

Prior to the commencement of this research project, ethics approval was obtained from Western Sydney University Human Research Ethics Committee (HREC) – HREC Approval H14958.

All efforts were made to design and conduct this study according to the practice of ethical human research as set out in the Helsinki Declaration and the National Statement on Ethical Conduct in Human Research. The recruitment and consent processes were designed to provide participants with sufficient information to enter into the research with fully informed consent and they were able to withdraw that consent at any time until analysis commenced. The participants’ anonymity was always safeguarded, and free, open access to mental health support services was offered and available to all the participants on completion of their interviews in recognition that they were being asked to revisit incidents that may have been distressing.

Results

Eight paramedics expressed interest in participating in the study. One was excluded due to dual registration as a nurse. No participants met the exclusion criteria of previously sharing a workplace with the researcher, for a period of longer than one month. No participant had a pre-existing relationship with the researcher. Seven paramedics met the inclusion criteria and were interviewed online. Participants’ ages ranged from 25 years to 64 years, with four participants employed in New South Wales and one each in Queensland, the Northern Territory and Tasmania. All participants worked in a metropolitan region. See Table 1 for full demographic data.

Giorgi and Giorgi's method requires that the elements of the participants responses be condense into a single ‘Essential Structure’ that encapsulates their experience. The individual elements of this structure are outlined in Table 2.

Table 2.

Summary of Elements within the Essential Structure.

Element 1	Establishing the Legitimacy of the Call for the Ambulance
Element 2	Staff Should Know About the Resident
Element 3	Access to the Resident Is Unobstructed
Element 4	RACF Staff Recognising and Appropriately Managing an Unwell Resident
Element 5	Handover of Resident Care Is Prioritised
Element 6	Transport to Hospital May Function as a ‘Desire Path’
Element 7	Professional Experience Adjusts Expectations and Improves the Experience

The ‘essential structure’ of the paramedic experience of interacting with aged-care facility staff

For paramedics interacting with aged care staff throughout the potential transfer of a resident, the experience is influenced by an exemplar of the ideal encounter, against which all experiences are compared. This ideal presupposes that an ambulance has been called for a truthful and legitimate reason, that all staff care for and are familiar with the resident, will uphold care that is only in the resident's best interests and that there is unobstructed access to the resident. The ideal interaction sets the expectations that staff will recognise and appropriately manage an unwell resident, are ready to communicate accurate, reliable and up-to-date information and that handover of resident care is prioritised over other tasks, irrespective of workload, and the staff member remains present throughout the interaction.

In circumstances where any experience does not, at least partly, meet these elements, there may be an apathy about the interaction, a loss of trust in the RACF staff member causing reassessment of the resident and an insistence on verifying all information provided by the staff member. When confidence in the ability of staff to advocate or care appropriately for the resident is diminished, the decision to transport the resident to hospital is strongly influenced by this experience. Irrespective of a positive or negative interaction, transport to hospital can be viewed as a desire path that is formed from external influences. Professional experience partly tempers the need for the ideal encounter and helps ameliorate the negative feedback loop of unmet expectations that are experienced when responding to aged care facilities.

Element 1: Establishing the legitimacy of the call for the ambulance

The determination of why an ambulance had been called and whether that call had been for a genuine and truthful reason, forms a key element of the essential structure. It is intertwined with participants’ trust that the information being provided to them by staff was correct, which then impacted their judgement regarding the staff's capacity to appropriately care for and manage a resident.

But calling us because your 65-year-old dementia patient is getting a little more agitated than usual isn’t a good excuse to call us. (P1)

The broader beliefs and attitudes held by some participants also influenced their determination of whether a call to an RACF was for a genuine reason or not and included factors such as the facility's policies or protocols. This element was characterised by a sense of frustration when participants alluded to staff attempting to justify why an ambulance had been called.

But then we’ll go … we’ll go to another one where, you know, there's a registered nurse that fudges the stories up a bit to make it sound a lot worse than it actually is. So, we do transport, you know. (P3)

Element 2: Staff should know about the resident

The participants had the expectation that all RACF staff would hold detailed and pertinent knowledge of the residents that were in their care; however, conceded this could be hindered for staff that had a greater clinical work burden. There is significant respect shown towards the non-clinical staff that closely correlates with resident-centred care. The participants’ experiences were positively shaped if their interactions with aged-care staff had been collaborative and resulted in an outcome that was believed to best meet the needs of the resident. Knowledge of the resident and making decisions that were in their best interests were inseparably linked, and when the participants felt that staff had been making decisions that were resident centred, this impacted positively on their interaction. The positivity expressed by the participants towards staff in these moments was often linked to non-transport decisions where everyone present shared an understanding of the resident's best interests and believed that an ED admission would be detrimental and should be avoided.

So, we actually had a good interaction with the nurses there … He ended up staying there because we all agreed that he was actually probably going to get better one-on-one care in the nursing home rather than going up to hospital and going through the whole rigmarole of going through in the red zone and not getting that one-on-one care. (P3)

So, I think it's just the fact of a good understanding of their patient, of the situation, and willing to work with the paramedics to be able to save or . .. try … How do I say it? Try and work through other options rather than just take them to hospital. You know, what's best for the patient. (P5)

However, incidents when another health care professional had already determined that the resident was to be transported to hospital were often seen as detrimental, particularly when framed as being potentially harmful to the resident.

So, I know that if I take that patient to the emergency department for one blood test, they’re going be on the ramp for nine hours. But those outside, like the doctors who have just called up the nurses, don’t understand that. Or if they do, they don’t care. I feel like they don’t care. (P7)

Element 3: Access to the resident is unobstructed

The perception of obstructed access is meaningfully connected to the legitimacy of an emergency call and in circumstances where participants felt staff were not focused on providing them access to the resident during an emergency, they queried how genuine the emergency was. Obstructed access to a resident during an emergency or any impediment that was viewed as having compromised resident wellbeing would generate feelings of negativity.

During the night-time, if the RN never picks up the phone while you’re at the intercom at the front door and you’re standing there for 20 minutes thinking, ‘Come on, you know? What are we doing here? You called for a lights and sirens transfer, and here we are standing for 20 bloody minutes waiting for you to answer the door.’ Like, what's going on? (P5)

Most of the participants cited specific cases where they had felt that their access to the resident had been thwarted.

We went to the building that we had been told to go to, and there was no one to be found. And then the person on the front desk, who was an RN, didn’t think an ambulance had been called for that patient…And then after five minutes of phone calls, it was established that this patient did need an ambulance. But then the elevator was broken but that hadn’t been filtered down to us, either. So, then we had to re-park the vehicle and come in through a back entrance. So, it was about 15 minutes before we made contact with the patient and that patient was actually very unwell. (P6)

The incidents were variously described as either related to the built environment of the facility itself – for example, having to relocate the ambulance due to issues with a driveway or building works – or to the actions of staff when attempting to gain access to the facility – for example, after hours when facilities are locked to prevent unauthorised entry.

Element 4: RACF staff recognising and appropriately managing an unwell resident

There was an expectation that RACF nursing staff possessed the knowledge and capability to recognise and manage an acutely unwell resident. This expectation was developed early in a participant's career and became a source of vexation when it was unmet, even in circumstances when barriers encountered by staff had been recognised, or the call was for a genuine emergency presentation:

So, you start getting your back up. You start getting …Your mindset starts going, ‘I’m dealing with stupidity.’ You know? And you go in and you realize, ‘Yes, that's exactly what it is’ or ‘Oh, shit, this person is actually quite sick.’ You know? ‘Why didn’t you tell us this information? This patient's now peri-arrest’ (P3)

This element of the essential structure is integral to the paramedic experience of interacting with aged-care staff. Each participant provided narratives whereby registered nursing staff had either not identified, or had not effectively managed, an extremely unwell resident. These cases often had multiple aspects of the essential structure and were cited as supporting evidence for staff dysfunction and incapability.

Element 5: Handover of resident care is prioritised

Clinical handover dominated descriptions of the participants’ experiences and was linked with the belief that RACF staff should be able to perform to a clinical level equal to that of ED nursing staff. Participants conceded that the ability for staff to be prepared for handover and remain with them through the interaction could be encumbered by factors such as workload, lack of staffing and competing priorities. Handover of important information regarding the resident was additionally related to how well the staff knew the resident and was influential in the decision-making process. Many examples given included descriptions of step-by-step ideal processes.

But we found that the RN, number one, welcomed us at the door, which was really good. She took us to the patient, had a concise history of the patient and what had exactly happened in the past 24 to 48 hours. Her paperwork was ready. She was willing to discuss the patient's situation options as well with us. It wasn’t simply a fact of here, take her away to hospital. (P5)

Participants felt that occasions where staff performance had met these criteria were moments that should be acknowledged and appreciated by them. This recognition was believed to improve the relationship with staff and create a sense of goodwill and a willingness to engage more deeply to come to a mutually agreeable outcome.

Element 6: Transport to hospital may function as a ‘desire path’

Participants decided to transport a resident to hospital for reasons other than clinical necessity. This desire path could be chosen for different reasons that are dependent on the individual and the circumstances.

But things like being hungry, a basic human sort of thing, may alter the decision that I make. When, for example, I’ve been working for 14 hours, I’m quite fatigued and I’m not necessarily capable of really managing this patient safely in this environment. Or my decision-making processes may not be as what they would be if I had been at the beginning of a shift. That sort of stuff will inevitably change the disposition of the patients. (P4)

Various decision-making pathways were described however, it became apparent from the data that resident transport to hospital routinely occurred for reasons other than clinical necessity. These exceptions included a desire to avoid conflict with staff, the leveraging of policy as a means of transferring liability, pre-determined practices based on experience, fatigue or confidence in the staff.

Element 7: Professional experience adjusts expectations and improves the experience

The participants’ experiences of interacting with RACF staff changed over time. This was due primarily to lowered expectations of aged-care staff, their increased clinical education or their modified attitude towards staff, which was grounded in greater understanding and personal experience and less influenced by peers and senior colleagues. Irrespective of the reasons behind the change, this transformed approach was considered to have created a more positive experience for the participants when interacting with RACF staff.

But I think as I approach my own aged-care (laughs) residential experience, and my silver back approach to being a clinician, I’ve just become kinder and gentler, you know? Everyone's doing their best, and, you know, you can’t expect too much of people. (P2)

For two of the participants with specialist clinical training, their approach to RACF incidents had been altered by the expectations placed on them in their roles. For these participants, the essential structure had continued to remain fundamental to their interactions; however, there were discrete differences in their experiences that had been created by their improved knowledge.

I think the longer the one stays in these environments managing or assessing the patient, then you’re part of that process and the more you recognise that, you realise there's actually quite a lot that is going on beyond that 20- to 30-minute interaction that initially was thought. And during that time that you’re immersed in that environment, you realise that it's not as easy as what I thought it used to be, which was that we would just transfer up to the hospital because the aged-care facilities couldn’t manage them effectively. (P4)

Discussion

This study describes the essential structure of the paramedic experience of interacting with aged-care staff during the potential transfer of a resident to hospital. It brings new understanding of this interaction to existing research on the interface between RACF and emergency ambulance services and ultimately, the ED.

The term ‘desire path’ stems from landscape architecture and is defined as an unplanned route that people create by repeatedly taking the same path through a space or environment that is contrary to the intended design.^31,32 It reflects a human divergence between the planned design of a space or system and the actual usage patterns of the people who interact with it. In the context of this study, the desire path was a theoretical one in which transport to hospital was decided on, irrespective of clinical need, rather than navigating with aged-care staff, residents, residents’ families and other healthcare professionals towards potential alternatives. Theoretical desire paths have been described by Nichols as ‘social desire paths’ and she further adds that ‘The labelling of phenomena as social desire paths and understanding why they form is a theoretical approach that allows empirically identified patterned behaviours, and the values behind why they form, to be made explicit’.³³^(p4)

This study found that participants would use transport to ED to avoid conflict with staff and other stakeholders and mitigate fatigue.

The participants had a psychological concept of an idealised encounter, which created a specific set of expectations and shaped their experience. Interactions that fell short of these expectations played an important role in the use of desire paths as way of avoiding confronting these unmet expectations. Other research across healthcare recognises that there are distinct cultural differences inherent in the ways healthcare professionals communicate with each other and the ways in which those differences impact effective communication and patient outcomes.³⁴ Our study particularly found expectations related to the importance of communicating a robust clinical handover.^35–37 An unsatisfactory handover, as perceived by the paramedics, erodes the inter-professional relationship, and potentially ends in an avoidable transfer to hospital. These findings are supported by other research that found poor handovers are associated with multiple hazards that could lead to substandard patient care and clinical error. A 2021 systematic review by Desmedt et al. noted that a particular challenge in improving clinical handovers are the divergent perspectives regarding key information to be exchanged between healthcare providers in differing settings.³⁸ Particular issues noted by our participants – such as distraction, workload and lack of time – are also consistent with this existing literature.^38–40

While the genesis of the ideal interaction remains unclear, a combination of the undergraduate paramedic curriculum, ongoing professional and employment-based training, and post-employment practice and inculturation have perhaps shaped some aspects of it. The assessment of validity of an emergency call may also be linked to the self-perception of the paramedic role.⁴¹ The findings suggest that expectations may be somewhat moderated over time by a clinician's own experiences and education. This is supported by the findings from Perona et al.'s 2019 review of the paramedic decision-making literature, which found that professional experience alters judgement and problem-solving.⁴²

Inter-professional practice (IP) is a collaborative and patient-centred approach to healthcare delivery.⁴³ Prior research into transitions of care from RACF to ED has focused on the provision of written information between the RACF and ED.^44,45 However, our study revealed that verbal information was more important than that provided by documentation. This expectation has been supported by the knowledge that communication of patient information during care transitions has a significant influence on patient safety and care outcomes.^46,47 When this information is lacking, it impacts negatively on the inter-professional relationship. McNulty and Politis’s findings that IP improves relationships is supported by literature examining mechanisms for improving collaboration between RACFs and ED. There has been an ongoing focus on IP communication as a key factor in avoiding unnecessary hospital admissions.^48–50

When participants described situations where their expectations had not been met, they experienced negative emotions that impacted their clinical decision-making. It has been recognised that negative feelings lead to cognitive biases and affect clinical decision-making, which then potentially compromises patient safety.^51,52 However, within the paramedic literature, a diversity of influences on decision-making have been previously identified. A 2014 qualitative study examining transitions of care in a UK ambulance service found interlinked factors contributed to paramedics decisions, including systems issues, access to appropriate alternatives to hospital and risk aversion whilst Sheffield et al. identified holistic healthcare, clinical experience, protocol use, referral processes and education as influencing factors in non-transport decision-making, aspects of which are more reflective of our findings^53,54 Whilst our study cannot fully unpack why paramedics had negative responses to aged-care staff, the fact that those experiences clearly impacted on their clinical decision-making bears deeper scrutiny.

Implications for research and practice

To date there has been limited application of research into desire paths within a healthcare context, and this is an aspect of paramedic practice that is worthy of greater time and attention. For options other than transporting a patient to ED to be successfully implemented, particularly in the RACF context where decision-making is complex and multifaceted, a deeper understanding of when and why paramedics decide to transport a resident to ED when there is no immediately pressing clinical need is essential, as this potentially has implications for clinical care, RACF resident outcomes and an increase in healthcare costs due to resource utilisation.

Any research into models of care that reduce unnecessary transfers from RACF must recognise the role that ambulance services and paramedics have in this environment and create approaches that are inclusive of the profession. Considerations for future studies should also examine the role of professional identity, communication and workforce constraints. Importantly, paramedic employers and health services should develop collaborative education and training programs, such as inter-professional simulation training and education, at both an undergraduate and employment level, to improve the understanding of each other's professions and inter-professional communication between aged-care staff and paramedics. Education aimed at imparting non-technical skills can play a role in equipping paramedics with the knowledge they need to be able to recognise and manage negative emotions and make informed decisions in challenging inter-professional situations.

Strengths and limitations

Our study collected data through online interviews. There are some recognised limitations when conducting research via this method, such as challenges with building rapport and barriers to recognising non-verbal cues;⁵⁵ however, the use of online interviewing supported the inclusion of a diverse participant population. Interviews may have been influenced by the researcher's bias or preconceptions; however, this was mitigated through the use of reflexive journalling and the adherence to methodological processes. Desirability and hindsight bias may have influenced participants to provide socially and culturally acceptable recollections of their experiences, however, in keeping with the descriptive phenomenology method, participant's descriptions were taken exactly as described. Participants thick description of their experiences is presented in a way that enables transferability. Their experiences provide the findings with a measure of universality that stem from a spectrum of the Australian paramedic workforce. The data and findings were from the paramedics’ perspective of their interactions with RACF staff, and all participants worked in metropolitan regions. There may be differences in the experiences of rural paramedics when attending RACF that were not collected due to this limitation. Interviews were held towards the end of two years of the Covid-19 global pandemic and the, predominantly negative, findings from the Australian Royal Commission on Aged Care Quality and Safety had been released approximately 18 months prior. This research was conducted at a time of significant challenges for both the Australian aged care industry and ambulance services and may have impacted on the experiences of the participants.

Conclusion

Our study provides a rich description of the paramedic experience of interacting with aged-care staff during the potential transfer of a resident to hospital. The use of desire paths in relation to resident care has implications for the healthcare system as a whole. The findings highlight the impact that communication, collaboration and shared decision-making have on IP practice in the aged-care setting. Targeted undergraduate education and professional training that emphasises collaboration and communication would promote more positive IP and provide a more holistic and balanced approach to RACF resident care that centralises their complex and diverse needs.

Footnotes

Ethics and consent statement

This study received ethical approval from Western Sydney University Human Research Ethics Committee (HREC) – HREC Approval H14958. All participants provided verbal consent prior to participating in the study.

ORCID iDs

Sascha Baldry

Paul Simpson

Author contribution(s)

Sascha Baldry: Conceptualization; Data curation; Formal analysis; Formal analysis; Investigation; Methodology; Project administration; Resources; Software; Validation; Visualization; Writing – original draft; Writing – review & editing.

Paul Simpson: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Supervision; Validation; Writing – review & editing.

Liz Thyer: Conceptualization; Data curation; Formal analysis; Formal analysis; Investigation; Methodology; Resources; Supervision; Validation; Writing – review & editing.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Western Sydney University – research training funds provided for transcription services and professional editing services.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: A/Prof Paul Simpson is Editor in Chief of Paramedicine but played no role in the editorial decision process which was conducted in adherence to the journal's peer review policy. A/Prof Paul Simpson is a Director of the Australasian College of Paramedicine, the primary funding source for the journal. Ms Sascha Baldry and A/Prof Liz Thyer declare no conflicts of interest.

Data availability

The data from this study is available via Western Sydney University on request.

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