“I was worried if I don’t have a broken leg they might not take it seriously”: Experiences of men accessing ambulance services for mental health and/or alcohol and other drug problems

Abstract Background A large proportion of ambulance callouts are for men with mental health and/or alcohol and other drug (AOD) problems, but little is known about their experiences of care. This study aimed to describe men's experiences of ambulance care for mental health and/or AOD problems, and factors that influence their care. Methods Interviews were undertaken with 30 men who used an ambulance service for mental health and/or AOD problems in Australia. Interviews were analysed using the Framework approach to thematic analysis. Results Three interconnected themes were abstracted from the data: (a) professionalism and compassion, (b) communication and (c) handover to emergency department staff. Positive experiences often involved paramedics communicating effectively and conveying compassion throughout the episode of care. Conversely, negative experiences often involved a perceived lack of professionalism, and poor communication, especially at handover to emergency department staff. Conclusion Increased training and organizational measures may be needed to enhance paramedics' communication when providing care to men with mental health and/or AOD problems.


| INTRODUC TI ON
Men frequently experience mental health and/or alcohol and other drug (AOD) concerns, yet are often reluctant to seek professional help. In 2014-2015, around 1.5 million Australian men had a self-reported mental or behavioural condition, 1 and suicide was the leading cause of death in men aged between 15 and 44 years. 2 Furthermore, men are more likely than women to experience alcohol and other drug problems. 3 Men access general practitioners and mental health services significantly less than women do. 4,5 Common barriers to men's helpseeking for mental health and/or AOD problems include masculine norms around stoicism, stigma, embarrassment, poor recognition and/or communication of symptoms or concerns. [5][6][7] When men do present for help, it is most often in the context of an acute physical illness or crisis, rather than help-seeking for mental health issues as the primary complaint. 8 Ambulance services are a key front-line emergency service, attending over 1.3 million emergency incidents annually, of which many are likely to include men with mental health and/or AOD issues. 9 Indeed, paramedics report that attending mental health and/ or AOD presentations comprises a significant proportion of their workload. 10,11 Australian studies have shown that between 10% and 20% of ambulance presentations are related to mental health and/ or AOD concerns. 12,13 Similar to stigmatizing attitudes documented in the general population and amongst some health professional groups, [14][15][16] research indicates that some paramedics display negative attitudes towards people who present with mental health and/ or AOD problems. 10,11,17 Such negative attitudes may act as a barrier to help-seeking and recovery in this population. 18 Despite this, little is known about the experiences and perceptions of paramedic care amongst people who present with mental health and/or AOD concerns. Studies relating to patient satisfaction have been criticized, as they are often not underpinned by any theoretical or conceptual development and may not accurately reflect patient experiences. 19,20 The relatively small body of literature around patient experiences of ambulance services is focused on factors associated with patient satisfaction irrespective of the presenting concerns 19 or key outcomes valued by patients broadly. 21 As paramedics are often the first health-care professionals encountered by men experiencing mental health and/or AOD problems, it is important to better understand men's experiences of care. This is because experiences of paramedic care have the potential to act as either a barrier or enabler to accessing future care in the community, and therefore affect their recovery and future well-being. 22 The aim of this study was to understand men's experiences of using ambulance services for mental health and/or AOD problems; with a view to identify the positive or helpful aspects of the care they received and the possible areas of care that could be improved. In particular, this article addresses the question: What factors impact on the perceived quality of ambulance care according to men who access ambulance services with mental health and/or AOD problems? This was part of a larger mixed methods study of paramedics' attitudes, confidence and experience in responding to patients with mental health and/or AOD problems. 23 of distress (as indicated by a score over 30) were not eligible to participate in the interview and were invited to rescreen at a later date.
Verbal consent was gained over the telephone for those participants who were eligible to participate.
Fifty-seven men expressed interest in participating in the study; of these, 49 met the inclusion criteria, and 30 consented to participate. Reasons eligible individuals declined to participate included; they were no longer interested in participating, no longer had time to complete the interview, or wanted to be compensated at a higher rate for their participation.

| Data analysis
Transcribed interviews were analysed drawing on principles of the Framework approach to thematic analysis. 24 The Framework approach was considered particularly appropriate given that it was developed for applied and practice relevant research, and allows themes to emerge inductively from the data as well as to be deductively derived from the relevant literature and study aims. 24 All coding was completed by the first author. Following transcription of interviews, the framework approach involved initial familiarization with the interview transcripts. NF and KE then coded several transcripts in NVivo (2011), which were used to inform the development of a coding framework. Codes were grouped into categories, which were discussed with MS and modified until consensus was achieved, and a working thematic framework emerged.
This framework was then applied to the remaining transcripts by NF, with new codes discussed, added and agreed upon by NF and MS as they arose. Data were then charted to examine the range of experiences and meanings within themes, and relationships between themes. Finally, data were interpreted in the light of our central focus on the factors that contribute to positive and negative experiences of care. In addition to analyst triangulation where authors discussed and agreed upon codes, other strategies were employed to enhance rigour including the incorporation of diverse experiences as well as those of participants with different mental health and/or AOD concerns. 25 We also employed reflexive techniques, such as meeting to discuss how ideas of quality care were filtered through the interpretive lens of the researchers. 25 This was important in deepening our analysis and obtaining consensus around the interpretation of participant accounts, as some of the authors worked in ambulance services whilst others did not.

| Participant characteristics
In total, 30 males who had accessed an ambulance service for a mental health and/or AOD problem between one and 12 months ago participated in the study. The mean age of participants was 40 years.
Twenty-two (72%) were born in Australia, of which 5 (16%) identi- Participants accessed an ambulance service for either a mental health concern (n = 15), AOD concern (n = 5) or a combination of mental health and AOD concerns (n = 7) with a minimum of 1 month and less than 12 months, post the time of contact. Some (n = 8) also presented with either self-harm, suicidal ideation or attempt in addition to other mental health or AOD concerns, or exclusively for suicidal ideation/attempt (n = 3), without other mental health and/or AOD concerns. Whilst participants often had multiple concerns, the most common specific concerns reported included anxiety or panic attack (n = 15), depression (n = 13), intoxication (n = 9), overdose (n = 3) and psychosis or hallucinations (n = 3). Those who reported AOD use were often intoxicated on more than one substance, with alcohol (n = 8) and methamphetamine (n = 2) being the most commonly reported (Table 1).

| Themes
Three main and interconnected themes were abstracted from the data relating to participants' experiences of care: professionalism and compassion, communication and handover. The themes contributed to positive or negative experiences, depending on how they emerged in participants' accounts. The first theme, professionalism and compassion, referred to participants' perceived competence of paramedics and the care provided, often referencing displays of compassion, or conversely a lack of compassion. The second theme, communication, referred to how participants were spoken to (or not spoken to), the language used and the types of comments that were directed towards participants. The third theme, handover, included participants' experiences of being transferred to emergency department staff, in which communication was also influential. The two participants who presented with methamphetamine issues consistently reported negative experiences in each of these three themes.

| Professionalism and compassion
Most participants used the word "professional" when describing their positive experiences with paramedics. Professionalism was often reflected in a combination of other positive attributes that are associated with exceptional health care, such as empathy and compassion, where participants described paramedics as being caring or understanding and having a calming effect on them. Conversely, participants' accounts of negative care experiences often lacked professionalism, and in these instances, they commented on the absence of care and comfort in their interactions with paramedics. This quote highlights a common concern that a mental health issue (including a mental health crisis) could be viewed as a less legitimate reason to engage ambulance services, which might be an access barrier for people who are seeking help for this type of issue.

| Presence of professionalism and compassion
However, as the quote illustrates, the professionalism and care shown by paramedics could act to dispel the perception that mental health issues constituted an "illegitimate" reason to contact ambulance services.
Descriptions of paramedics being empathetic, polite and caring were also mentioned frequently in positive experiences with ambulance services. One participant described being initially hesitant to accept paramedics help: I didn't let them in at first but I spoke to them through the door for a while. I eventually let them in. They were very understanding and caring, which was great, and sympathetic. So yeah, it was just a matter of getting comfortable. (Interview 4, age 45, mental health and AOD/self-harm/suicide attempt) Although the participant did not initially allow paramedics to enter his home, paramedics were able to persist, gain trust through displays of empathy and care, and were eventually granted access to provide care. This account illustrates how persistent displays of empathy can

| Lack of professionalism and compassion
Whilst most participants experienced positive interactions, some described experiences in which they did not receive the compassion they desired. For example, one participant described wanting: Just a little bit more care and understanding and effort when it comes to mental health. But the effort and the response that goes into the (patients) call-ers…that had a stroke or a heart attack then people will be "climbing all over you" (very responsive

| Communication and attitudes
One of the main ways in which care and compassion was shown

| Good communication and nonjudgemental attitudes
Participants reporting experiences of positive communication often described communication that was non-judgemental, and egalitarian, which made them feel reassured and cared for. For example, one participant explained: Yeah, look they asked for permission to examine me.

| Poor communication and judgemental attitudes
Whilst there were participants who had positive experiences of paramedic communication, some reported experiences of poor communication. In these instances, communication was not used to de-escalate situations, or was replaced with a focus on restraint and/or sedation as a management tool with little explanation to the participant.
One participant explained that he found the experience of chemical sedation confronting and thought that: The police and ambulance lack the therapeutic tools to diffuse the situation without conflict and sedation. As illustrated in the above account, this form of judgemental communication can lead to feelings of shame or embarrassment for men with mental health and/or AOD concerns.
Silence and lack of communication were also evident as no participants mentioned receiving any information or referrals (around mental health and/or AOD) in their interactions with paramedics as part of their care.

| Handover to emergency department clinicians
For particpants who were transported, their ambulance care journey was completed when handover to emergency department clinicians occurred. Although this is the final interaction between patients and paramedics, it emerged as an important component in participants' experiences of care and had the potential to be a positive or negative experience depending on the level and quality of communication at handover.

| Positive handover interactions
For some participants, handover by paramedics involved a smooth transition to emergency department and hospital care.
Participants giving examples of positive handover experiences described the handover process being fast and efficient and also feeling well informed by attending paramedics and/or hospital staff. In this exemplar, the participant describes a positive experience that is timely and demonstrates an efficient handover process with clear communication between paramedics and hospital staff, which also shows care for the participant. Another participant also described a positive handover experience: I found it was really good because they actually explained it [the handover process] even though… the alcohol was kicking in and…I couldn't hold a straight [conversation]. Yeah, but they managed to actually, yeah, managed to tell the story and stuff.
(Interview 47, aged 32, mental health and AOD/ suicidal ideation) In this account, the participant benefited from good explanation and communication during handover, despite the challenging circumstances of intoxication. In this quote, it is evident that poor communication during handover can make a patient feel juvenile or "stupid." For another participant, the handover between the paramedic and hospital staff was a difficult experience, forcing the participant to repeat his story:

| Negative handover interactions
I was in quite a vulnerable situation and I'm not sure how much conversation was had between the paramedics and the hospital that I was going to. As soon as I got to hospital, I had to pretty much explain why I was there. As if, like the first time wasn't hard enough. I felt it was quite unprofessional. I don't know whose fault that was but I think that just bridging that gap a little bit more in that transition would be good, to make sure that the people that you're being handed over to know your situation.
(Interview 20, aged 24, mental health/suicidal ideation) This exemplar illustrates that when the responsibility for communicating during handover is left solely to patients, it is not only onerous; but can also be traumatizing to have to re-explain a situation after experiencing a mental health crisis.

| D ISCUSS I ON
This study provides a rare exploration of men's experiences of using ambulance services for mental health and/or AOD problems and illustrated three interconnected factors that influenced their care in different ways: professionalism and compassion, communication and handover to emergency department clinicians. As we will discuss, the findings of this study also give rise to a number of implications in terms of improving the quality of ambulance care for people with mental health and/or AOD issues.
In the first theme, professionalism and compassion, men who accessed ambulance services for mental health and/or AOD concerns greatly valued paramedics who displayed such attributes, and conversely were adversely affected when these attributes were not present in interactions. This finding is consistent with those from a qualitative study conducted in England, in which participants described how the perceived professionalism of health professionals reduced anxiety levels in patients and created confidence in the quality of care provided by the ambulance service. 21 Although Togher et al's 21 study was inclusive of perspectives from a much broader range of presentations types (including mental health), a similar set of interpersonal skill attributes that patients described as "professional" were identified. These included being "calm, kind and informative," which were equally valued regardless of presentation type. 21(p2956) Similarly and consistent with the findings of our study, results from a qualitative study of patient reports of being "badly treated" by ambulance service found that patients suffered when exposed to judgemental attitudes or when interactions with paramedics were perceived as lacking empathy or compassion. 26 As noted, this may be the experience for patients who present with methamphetamine issues, which could be related to recent stigmatizing portrayals of people who use methamphetamines via the media, polices and public health campaigns. 27,28 Given the stigma associated with mental health and AOD issues, experiences of professionalism and compassion by health professionals, such as paramedics, are likely to be highly valued. As our findings suggest, the absence of professionalism and compassion may not only result in negative experiences of care but also perpetuate self-stigma, which may act as a disincentive to further health and social service utilization. 15

| Strengths and limitations
This study was conducted in the context of ambulance care provided to men with mental health and/or AOD issues across

| Implications
Overall, our findings reiterate broader calls for improving the quality of ambulance care for people presenting with mental health and/or AOD issues. 11,12 A range of measures could be included to achieve this, including an educational approach to address potential skills gaps around communication. This could include training around therapeutic communication skills in pre-qualification university curricula and in-service education programs. Low-cost strategies, such as the provision of referral and information cards, could be piloted in order to facilitate access to appropriate support and ongoing care for patients who need/desire it.
Paramedics who demonstrate good communication skills and empathic attitudes could also act as "mental health champions" within ambulance services in order to help cultivate an organizational culture in which stigmatizing attitudes are considered unacceptable. Stigma reduction campaigns and initiatives could also be useful in facilitating empathy and high-quality care. 34 Consideration should also be given to reviewing policies and clinical practice guidelines to ensure they provide a framework that reflects a broader view of practice, beyond the current medically dominated scope of practice. 23 Future research is needed to examine the impacts and experiences of initatives for improving the quality of ambulance care for people with mental health and/or AOD issues.

ACK N OWLED G EM ENTS
We are grateful to the men who participated in the study for openly sharing their views and experiences. We are also grateful to the follow- Committee members for their important guidance in the project.

CO N FLI C T O F I NTE R E S T
The authors have declared that they have no competing interests.
In the past three years, DL has received speaking honoraria from AstraZeneca, Indivior, Janssen, Servier and Shire, and has provided consultancy advice to Lundbeck and Indivior. In the past three years, TMcC and DL were recipients of an educational grant from Janssen-Cilag to assist with writing a book for family caregivers of people with schizophrenia.