Exploring Challenges in Mental Health Crisis Response

Abstract

Introduction: The paramedics in ambulance services are currently been required to be involved at an increased rate in managing patients representing mental health crisis for which they have involved in harmful actions leading to accidental deterioration of them health. However, the paramedics inform they face various obstacles due to which effective care could not be delivered by them to the patients in mental health which is leading to increased fatal consequences among patients. Thus, the current study is required to be developed to understand and identify the obstacles to be resolved.

Aim: The study aims to examine the obstacles faced by ambulance service paramedics in managing pre-hospital patients who are suffering from mental health crisis.

Methodology: The qualitative methodology will be followed in executing the study.

Methods: The interview transcripts and information regarding the topic from participants who are paramedics will be used in the study.

Conclusion: The results developed from the review will be used in improving the paramedics ability in managing patients with mental health crisis in effective manner.

In the UK, after the consideration of the paramedics as a registered profession in 2001, an increase in their contribution towards early joined-up care is seen in specialised health contexts such as cardiac, stroke and primary care management. The purpose of paramedic education and skills is to make them perform effective medical action in the primary stage of threatening emergencies, resuscitation and trauma among people before their hospitalisation (Burns, 2021). In the current scenario, three times more deaths are reported in the UK due to suicide compared to road accidents (samaritans.org, 2018). Self-harm is not always performed for attempting suicide but is one of the major risks which contributes to the risk of suicide among people (Ramluggun et al., 2020). In the UK, nearly 6.4% of self-harm is reported among 16-74 years old where as 24% of them considered to be occurring among 16-24years old boys. The percentage of women involving in self-harm and suicide include 19.7% accept the action face-to-face and 1 in 6 women accepting the fact through examination (beheadstrong.uk, 2020; rcpsych.ac.uk, 2019).

In case of self-harm that is mainly caused by individual due to mental health crisis, the paramedics are the first health professional contact to manage the situation and assist in providing first-aid before the requirement of hospitalisation (Rolfe, Pope & Crouch, 2020). In addition, paramedics are to intervene and respond to the calls of patients who have mental health problems that are defined within the ambulance triage system (Green and Pound, 2020). However, most paramedics report various complication to be faced in attending to the patients suffering from mental health crisis in the pre-hospital stage. Thus, the current study is focussed on investigating the obstacles faced by paramedics as a part of ambulance service in managing pre-hospital patients who are suffering from mental health crisis. It is to understand the actions that may tackle limiting the obstacles to enhance the ability to paramedics in performing better care management in pre-hospital conditions of mental health crisis patients.

Literature Review

A mental health crisis is referred to the situation in which the behaviour of a person puts them at risk of hurting self as well as others who are intending to prevent them from harming themselves. The examples of mental health crisis include eating disorders, trauma, substance abuse, depression, suicidal thoughts, self-harm and others (Newbigging et al., 2020). The mental health crisis leads to mental health emergency in which an individual is found to threaten immediate harm to others or self because of disoriented mental health or out of touch reality leading the situations to be out of control (White, 2021). In the UK, one of the key mental health crises found to be commonly managed is attempted suicide or self-harm by individuals in the pre-hospitalisation stage. This is evident as in 2019 nearly 52,427 individuals who are 17-year-olds are mentioned to have attempted suicide with 170,744 of 17-years old reporting they have attempted self-harm (Marsh, 2021).

In regard to overall data among different ages, it is mentioned that 16.7% of females compared to 4.8% of men are involved in self-harming for which they require serious care (rcpsych.ac.uk, 2020). This indicates that increased self-harm is seen among women compared to men whom the paramedics require to manage in the pre-hospitalisation stage. However, more attempted suicide is seen among men in the UK compared to women with men reporting 15.5 per 10000 population to have attempted and succeeded in suicide attempts. the exact figures for suicide attempts in the UK among adults are not available (ons.gov.uk, 2017). It informs that the paramedics are required to equally provide care to both men and women for varied mental health crisis like self-harm and attempted suicide around all ages.

In mental health crisis management, the paramedics in the ambulance service are initial professionals to take intervention. This is because they are initial health professionals who are able to reach the site of the situation irrespective of the place like house, community centre, care home, clubs, roadside and others for providing first-aid treatment to the individuals (Cush et al., 2020). It is important as without effective management of patients at the pre-hospitalisation stage through the ambulance services, it would create life risk or threatening situation for the patients to cope up and respond to the care after reaching the hospital (Shirzad et al., 2020). Thus, paramedics are made to work in the settings before the hospital with limited equipment and human resources compared to the clinical settings to provide trauma or acute care.

In the contemporary condition of increased mental health crisis being raised in the health context, paramedics are found to increasingly attend mental health emergencies. It is evident from the study of Duncan et al. (2019) where it is mentioned that paramedic ambulance services nearly attended 6802 cases of mental health or self-harm on 9014 occasions in Scotland. This represents nearly 11% of the call attended by the paramedics in the year. However, none of the studies mentioned the extent of problems and obstacles faced by paramedics in the management of the patients in emergency situations who are facing mental health crisis. The existing studies did not highlight the perspective of the paramedics while controlling patients with mental health crisis to understand issues being faced by them at the work. The existing studies also fail to inform the impact of obstacles of paramedics in controlling patients with mental health crisis in pre-hospitalization stage on the care and support of the patients and control of the situation. Thus, the current study is been developed so that wide and in-depth data regarding the obstacles faced by paramedics in mental health crisis patient management can be gathered and investigated to develop detailed idea regarding factors related to the condition and its effect on care delivery.

Aim and Research Question

Aim:

The study aims to examine the obstacles faced by ambulance service paramedics in managing pre-hospital patients who are suffering from mental health crisis.

Objectives

To identify the concept of ambulance service paramedics in managing pre-hospital patients suffering from mental health crisis

To assess the obstacles faced by ambulance service paramedics in managing pre-hospital patients suffering from mental health crisis

To evaluate the impact of the obstacles faced ambulance service paramedics in supporting care for pre-hospital patients suffering from mental health crisis

To recommend strategies to overcome obstacles faced by ambulance service paramedics in managing pre-hospital patients with mental health crisis

Methodology

The research methodology is referred to the system of methods and paradigm that is used to determine the way scientifically any research problem is to be resolved and facts are to be shared in developing the results (Gregório et al., 2021). According to Rosskam (2018), the researchers are required to have a valid conclusion regarding which methods are most suitable for answering any particular research question. It is imperative for the researchers to understand strength and weakness of each of the two research approaches and the fundamental principles related with them to evaluate the designs and determine which of them is appropriate to be used. As argued by Franco et al. (2018), following rigorous and strict methodologies are important in avoiding misleading data to be included. This is essential as misleading data in the study leads to create error and bias leading to reach gendered research conclusion. Thus, making good methodological choices is important part of executing the study. The current research is investigation type for which gathering of wider information is necessary so that the evidence can be analysed to identify the basic data needed to develop well-focused understanding of the topic.

Research Paradigm

The qualitative and quantitative are the two basic primary research paradigms used for executing the study. The quantitative research is also mentioned as hypothetico-deductive as well as positivist whereas qualitative research is mentioned as holistic-inductive study (Kelly, Dowling and Millar, 2018). The quantitative research paradigm mentions that to construct a scientific theory, results are to be obtained from direct experimentation and observation which through effective reference are to be used in predicting further impact that can be disproved or verified with the help of empirical evidence. It perceives reality to be the objective and the world to be free of human perception due to which scientific perspective and experimentation are to be the basis for collecting data in the study (Khaldi, 2017). In contrast, qualitative research considers the idea of multi-subjective realities and mentions the study is to be holistic, interactive, non-generalisable but transferable. The qualitative research examines different aspects of life including their expression, beliefs, culture, imagination, stress and others (Jaworsky, 2019). In contrast, qualitative research focus on quantifying objectives and analyse data to deduct results for the study (Khaldi, 2017).

In qualitive research, hypothesis is developed to form clear statement regarding the problem considered for investigation. This is unlike the quantitative research design where research hypothesis is developed only for examination purpose, but in qualitative research, the hypothesis is developed for examination of the hypothesis as well as generating outcomes regarding the hypothesis (Makombe, 2017). Thus, qualitative research will be preferred over quantitative research as the former assist in testing the problem as well as outcome developed in the study to ensure they meet the criteria in the research. The qualitative research act as content generator which means that it allows gathering of genuine ideas from different demographics to be turned into valuable data which can be used in creating enhanced content that reflects the solution of the raised problem in the study (Rahman Rahman, Ationg and Zulhaimi, 2017). In contrast, quantitative research acts as statistical data generation design with objective information to be gathered through the process (Khalid, 2017). Thus, qualitative research will be preferred over quantitative research in the current study as the present research focus on gathering wider explainable content increased of injective information regarding obstacles faced by the paramedics in controlling patients with mental health crisis in pre-hospital condition.

The quantitaive research helps in gathering information in real-time scenarios within least time. They allow statistical analysis to be made with fewer acquisitions of resources to present a useful conclusion (Shava and Nkengbeza, 2019). In contrast, the qualitative research paradigm involves taking increased time in gathering information by exploring experiences, attitudes, feelings and others of participants as well as by analysing existing evidence presented in articles (Chimhundu, 2018). In the current COVID-19 condition, limited ability to make contacts with real-time population is allowed due to which it is difficult to perform qualitative research. However, online contact can be directly made to the participants due to which qualitative research will be able to be performed. Moreover, the qualitative research paradigm will be preferred paradigm for the current research as it would help in explaining the attitude and real-life experiences of the paramedics while controlling mental health crisis patients. The objective results gathered through quantitative research are unable to explain in detail the range of obstacles by paramedics in controlling mentally-ill individuals due to which the research methodology will not be used.

Qualitative Research Design

The different designs under the qualitative research approach is to be discussed to mention the nature of design to be followed for identifying existing studies for including valuable information in the research. The research design is referred to the framework followed for ensuring the evidence to be included in answering the raised hypothesis in unambiguous way is gathered through the process that is reliable, replicable and valid (Tuffour, 2017). The major types of qualitative research design are phenomenological, narrative and ethnography (Tuffour, 2017).

Ethnography is referred to the qualitative research design that involves the researcher observing or interacting with a participant in real-life environment to gather information (Ottrey et al., 2018). The advantage of using ethnographic research is that it helps the researcher to look into the attitude, motivation and behaviours of the target participants in the study regarding any action or services (Atherton et al., 2018). Moreover, it helps in creating an in-depth approach to reveal valuable insights regarding any situation which cannot be gathered through a survey. The additional advantage is that it helps in pinpointing the researchers regarding the needs versus the wants of the participants in a certain situation which assist the researcher to develop direction regarding the way a problem is to be resolved (Côté-Boileau et al., 2020). Thus, the ethnographic research will be used because it would help in highlighting the needs versus wants of the paramedics which are to be fulfilled so that they can overcome complications and obstacles while caring for mentally-ill individuals. The phenomenological research will not be used in framing the current study. This is because its use creates difficulty in the analysis as well as interpretation of results. Moreover, the methodology lowers the reliability and validity of the results and creates taking more time along with resources in gathering the required data to execute the study (Morrell-Scott, 2018).

Methods

In framing the qualitative research, Nominal Group Technique (NGT) will be used in limiting the respondent interaction to minimum whole trying to maximise the input from the individual selected for the study (Søndergaard et al., 2018). The Nominal Group Technique (NGT) is referred to structured variation belonging from a small-group discussion for reaching consensus. It allows to gather information by leading individuals to answer or respond to questions provided by the moderator and later asking the participants in prioritising their ideas or suggestion of all small groups (Manera et al., 2019). The NGT will be used in framing the interview session for the study because it ensures relative equal participation of participants to provide meaningful input regarding the raised focus of the study. It is also time-saving technique and allows gathering large number of ideas along with provide sense of closure which is often unable to be found in less-structured participant groups (Paz-Pascual, Artieta-Pinedo & Grandes, 2019). The use of NGT in making interview sessions also helps in resolving problems like the reluctance of participants in providing their views out of fear of being criticised by others. Moreover, the process helps in creating a pleasant climate for the interview which helps members reluctant to conflicts in groups to feel at peace in attending the interview session (Manera et al., 2019).

Sampling

In order to gather opinions and judgements regarding the obstacles faced by paramedics in caring for mentally-ill individuals, the purposive sampling method will be used. The purposive sampling is the nature of non-probability sampling method often used in qualitative studies where researchers are seen to rely on their personal judgement in selecting participants for the study from the target population (Campbell et al., 2020). In this study, the purposive sampling method will be used because it is time-effective along with cost-effective. Moreover, the method helps in gathering effective relatable data for the study in presence of limited number of participants or primary resources (Ames, Glenton & Lewin, 2019). In the current study, the number of individuals to be interviewed are small due to which the presence of participants who are adequately relatable for the study is required so that effective information can be gathered in resolving the raised questions in the study. Purposive sampling will also to be used because it provides opportunity to create generalisation of the data. This is because it helps in logical, theoretical or analytical data collection from potential participants who represent the commonly targeted group in the study (Campbell et al., 2020).

The purposive sampling allows gathering extreme perspectives of the participants regarding the study topic which provide better understanding of the extent of different behavioural pattern present in a certain group regarding any certain cause or problem (Andrade, 2021). This indicates that using purposive sampling will help in gathering wider perspectives of the paramedics regarding mentally-ill patient management which would help in gathering in-depth information various unexplored obstacles faced by them in treating such individuals in emergency condition. As mentioned by Ames, Glenton & Lewin (2019), purposive sampling helps in gathering real time data. This is because it allows selected participants to be asked targeted questions in producing exact real-time answers or responses required in regard to any topic or study. Thus, it will be used in framing the current study as it would provide practical experience of paramedics in treating mentally-ill individuals to determine real-time obstacles faced by them in the context of the action which is focus of the study. The participants to be selected through purposive sampling will be paramedics who are working in the emergency ambulance services and taking care of patients suffering from mental health crisis in the pre-hospitalisation stage. A total of 5 paramedics will be included in performing the study as it the range of individuals can be interviewed within the short time of execution of the project.

Data Collection

In the current study, the interview method will be used in gathering data. This is because the process helps in avoiding misunderstanding and rectify the mistakes regarding any perception of a topic as the interviewee and interviewer are present to interact directly with one another (Luppa et al., 2020). Thus, the interview method will be used as it would help the researchers and paramedics to personally form interaction with one another to resolve misconception regarding obstacles and access a real overview of barriers faced by the paramedics in pre-hospitalisation care of patients with mental health crisis. The interview helps in building rapport with the interviewee which leads to promote cooperation and understanding between one another leading to draw out vital information which would otherwise avoided to be shared due to feelings of objection or shyness. The process also helps in the collection of clarified and new primary information assist to provide overview of the current scenario regarding any topic (Andresen, Laursen & Rosenberg, 2018).

The interview provides sufficient information to be gathered by the interviewer in critical understanding of the topic and allows them to gather valuable in-depth comprehensive information rather than objective data for the study (Luppa et al., 2020). Thus, the interview process will be used in data collection for the current study as it will help in providing in-depth information about way obstacles are faced and reason for them in the pre-hospitalization care of mentally-ill patients by the paramedics. The interview process is cost-effective and time-effective (Andresen, Laursen & Rosenberg, 2018). Since the budget and time for the study is restricted, thus the use of the data collection process as an interview will be advantageous for the study for which it is considered to be used. The interview process will be implemented to collect data through use of the semi-structured questionnaire. This is because a semi-structured questionnaire in interview acts as guide for the way interview is to be conducted and allows open-ended responses to be made through the process in supporting in-depth gathering data (Luppa et al., 2020). The interview will be conducted by using Skype in which the interviewer and interviewee can directly interact with one another in face-to-face manner to capture the emotions and attitudes of the participants for better analysis of the gathered responses. It would also help to abide by the restrictions created due to current Covid-19 situation of maintaining social distancing between one another by arrangement of the virtual meet.

Data Analysis

The gathered data in the study will be analysed by using thematic analysis method. The gathered data which is to be made in written, audio and video recorded is to be analysed by examining the verbatim of the participants in response to determined interview questions. The benefit of using thematic analysis is that it provides opportunity to the researcher in analysing huge texts to comprehensively arrange them under themes so that duplication of facts can be avoided. The method also assists in applying personal as well as theoretical knowledge in evaluating different parts of the data to be categorised under themes (Semaan et al., 2020). As mentioned by Valley & Stallones (2018), the thematic analysis method allows the researcher to be flexible in managing data. This is because of the wide range of analytical methods which are possible to be applied by the researcher in evaluating the data. The method helps in developing various themes for data presentation which assist in improved overview and categorisation of the facts gathered for the study (Zarotti et al., 2019). Thus, the use of thematic analysis method will help in gathering of different category of facts relevant to the study which would help in understanding key obstacles faced by the paramedics in managing care of mentally-ill patients.

Strategies for Promoting Methodological Rigour

In research, rigour is referred to establishment of trust or confidence in the findings of the present study which allows the researcher in establishing consistency in the methods used within the study for its development. The rigour in the study is to be ensured as it leads to support accurate presentation of population (Daniel, 2019). The rigour in the research is assessed by determining the credibility, trustworthiness, transferability and confirmability of the study (Daniel, 2019). In studies, the use of questionnaire is executed on the basis of honesty and integrity of the response of the participants which limits the value of the results (Daniel, 2019). The anonymity in the study while performing interview makes the participants feel empowered to answer openly and honestly, therefore, providing scope for insightful data for the research (Ospina, Esteve & Lee, 2018). The repetition of the researchers to go back to the participants in clarifying their response during the interview ensures accuracy of the findings and enhance the data credibility and conformity. This is because the researcher absolutely avoided personal perception to be included in analysing data during confusion and reach the determined participants in clarifying the facts to ensure authentic presentation of data (Daniel, 2019). In the qualitative studies, there is consensus that for allowing transferability, description of the determined findings is to be present in detail (Ospina, Esteve & Lee, 2018). In the currents study, the gathering of data is planned to be made in detailed way by audio and video recording the interview which ensures effective transferability will be reached ensuring rigour will be achieved in the study.

Recruitment and Ethical Consideration

In the study, during recruitment, to maintain effective ethical consideration, the researcher will be ensuring effective protection of identity and confidentiality of the participants. This is because confidentiality ensures protection from abuse or harm of the individuals from others in the society on identifying they have participated in an interview and provided facts that are not acceptable by others. The confidentiality and privacy of the participants will be ensured by following the guidance of the Data Protection Act 1998. The Act mentions that under no consideration the personal details of the individuals are to be revealed and the information is to be secured in a safe place which would be shared with responsible authorities in best interest of the patients without their prior consent (legislation.gov.uk, 1998). The participants will be recruited independently by avoiding forcing any individual to be involved in the study. The participants to be recruited will be required to be informed in detail of the purpose of the study, way their responses are to be used, way their responses are to be stored, the tenure for which their responses are to be stored and their information are to be destroyed. It is to make them develop informed decision to participant in the study and provide informed consent towards use of their responses in the study.

The four key ethical principles in healthcare are autonomy, beneficence, non-maleficence and justice (Collier, 2019). Autonomy indicates providing the right to the individual in making informed decisions regarding their actions (Collier, 2019). In the study to maintain autonomy, the participants will be allowed to leave the interview at any point where they feel their confidentiality or privacy is compromised without providing any explanation. They will also be allowed to avoid responding to any questions without need to the explanation of avoiding the query to the researchers. Beneficence is referred to taking actions so that it benefits others and ensure good actions for them (Brophy, Keith & Hurley, 2018). In this context, to maintain beneficence, the researcher will be responsible in taking actions that maintain the anonymity, confidentiality and privacy of each of the participants. The non-maleficence is referred to taking action to ensure no harm is caused to the individuals under the care or supervision of the practitioner or researcher (Brophy, Keith & Hurley, 2018). In this respect, the researcher has the duty to develop protocols and policies that will be followed in interviewing the participants so that they experience no threat from the researcher as well as other outsiders during the execution of the interview. Justice is referred to taking equal actions for all without creating any discrimination (Collier, 2019). The justice will be ensured in the study by avoiding any form of discrimination while selection of the participants and equal opportunity to all paramedics are to be provided so that they can selected for the purpose of the study.

Timetable

The timetable is presented in Appendix A.

Budget and Funding Source

The budget will be mentioning the cost and the items to be used in performing the study. Few of the resources will be provided by the Glasgow Caledonian University (GCU) and the remaining resources are to be gathered from self.

Dissemination of Results

The dissemination of results involves making the parties interested in the study aware of the findings and allowing them access to the findings to be used in their own field. On fulfilment of the dissertation based on the topic, the copy will be submitted to the University and emailed to key major international stakeholders who are involved in taking actions for improving paramedics care delivery in all aspect. A manuscript of the dissertation will be made available online for publication consideration.

Looking for further insights on Exploring Attitudinal and Emotional Barriers to Vaccination Uptake? Click here.

References

Ames, H., Glenton, C., & Lewin, S. (2019). Purposive sampling in a qualitative evidence synthesis: A worked example from a synthesis on parental perceptions of vaccination communication. BMC medical research methodology, 19(1), 1-9. [Accessed on: 6 January, 2022]. Available at: https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/s12874-019-0665-4

Andrade, C. (2021). The inconvenient truth about convenience and purposive samples. Indian Journal of Psychological Medicine, 43(1), 86-88. [Accessed on: 6 January, 2022]. Available at: https://journals.sagepub.com/doi/full/10.1177/0253717620977000

Andresen, K., Laursen, J., & Rosenberg, J. (2018). Outlining and dictating scientific manuscripts is a useful method for health researchers: A focus group interview. SAGE open medicine, 6, 2050312118778728. [Accessed on: 6 January, 2022]. Available at: https://journals.sagepub.com/doi/pdf/10.1177/2050312118778728

Atherton, H., Brant, H., Ziebland, S., Bikker, A., Campbell, J., Gibson, A., ... & Salisbury, C. (2018). Alternatives to the face-to-face consultation in general practice: focused ethnographic case study. British Journal of General Practice, 68(669), e293-e300. [Accessed on: 6 January, 2022]. Available at: https://bjgp.org/content/bjgp/68/669/e293.full.pdf

beheadstrong.uk 2020, Self-Harm statistics, Available at: https://www.beheadstrong.uk/info/self-harm-statistics [Accessed on:15 December 2021]

Brophy, J. T., Keith, M. M., & Hurley, M. (2018). Assaulted and unheard: violence against healthcare staff. New solutions: a journal of environmental and occupational health policy, 27(4), 581-606. [Accessed on: 6 January, 2022]. Available at: https://ochu.on.ca/wp-content/uploads/2019/08/2017-11-27-Assaulted-and-Unheard-Violence-Against-Healthcare-Staff-New-Solutions-Article.pdf

Burns, J., 2021. Paramedic-led acute home visiting services in primary care. Journal of Paramedic Practice, 13(6), pp.238-244. [Accessed on: 22 December, 2021]. Available at: https://www.magonlinelibrary.com/doi/abs/10.12968/jpar.2021.13.6.238

Campbell, S., Greenwood, M., Prior, S., Shearer, T., Walkem, K., Young, S., ... & Walker, K. (2020). Purposive sampling: complex or simple? Research case examples. Journal of Research in Nursing, 25(8), 652-661. [Accessed on: 6 January, 2022]. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932468/

Chimhundu, R., 2018. Research Paradigm, Research Method and Research Design. In Marketing Food Brands (pp. 125-150). Palgrave Macmillan, Cham. [Accessed on: 22 December, 2021]. Available at: http://ndl.ethernet.edu.et/bitstream/123456789/67576/1/448.pdf#page=137

Collier, H. (2019). Time to think about the role of ethics in aesthetics. Journal of Aesthetic Nursing, 8(2), 80-81. [Accessed on: 6 January, 2022]. Available at: https://www.magonlinelibrary.com/doi/pdf/10.12968/joan.2019.8.2.80

Côté-Boileau, É., Gaboury, I., Breton, M., & Denis, J. L. (2020). Organizational Ethnographic Case Studies: Toward a New Generative In-Depth Qualitative Methodology for Health Care Research?. International Journal of Qualitative Methods, 19, 1609406920926904. [Accessed on: 6 January, 2022]. Available at: https://journals.sagepub.com/doi/pdf/10.1177/1609406920926904

Cush, P., Walsh, K., Carroll, B., O’Donovan, D., Keogh, S., Scharf, T., MacFarlane, A. & O’Shea, E., 2020. Positive health among older Traveller and older homeless adults: A scoping review of life‐course and structural determinants. Health & Social Care in the Community, 28(6), pp.1961-1978. [Accessed on: 22 December, 2021]. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/hsc.13060

Daniel, B. K. (2019). Using the TACT framework to learn the principles of rigour in qualitative research. Electronic Journal of Business Research Methods, 17(3), pp118-129. [Accessed on: 6 January, 2022]. Available at: https://academic-publishing.org/index.php/ejbrm/article/view/1396

Daniel, B. K. (2019). What constitutes a good qualitative research study? Fundamental dimensions and indicators of rigour in qualitative research: The TACT framework. In Proceedings of the European Conference of Research Methods for Business & Management Studies (pp. 101-108). [Accessed on: 6 January, 2022]. Available at: https://core.ac.uk/download/pdf/223235145.pdf#page=116

Duncan, E.A., Best, C., Dougall, N., Skar, S., Evans, J., Corfield, A.R., Fitzpatrick, D., Goldie, I., Maxwell, M., Snooks, H. & Stark, C., 2019. Epidemiology of emergency ambulance service calls related to mental health problems and self harm: a national record linkage study. Scandinavian journal of trauma, resuscitation and emergency medicine, 27(1), pp.1-8. [Accessed on: 22 December, 2021]. Available at: https://pubmed.ncbi.nlm.nih.gov/30894214/

Franco, J.V.A., Arancibia, M., Simancas-Racines, D. & Madrid, E., 2018. Syntheses of biomedical information: narrative reviews, systematic reviews and emerging formats. Medwave, 18(07).pp.90-123. [Accessed on: 22 December, 2021]. Available at: https://www.medwave.cl/link.cgi/English/Reviews/GeneralReviews/7355.act?ver=sindiseno

Green, A. & Pound, A., 2020. Undergraduate paramedics' understanding of mental health insight placements. Journal of Paramedic Practice, 12(10), pp.397-400. [Accessed on: 22 December, 2021]. Available at: https://www.magonlinelibrary.com/doi/abs/10.12968/jpar.2020.12.10.397

Gregório, J., Reis, L., dos Santos, M., Maia, M., da Silva, M.M. & Lapão, L.V., 2021. The role of Design Science Research Methodology in developing Pharmacy eHealth services. Research in Social and Administrative Pharmacy.pp.34-67. [Accessed on: 22 December, 2021]. Available at: https://www.sciencedirect.com/science/article/abs/pii/S1551741121001820

Jaworsky, D., 2019. An allied research paradigm for epidemiology research with Indigenous peoples. Archives of Public Health, 77(1), pp.1-12. [Accessed on: 22 December, 2021]. Available at: https://archpublichealth.biomedcentral.com/articles/10.1186/s13690-019-0353-1

Kelly, M., Dowling, M. & Millar, M., 2018. The search for understanding: The role of paradigms. Nurse Researcher, 25(4), pp.9-13. [Accessed on: 22 December, 2021]. Available at: https://pubmed.ncbi.nlm.nih.gov/29546961/

Khaldi, K., 2017. Quantitative, qualitative or mixed research: which research paradigm to use?. Journal of Educational and Social Research, 7(2), pp.15-15. [Accessed on: 22 December, 2021]. Available at: https://www.richtmann.org/journal/index.php/jesr/article/view/9915

Khalidi, K., 2017. Quantitative, Qualitative Or Mixed Methods Research: Which Research Paradigm To Use?. 10(14), pp.160-175. [Accessed on: 22 December, 2021]. Available at: https://www.asjp.cerist.dz/en/article/65279

Kininmonth, A.R., Jamil, N., Almatrouk, N. & Evans, C.E., 2017. Quality assessment of nutrition coverage in the media: a 6-week survey of five popular UK newspapers. BMJ open, 7(12), p.e014633. [Accessed on: 22 December, 2021]. Available at: https://bmjopen.bmj.com/content/7/12/e014633.abstract

legislation.gov.uk 1998, Data Protection Act 1998, [Accessed on: 6 January, 2022]. Available at: https://www.legislation.gov.uk/ukpga/1998/29/contents

Luppa, M., Giersdorf, J., Riedel-Heller, S., Prütz, F., & Rommel, A. (2020). Frequent attenders in the German healthcare system: determinants of high utilization of primary care services. Results from the cross-sectional German health interview and examination survey for adults (DEGS). BMC family practice, 21(1), 1-10. [Accessed on: 6 January, 2022]. Available at: https://link.springer.com/article/10.1186/s12875-020-1082-9

Manera, K. E., Johnson, D. W., Craig, J. C., Shen, J. I., Ruiz, L., Wang, A. Y. M., ... & Tong, A. (2019). Patient and caregiver priorities for outcomes in peritoneal dialysis: multinational nominal group technique study. Clinical Journal of the American Society of Nephrology, 14(1), 74-83. [Accessed on: 6 January, 2022]. Available at: https://cjasn.asnjournals.org/content/clinjasn/14/1/74.full.pdf

Marsh 2021, About 7% of UK children have attempted suicide by age of 17 – study, Available at: https://www.theguardian.com/society/2021/feb/21/uk-17-year-olds-mental-health-crisis [Accessed on:15 December 2021]

Newbigging, K., Rees, J., Ince, R., Mohan, J., Joseph, D., Ashman, M., Norden, B., Dare, C., Bourke, S. & Costello, B., 2020. The contribution of the voluntary sector to mental health crisis care: a mixed-methods study. Health Services and Delivery Research, 8(29), pp.1-200. [Accessed on: 22 December, 2021]. Available at: http://oro.open.ac.uk/71294/

Ottrey, E., Jong, J. & Porter, J., 2018. Ethnography in nutrition and dietetics research: a systematic review. Journal of the Academy of Nutrition and Dietetics, 118(10), pp.1903-1942. [Accessed on: 22 December, 2021]. Available at: https://www.sciencedirect.com/science/article/abs/pii/S2212267218308864

Paz-Pascual, C., Artieta-Pinedo, I., & Grandes, G. (2019). Consensus on priorities in maternal education: results of Delphi and nominal group technique approaches. BMC pregnancy and childbirth, 19(1), 1-13. [Accessed on: 6 January, 2022]. Available at: https://link.springer.com/article/10.1186/s12884-019-2382-8

Rahman, A.T.A., Ationg, R. & Zulhaimi, N.A., 2017. A paradigm shift in understanding mixed method research: A Malaysian perspective. Journal of Advanced Research in Social and Behavioural Sciences, 9(1), pp.46-56. [Accessed on: 22 December, 2021]. Available at: https://www.akademiabaru.com/doc/ARSBSV9_N1_P46_56.pdf

Ramluggun, P., Freeman-May, A., Barody, G., Groom, N. & Townsend, C., 2020. Changing paramedic students' perception of people who self-harm. Journal of Paramedic Practice, 12(10), pp.403-412. [Accessed on: 22 December, 2021]. Available at: https://www.magonlinelibrary.com/doi/abs/10.12968/jpar.2020.12.10.403

rcpsych.ac.uk 2019, Suicide and self-harm in Britan, Available at: https://www.rcpsych.ac.uk/docs/default-source/improving-care/nccmh/suicide-prevention/monthly-clinic/(5a)-suicide-and-self-harm-in-britain-summary-report-natcen.pdf [Accessed on:15 December 2021]

rcpsych.ac.uk 2020, Self-harm and suicide in adults, Available at: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr229-self-harm-and-suicide.pdf?sfvrsn=b6fdf395_10 [Accessed on:15 December 2021]

Rolfe, U., Pope, C. & Crouch, R., 2020. Paramedic performance when managing patients experiencing mental health issues–Exploring paramedics’ Presentation of Self. International emergency nursing, 49, p.100828. [Accessed on: 22 December, 2021]. Available at: https://www.sciencedirect.com/science/article/abs/pii/S1755599X19301193

Rosskam, E., 2018. Using participatory action research methodology to improve worker health. In Unhealthy Work (pp. 211-228). Routledge. [Accessed on: 22 December, 2021]. Available at: https://www.taylorfrancis.com/chapters/edit/10.4324/9781315223421-15/using-participatory-action-research-methodology-improve-worker-health-ellen-rosskam

samaritans.org 2017, Samaritans today welcomes the government’s focus on improved mental health services and strengthened suicide prevention work but wants today’s announcements to result in lives saved, Available at: https://www.samaritans.org/news/suicide-kills-three-times-more-people-road-traffic-accidents-we-urgently-need-act/ [Accessed on:15 December 2021]

Semaan, A., Audet, C., Huysmans, E., Afolabi, B., Assarag, B., Banke-Thomas, A., ... & Benova, L. (2020). Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic. BMJ Global Health, 5(6), e002967. [Accessed on: 6 January, 2022]. Available at: https://gh.bmj.com/content/5/6/e002967.abstract

Shava, G.N. & Nkengbeza, D., 2019. Qualitative research paradigm. The Namibia CPD Journal for Educators, 5, pp.237-258. [Accessed on: 22 December, 2021]. Available at: http://journals.unam.edu.na/index.php/NCPDJE/article/view/1251

Shirzad, F., Hadi, F., Mortazavi, S.S., Biglari, M., Sari, H.N., Mohammadi, Z., Atoofi, M.K. & Shariat, S.V., 2020. First line in psychiatric emergency: pre-hospital emergency protocol for mental disorders in Iran. BMC emergency medicine, 20(1), pp.1-9. [Accessed on: 22 December, 2021]. Available at: https://link.springer.com/article/10.1186/s12873-020-00313-2

Søndergaard, E., Ertmann, R. K., Reventlow, S., & Lykke, K. (2018). Using a modified nominal group technique to develop general practice. BMC family practice, 19(1), 1-9. [Accessed on: 6 January, 2022]. Available at: https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-018-0811-9

Tuffour, I., 2017. A critical overview of interpretative phenomenological analysis: A contemporary qualitative research approach. Journal of Healthcare Communications, 2(4), p.52. [Accessed on: 22 December, 2021]. Available at: http://repository.uwl.ac.uk/id/eprint/4082/

Valley, M., & Stallones, L. (2018). A thematic analysis of health care workers’ adoption of mindfulness practices. Workplace health & safety, 66(11), 538-544. [Accessed on: 6 January, 2022]. Available at: https://journals.sagepub.com/doi/full/10.1177/2165079918771991

White, C.J., 2021. An inevitable response? A lived experienced perspective on emergency responses to mental health crises. Journal of psychiatric and mental health nursing, 28(1), pp.90-93. [Accessed on: 22 December, 2021]. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/jpm.12631

Appendix

Appendix A

Interview Questionnaire:

What are your responsibilities in managing patients suffering from mental health crisis at pre-hospitalisation stage?

What hardships and obstacles you face being ambulance paramedics required to manage patients suffering from mental health crisis in pre-hospitalisation stage?

What is the effect of the obstacles you face being ambulance paramedics required to manage patients suffering from mental health crisis in pre-hospitalisation stage?

What support do you need to overcome the obstacles you face being ambulance paramedics required to manage patients suffering from mental health crisis in pre-hospitalisation stage?