Objective To investigate whether the New Zealand Early Warning Score (NZEWS) has greater diagnostic accuracy than current clinical triage Status Codes for predicting 2-day mortality in the Aotearoa New Zealand pre-hospital setting. Methods A retrospective cohort study used de-identified data from the Aotearoa New Zealand Paramedic Care Collection. Records from patients attended by the Hato Hone St John ambulance service between 1 July 2022 and 31 December 2022 were screened for eligibility. Included patients were adults (≥15 years) transported to hospital with a complete set of initial vital signs and an initial clinical triage Status Code. NZEWS was applied retrospectively and compared with clinical triage Status Codes for predicting 2-day mortality using area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive predictive value and negative predictive value. The optimal NZEWS threshold was identified using the best balance of sensitivity and specificity. Secondary analyses used Chi-square and Mann–Whitney U tests to describe demographic differences, while logistic regression examined associations between demographic and contextual factors and 2-day mortality. Results The study included 125,278 patients. Both NZEWS and clinical triage Status Codes were strongly associated with 2-day mortality. NZEWS demonstrated superior diagnostic accuracy (AUROC 0.80, 95% CI 0.79–0.81) compared with clinical triage Status Codes (AUROC 0.74, 95% CI 0.73–0.76; DeLong test: Z = 9.66, p < 0.001). The optimal NZEWS threshold for predicting 2-day mortality was lower than previously reported high-risk thresholds (score of 6), identifying more at-risk patients but increasing over-triage. Older age, Māori and Pacific ethnicity and rurality were independently associated with increased 2-day mortality. Conclusion NZEWS outperformed clinical triage Status Codes in predicting 2-day mortality, identifying more at-risk patients at the cost of increased over-triage. NZEWS may support earlier recognition of high-risk patients in the pre-hospital setting, although further research is needed to refine thresholds and guide implementation.
Background Māori face significant inequities in health care, access and outcomes. One approach to reducing these inequities is to increase Māori representation in the health workforce, including paramedicine. Despite this, Māori remain underrepresented in paramedicine, from tertiary education to the paramedic workforce, with limited research understanding this gap. This study aimed to explore the experiences of Māori paramedicine tauira (students) at Auckland University of Technology, Aotearoa New Zealand. Methods This qualitative study, underpinned by a kaupapa Māori methodology, involved an in-depth, full-day wānanga with seven Māori paramedicine tauira. The research aimed to understand the key barriers and enablers that influenced tauira Māori participation and engagement in paramedic tertiary education. A general inductive approach, underpinned by kaupapa Māori principles, was employed to analyse tauira Māori experiences. Results Three key themes were identified: (1) Mana-Enhancing Environments and Experiences, (2) The Impact of Westernised Institutions, and (3) Cultural Safety within Institutions. Māori paramedicine tauira identified culturally appropriate teaching practices, culturally safe learning environments and supportive relationships as key factors contributing to positive, mana-enhancing experiences. Key barriers to their experiences and participation were identified as culturally inappropriate teaching practices, culturally unsafe learning environments and placements, a lack of Māori-focused content and insufficient cultural safety education. Study Implications The findings of this study suggest significant implications for improving Indigenous participation and engagement in paramedic tertiary education. By identifying and addressing barriers to participation and engagement, it is possible to improve the experiences and completion of paramedic qualifications among Indigenous peoples. This, in turn, can increase Indigenous representation in the ambulatory workforce and contribute to mitigating health inequities faced by Indigenous communities.
Background Prehospital intensive care is commonly delivered within tiered service delivery models. Road-based Intensive Care Paramedic (ICP) crewing varies across international contexts and national jurisdictions, yet the way these models are evaluated is often inconsistent and incomplete. The literature is narrowly focused on out of hospital cardiac arrest (OHCA), frequently infers efficiency from tiered models without rigorous evaluation, and rarely incorporates provider perspectives. Together, these limitations make it difficult for Emergency Medical Services (EMS) leaders to compare crewing models in a meaningful way. Objectives To present a theory-informed conceptual framework for the comparative evaluation of ICP crewing configurations using multidimensional outcome measures. Methods Framework development drew on a scoping review with systematic searching and screening and was theoretically grounded in aspects of the Quadruple Aim, labour economics, and institutional theory. It is intended for application to Australian road-based ICP crewing while remaining adaptable across EMS systems. Results The framework specifies four outcome domains: (a) patient outcomes (e.g. survival), (b) provider experience (e.g. workload, burnout, safety climate), (c) operational efficiency (e.g. response/scene times paired with meaningful outcomes), and (d) economic sustainability (e.g. cost, productivity, overtime/backfill). Each domain is supported by theory that helps explain why these outcomes matter and how they may interact. Conclusion The framework provides a structured approach to comparing road-based ICP crewing configurations across patient, provider, operational, and economic domains. Future research should test and refine the framework within the Australian EMS context.
Background Expansion of paramedic roles in the community could reduce non-urgent emergency department (ED) attendances. In Ireland a knowledge gap exists regarding the development of alternative care pathways that avoid ED conveyance. The aim of this research was to explore inter-rater agreement amongst advanced paramedics (AP) about the ‘appropriateness’ of attendances to the ED in Ireland utilising data from the Better Data, Better Planning (BDBP) Study. Methods The BDBP study was a multi-centre study investigating factors influencing ED utilisation in Ireland. For this secondary data analysis, a chart review was conducted and adult patient summary files ( n = 306) were assessed for measures of appropriateness by a national panel of six AP, including whether each presentation was considered an inappropriate use of ED resources and potentially could be managed by a General Practitioner (GP) within 24–48 h. A subset analysis compared outcomes for patients transported by ambulance with those that were transported to the ED by other means. Results The AP panellists determined that between 12% to 73% of ED attendances were considered an inappropriate use of ED resources (Inter-rater Agreement 19%, κ = 0.182, p < .001) and that between 12% to 79% of cases were suitable for management by a GP within 24–48 h (Inter-rater Agreement 11%, κ = 0.120, p < .001). Inter-rater agreement was higher for patients transported by ambulance who tended to be older ( p < .001), live alone ( p ≤ .01), have higher triage scores ( p ≤ .01), and be admitted to hospital ( p ≤ .01). Conclusions APs did not reach agreement on what constitutes an ‘inappropriate’ attendance to the ED. The reasons for this are multifactorial but it highlights the complexities in developing alternative care pathways for ED avoidance in the community setting. The potential for development of alternative care pathways in Ireland is significant but requires appropriate supervision and governance to support decision-making for paramedic roles with an expanded scope of practice.
Introduction Community paramedics provide care in a diverse range of settings that address the needs of the communities they serve. Recent developments have resulted in a call for guidance on the education requirements of community paramedics at a national level in Canada. To inform the development of such guidance, we sought to identify the various roles that community paramedics in Canada enact. Methods This was a three-phase study that combined (1) frameworks describing community paramedicine in Canada, (2) a review of community paramedicine literature focused within the Canadian setting, and (3) a review of data reported by a pan-Canadian working group. Elements identified at each phase were extracted and mapped to an existing role description for paramedics in Canada. Elements central or unique to community paramedic practice were iteratively identified and highlighted. Results Community paramedics perform multiple roles that span a broad continuum of the healthcare system. They deliver and support person-centred care through expanded assessment, diagnostic and therapeutic interventions (Clinician). They are situated in and engage with communities in designing programs to meet community needs (Professional). Through their trusted relationships with people receiving care and care partners, they engage in health promotion and education activities (Educator). They coordinate care and help patients navigate the care system (Health and Social Advocate). As members of interprofessional care teams (Team Member), they both accept referrals and refer within these teams, as well as support a range of disposition options. They continually assess and maintain their professional competence and personal wellbeing (Reflective Practitioner). Discussion and conclusion Community paramedics share common roles with other paramedics in Canada, but their enactment of these roles is contextually specific and involves elements that are unique or more prominent. The description of these roles in the community paramedic context will guide future developments in community paramedic education.
Paramedicine occupies a distinctive position within contemporary healthcare, characterised by complexity, unpredictability and moral intensity. Unlike clinical professions operating in controlled environments, paramedics deliver care within dynamic, uncertain and often resource-limited contexts. While these operational challenges of paramedicine are well acknowledged, the philosophical and conceptual dimensions of paramedic practice remain comparatively underexplored. This paper proposes a reconceptualisation of paramedicine as a ‘KNUTS’ profession – extending Lupien's NUTS stress model (Novelty, Unpredictability, Threat, Sense of lack of control) by adding ‘knowledge’ as a fifth, epistemic dimension. This framework is used as a heuristic to explore the epistemological, ontological and existential nature of paramedic work. Using a conceptual analytic approach, the paper synthesises contemporary paramedicine literature with philosophical, sociological and educational theory. Key concepts from Heidegger, Schön, Polanyi, Dall’Alba and Lave and Wenger, are selectively engaged to explore how knowledge, uncertainty, judgement and identity interact in the everydayness of paramedic work. Knowledge emerges as the epistemic core of paramedic practice, legitimising autonomy and shaping professional identity. Novelty and unpredictability define the profession's lived reality, requiring practitioners to engage in rapid, situated judgement and ethical decision-making under uncertainty. Threat and control reflect the profession's existential tensions, as paramedics navigate vulnerability, accountability and limited autonomy within complex systems. Together, these interdependent dimensions reveal paramedicine as a practice of continual becoming shaped by embodied expertise, ethical reflection and adaptive expertise. Understanding paramedicine as a KNUTS profession provides a theoretically grounded lens to conceptualise its unique demands. Clarifying the heuristic use of a biologically derived stress model within a socio-cultural domain strengthens the framework's analytical contribution and highlights implications for education, leadership, policy and workforce wellbeing. This perspective carries implications for professional education, policy and leadership – emphasising the cultivation of reflective, ethically grounded practitioners capable of thriving amid complexity.
Preparing paramedic students for demanding and unpredictable care contexts requires the development of competencies such as emotional intelligence and compassion, particularly in relation to emotional regulation, interpersonal interactions, and decision-making. This descriptive correlational study aimed to examine the relationship between emotional intelligence and compassion among paramedic students, explore the associations between the subdimensions of emotional intelligence and compassion, and determine which emotional intelligence dimensions explain variance in compassion levels. The study included 113 paramedic students. Data were collected using a Personal Information Form, the Trait Emotional Intelligence Questionnaire-Short Form (TEIQue-SF), and the Compassion Scale (CS). Descriptive statistics and simple and multiple linear regression analyses were performed. The results showed that paramedic students demonstrated a high level of compassion (102.12 ± 10.00). Emotional intelligence was significantly associated with compassion and its subdimensions ( p < 0.001), explaining a substantial proportion of the variance. These findings indicate that emotional intelligence is a relevant psychological characteristic associated with compassion among paramedic students. From an educational perspective, the observed associations suggest that emotional intelligence training may emerge as an important focus to bolster compassionate capacities among paramedic students. Further research could examine its relevance for curriculum design.
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.
Background Paramedics operate in diverse, unpredictable environments where they encounter people requiring not just clinical intervention but compassionate, dignified care. Currently, paramedicine has no conceptual framework specific to their profession. Person-centredness is the global standard for healthcare delivery, offering an appropriate philosophical foundation for emergency practice contexts. Aim This hybrid scoping/methodological review examined international literature on person-centredness in paramedicine, specifically its conceptualisation and implementation in emergency settings, and paramedics’ understanding and delivery of person-centred approaches in practice. Method Systematic searches across five databases identified relevant studies. Critical realist analysis employed the Person-Centred Practice Framework as analytical infrastructure, maintaining appropriate epistemological boundaries for secondary literature. The JBI checklists assessed methodological quality, and thematic synthesis examined conceptual patterns, research approaches and structural mechanisms shaping practice. Results Seventeen studies were included: 13 qualitative studies, 2 quantitative studies, and 2 systematic reviews. Geographic concentration was striking; 76% originated from Sweden, where ambulance personnel are nurse-trained rather than paramedic-trained, representing fundamentally different professional preparation for scopes of practice. Analysis revealed systematic tensions across three domains. Conceptually, paramedics lack shared understanding of what person-centredness means for emergency practice. Relationally, they navigate emotional regulation, power asymmetries and temporal constraints that challenge person-centred ideals. Ethically, they face conflicts between autonomy principles and risk management demands. A fundamental paradox defines current practice: paramedics demonstrate excellence in relational care yet reject person-centred language, citing poor conceptual clarity and lack of profession-specific guidance. Conclusion The articulation of person-centredness is largely absent from paramedic-specific evidence. Systematic tensions expose gaps between theoretical ideals and practice realities shaped by structural constraints, organisational cultures and professional hierarchies. Without paramedic-led research and context-specific frameworks, person-centredness risks remaining borrowed rhetoric rather than authentic professional identity. Future research must develop profession-specific conceptualisations that bridge policy frameworks, educational programmes and practice cultures to embed person-centredness within paramedic professional identity.
Placement experiences are a fundamental component of tertiary paramedicine programs, where students can link theory with practice. However, the quality of placement experiences has been known to vary. Students have reported varying levels of placement satisfaction, supervisory support, clinical exposure and opportunities for learning. This scoping review aims to explore the factors that influence quality paramedicine student placements. The Joanna Briggs Institute Scoping Review Methodology guided this study. The electronic databases MEDLINE, Emcare, Scopus and CINAHL were comprehensively searched in February 2025 and again in October 2025 for relevant peer-reviewed research articles. The initial search strategy was developed in MEDLINE and subsequently adapted to each database. Title and abstract screening was conducted first, followed by full-text screening, as per the Joanna Briggs Institute Scoping Review methodology. Included articles were assessed for methodological quality. The search strategy resulted in 13,479 articles for screening. A total of 25 met the inclusion criteria. Several key factors were identified which influence quality paramedicine student placements: (i) the impact of supervisors; (ii) the learning experiences of students; (iii) placement setting and structure; and (iv) student satisfaction. Identifying these quality indicators will allow stakeholders, including universities and placement providers, to develop strategies to improve the paramedicine student placement experience.
Attrition and certification failure remain persistent challenges in paramedic education, reducing workforce readiness and straining training programs. Despite widespread use of selective admissions criteria, little empirical evidence exists regarding the predictive validity of selective admissions examinations in paramedicine. The aim of this study is to evaluate whether preadmission academic performance and scores on the Fisdap Paramedic Entrance Exam predict successful program completion and first-attempt certification. A repeated cross-sectional study was conducted using records from one paramedic program (N = 109). Program completion was defined as on-time graduation with first-attempt success on the NREMT examination. Three logistic regression models were tested: academic predictors, Fisdap entrance exam subscales, and a combined model. Model performance was evaluated using likelihood-ratio chi-square tests, Nagelkerke R 2 , and AUC. Both the academic model (R 2 = 0.15; AUC = 0.69, 95% CI [0.57–0.81]; LR χ 2 (4) = 11.19, p = 0.025) and the Fisdap model (R 2 = 0.28; AUC = 0.77, 95% CI [0.68–0.87]; LR χ 2 (3) = 21.59, p < 0.001) were statistically significant. Institutional grade point average (GPA) and anatomy grade positively predicted completion in the academic model, while only the reading subscale was a significant positive predictor in the Fisdap model. In the combined model (R 2 = 0.26; AUC = 0.77, 95% CI [0.68–0.86]; LR χ 2 (2) = 19.79, p < 0.001), the Fisdap composite score remained a significant positive predictor, whereas the GPA did not. The combined model demonstrated a sensitivity of 0.81 and a specificity of 0.43. Entrance exam performance, particularly reading comprehension, demonstrated moderate predictive validity beyond prior academic achievement and showed stronger associations with program completion than did institutional GPA. These findings support using cognitive entrance exam data to assess readiness and complement holistic admissions processes in paramedic education. Multi-site studies are needed to confirm generalizability and refine evidence-based selection and support practices.
Introduction Health inequities in rural and regional areas highlight the need to understand prehospital care for time-critical conditions. Despite the significance of symptomatic bradycardia, limited research exists on its management in prehospital settings, particularly outside metropolitan centres. Therefore, the purpose of this study is to examine how symptomatic bradycardia is managed in the prehospital environment. Methods A retrospective observational analysis was conducted on adult patient data (aged 18 years and older) with clinically significant symptomatic bradycardia as attended by Queensland Ambulance Service paramedics in 2023. Cases were identified from electronic Ambulance Report Forms. Demographic, clinical, and treatment data encompassing the use of atropine, transcutaneous pacing (TCP), and adrenaline were extracted. Comparisons in geolocation, ambulance response time, intervention, and clinical outcomes were conducted using descriptive and inferential statistics. Results A total of 2418 bradycardia cases were included with a median age of 77 years (IQR 65 to 84), and 58.1% were male. Atropine was administered in 18.0% of cases (n = 436), while adrenaline was administered in 5.8% of cases (n = 140). TCP was performed in 10.1% of atropine cases (n = 44). Heart rate increased following prehospital treatment, rising from a median of 40 beats per minute (IQR 34 to 48) to 60 beats per minute (IQR 45 to 76) after treatment. Critical Care Paramedics attended 38.8% of metropolitan bradycardia cases compared with 21.4% in remote regions. Ambulance response time was shorter in remote areas, with a median of 14.8 min (IQR 7.8 to 28.1) compared with metropolitan areas at 18.2 min (IQR 11.1 to 29.5), (H = 58.228, p < 0.0001). However, the time interval from call received to atropine administration was longer in remote areas, with a median of 67.6 min (IQR 45.9 to 122.9) compared with 51.3 min (IQR 40.3 to 61.9) in metropolitan regions (H = 11.125, p < 0.01). Conclusion Prehospital treatment of symptomatic bradycardia was shown to increase heart rate. However, geolocational differences in the time interval for the advanced treatment option of atropine were observed. Further research is required to corroborate these findings and inform strategies to address geolocational-based disparities in prehospital cardiac care.
Background Paramedicine is in the midst of a global shift towards professionalisation, marked by advances in education, regulation, and integration within healthcare systems. While barriers to this process have been well described, less is known about the facilitators that enable progress. Aim This study explores key facilitators of paramedic professionalisation across five high-income healthcare systems. Methods Semi-structured interviews were conducted with 15 stakeholders, including clinicians, educators, policymakers, and leaders, from the United Kingdom, Ireland, Canada, Australia, and the United States. Interviews were conducted online, recorded, transcribed verbatim, and analysed thematically within a critical theory framework. Results Six themes were identified: 1. The evolution and expansion of paramedic roles, including specialisation and increased autonomy. 2. Community paramedicine as a catalyst for integration and preventative care. 3. Professionalisation and recognition through advanced education, regulation, and career pathways. 4. Socio-political, Governance and Leadership Enablers. 5. Interprofessional collaboration and strong professional leadership. 6. The impact of Coronavirus Disease 2019 (COVID-19) as an accelerator of change, highlighting opportunities for innovation, research, and lifelong learning. Conclusion Facilitators of professionalisation include political investment, regulatory reform, educational advancement, and collaborative leadership. Harnessing these enablers is essential for embedding paramedics as integral healthcare professionals. Together with companion work on barriers, this analysis provides an understanding of the challenges and opportunities shaping the future of paramedicine.
Aim: This exploratory qualitative study examined the experiences of frontline ambulance staff in English National Health Service ambulance services regarding their senior leadership. Background: Recently, leadership effectiveness in English ambulance services has attracted significant regulatory and policy attention following failures in organisational culture, staff well-being and patient safety. Despite strategic initiatives to enhance leadership development, government regulatory inspections continue to identify dysfunctional leadership practices, including a possible disconnect between leaders and frontline operations, insufficient staff support and ambivalence towards toxic workplace cultures. Limited research has explored how English ambulance staff directly experience and perceive their senior leaders. This study seeks to fill this gap. Method: An exploratory-descriptive qualitative methodology employing semi-structured interviews was utilised. Participants were purposively recruited via social media. Ten frontline ambulance staff, all in operational roles in England, participated in recorded online interviews. Transcribed data was analysed using Reflexive Thematic Analysis, within an interpretivist-constructivist paradigm. Results: Analysis revealed three major themes: (a) Culture – encompassing communication effectiveness, organisational transparency and psychological safety; (b) Ethics – including honesty, accountability, fairness in decision-making and compassion; and (c) Influence – examining external pressures, professional voice, clinical understanding and impacts upon retention. Participants reported having valued leaders who demonstrated authentic communication and genuine connection, while describing how poor visibility, ambiguous messaging and perceived dishonesty had often fostered dysfunctional coping strategies within the workforce. Participants particularly attributed disconnection between strategic and operational levels to high turnover in leadership personnel, who were often seen to be politically rather than practically ambitious, and a lack of direct clinical experience among senior leaders. Conclusion: Although participants recognised external constraints on senior leaders, and cited many examples of good practice, their reported experiences routinely highlighted significant gaps between leadership strategies and operational realities that contributed to staff attrition which was perceived to contribute to a compromised organisational performance.
Over the past two decades, paramedicine research has expanded significantly. While much of this work has been conducted within individual countries, there is now a critical need to foster international collaboration to improve knowledge synthesis and dissemination. This perspective paper draws on the authors’ experience conducting a multi-country study involving Canada, the USA, the UK, and Australia to reflect critically on the structural, methodological, and ethical challenges of international research in paramedicine. Rather than positioning the project as the central focus, it serves as a lens to explore broader issues that impact cross-jurisdictional research, such as differences in ethical review processes, variability in academic and regulatory infrastructures, and the complexity of designing context-sensitive methodologies across systems. These reflections highlight both tensions and opportunities for advancing paramedic research on a global scale. The paper underscores the importance of early engagement with partner organisations, flexible planning when working with operational clinicians, and deliberate strategies to foster mutual understanding within interdisciplinary teams.
Introduction In Canada, paramedics and hospital emergency department (ED) nurses utilize the Canadian Triage and Acuity Scale (CTAS) to assign acuity. This study examined concordance of assessment between paramedics and emergency department triage nurses. We also assessed operational factors to provide confidence that paramedic triage scores were not being influenced by non-patient-related factors such as workload, delays in handover or destination type. Methods We conducted a retrospective cohort study of all paramedic-transported patients to hospitals from 1 January 2018 to 31 December 2022. All records of patients transported by paramedics to in-region EDs or urgent care centres (UCCs) where CTAS was recorded at two different points by paramedics (at time of transport) and triage nurses (at time of ED triage) were reviewed. We analyzed concordance using crude percentages, inter-rater agreement using a weighted kappa ( kW ) analysis, and computed an adjusted multilevel binomial regression model to determine independent associations between agreement and operational and clinical factors using odds ratios (OR) with 95% confidence intervals (CIs). Results Inter-rater reliability analysis showed ‘substantial’ agreement for the most critical patients (CTAS 1: 78.8%, κW = 0.66) and ‘fair’ agreement for the least urgent patients (CTAS 4: 32.8%, κW = 0.30; CTAS 5: 25.9%, κW = 0.34). Discordance increased with patient complexity (i.e. higher numbers of medical conditions [OR 0.98, 95% CI 0.97–0.98], patients aged ≥18, primary problems of mental health or soft tissue injury/pain presentations). Concordance increased with patient age and paramedic certification level. No operational factors examined demonstrated an independent association with CTAS agreement. Conclusions Patient acuity agreement declined with lower acuity scores. Operational influences were not detected as significant predictors of CTAS disagreement. Several clinical factors were found to potentially affect agreement, particularly with increasing patient complexity. The implications for paramedic practice, paramedic education and EMS response priority planning warrant further investigation.
Background 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.
