cns.sciedup ess.com Clinical Nu sing S udies 2016, Vol. 4, No. 4
ORIGINAL ARTICLE
Non-con eyance o pa ien s: Challenges o
decision-making in eme gency ca e
Päi i K. Leikkola∗1, Rii a K. Mikkola1,2, Ma i H. Salminen-Tuomaala3, Eija E.M. Paa ilainen1,2
1Hospi al Dis ic o Sou h Os obo hnia, Seinäjoki, Finland
2Uni e si y o Tampe e, School o Heal h Sciences,Tampe e, Finland
3Uni e si y o Applied Sciences, School o Heal h Ca e and Social Wo k, Seinäjoki, Finland
Recei ed: June 2, 2016 Accep ed: Augus 26, 2016 Online Published: Sep embe 20, 2016
DOI: 10.5430/cns. 4n4p31 URL: h p://dx.doi.o g/10.5430/cns. 4n4p31
ABSTRACT
Backg ound:
I has been sugges ed ha eme gency ca e p o ide s’ decision-making compe ence should be s eng hened
ega ding whe he o no o anspo he pa ien . This quali a i e s udy desc ibes challenges ela ed o non-con eyance si ua ions
om eme gency ca e p o ide s’ pe spec i e.
Me hods:
Da a we e collec ed by a ques ionnai e om eme gency ca e p o ide s o a hospi al dis ic in Finland in 2014.
Responses o open ques ions we e analyzed using induc i e con en analysis o examine he di icul y o non-con eyance
decisions, easons o non-con eyance and challenges ela ed o he non-con eyance decision a e immedia e ca e.
Resul s:
The majo i y (70%) o ca e p o ide s did no expe ienced di icul y in making non-con eyance decisions, al hough
hose wo king in basic eme gence ca e ound decision-making sligh ly mo e challenging han wo ke s in ad anced eme gency
ca e. Ca e p o ide s’ easons o no anspo ing pa ien s we e mos commonly connec ed wi h hei assessmen o ca e needs
and he conclusion ha no hospi al ca e was equi ed. O he easons in ol ed ea ing he pa ien on si e, psychosocial easons
and no seeing he pa ien as an eme gency ca e clien . Di icul y o eaching mu ual unde s anding wi h pa ien s was conside ed
he g ea es challenge. O he challenges included wo ying abou he pa ien ’s coping a home and p oblems in in e -p o essional
co-ope a ion, ela ed o hu y and he conce n ha doc o s did no always documen eques s o ca e ins uc ions.
Conclusions:
The esul s sugges ha ca e p o ide s’ skills in assessing ca e needs and making decisions based on assessmen s
a e a decisi e ac o in non-con eyance si ua ions. Reaching a mu ual unde s anding wi h he pa ien is he g ea es challenge.
Key Wo ds: Pa ien , Family membe , Counseling, Eme gency ca e, Non-con eyance
1. INTRODUCTION
No e y much is ye known abou eme gency ca e admin-
is e ed in he pa ien ’s home o in ano he ou -o -hospi al
se ing, and ela i ely li le esea ch knowledge exis s on
eme gency ca e in gene al and on decisions no o con ey
pa ien s o hospi al.
[1,2]
I has been p oposed ha ins ead o
na owly ocusing on pa ien ca e p ocedu es, esea che s
should de elop mo e comp ehensi e heo ies o he whole
pa amedic p ac ice.
[1]
Resea ch e idence can be used o p o-
mo e eme gency ca e p o ide s’ p o essional iden i y and
compe ence, inc ease pa ien sa e y and b ing ou he ole
o he pa amedic p ac ice as a sou ce o esea ch opics o
nu sing science.[1,3]
The e m ou -o -hospi al eme gency ca e used in his a i-
cle e e s o he ca e o acu ely ill pa ien s in a p e-hospi al
se ing.
[4]
Eme gency ca e consis s o apidly changing, chal-
∗Co espondence: Päi i K. Leikkola; Email: pai[email p o ec ed]; Add ess: Hospi al Dis ic o Sou h Os obo hnia, Seinäjoki, Finland.
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lenging si ua ions, which c ea e a sense o u gency and in-
duce s ess in ca e p o ide s.
[3]
De eloping ou -o -hospi al
eme gency ca e is o g ea impo ance in o de o dec ease
pa ien mo ali y and disabili y. E ec i e ca e deli e ed in
he pa ien ’s home o o he p e-hospi al se ing also imp o es
he o e all quali y o pa ien ca e and po en ially cu s ca e
cos s.[4–6]
In Finland, eme gency medical se ices ha e been o ganized
on a egional basis as a pa o he heal h ca e sys em,
[7]
egula ed by he Heal h Ca e Ac and Dec ee on Eme gency
Medical Se ices. The way o o ganizing se ices is de ined
by each egional hospi al dis ic , which means ha he con-
en s o he se ices can a y om one dis ic o ano he . A
popula ion wi hin a single hospi al dis ic , howe e , mus
be se ed based on a p inciple o equali y.
[8]
Finnish law
also se s ou quali ica ion equi emen s o eme gency heal h
ca e p o ide s, ha is o heal h ca e p o essionals and escue
wo ke s.
[8]
The in oduc ion o he mo e explici quali ica-
ion equi emen s a ew yea s ago has been ound o imp o e
pa ien sa e y and he quali y o he ca e.
[9]
In Finland, am-
bulances a e di ided in o basic and ad anced le el ehicles
depending on he quali ica ions o he s a . A basic le el am-
bulance c ew consis s o egis e ed nu ses, p ac ical nu ses
and eme gency medical echnicians, all ained o pe o m a
leas basic li e-sa ing p ocedu es. An ad anced le el ambu-
lance eam can only ha e egis e ed nu ses and eme gency
nu ses, quali ied in mo e ad anced li e suppo echniques
and also p epa ed o manage mul iple pa ien si ua ions.
[10,11]
Ca e p o ide s assess he pa ien ’s need o eme gency ca e
on si e and make a decision on whe he and how o con ey
he pa ien o u he ca e. In o he wo ds, non-con eyance
o only ea ing he pa ien on loca ion is a possible op ion.
[8]
I has been epo ed ha up o 30% o pa ien s a e no ans-
po ed o hospi al ollowing a endance by an eme gency
c ew.
[12,13]
On he o he hand, i has been es ima ed ha
11%-61% o he anspo s a e medically no necessa y.
[14]
Typical easons o non-con eyance seem o include e usal
o a el, mino o no inju ies, eco e y a e ea men on
scene, alls in elde ly people o a isi by he pa ien ’s gene al
p ac i ione . Some imes amily membe s decide o a ange
hei own anspo . The non-con eyance decision can be
a esul o pa ien -ca e nego ia ion; ew pa ien s e use o
a el agains ad ice.[12,15]
In ecen yea s, ea ing eme gency pa ien s in hei homes
has come mo e o he o e as a de elopmen a ge .
[6,12]
Ca e
p o ide s ea mo e di e se pa ien popula ions han e e ,
and o be able o manage well, hey mus possess a wide
ange o skills.
[2]
Especially pa amedic ield manage s, who
also pa icipa e in pa ien ca e, equi e si ua ional awa eness.
They mus cons an ly be awa e o wha is going on and wha
migh happen nex , and hey ha e been ound o ac ou mul-
iple oles based on a ious ca ego ies o in o ma ion.
[16]
Fo
some ime i has been sugges ed ha ca e p o ide s should
ha e mo e o say abou whe he o con ey he pa ien o hos-
pi al o no .
[6]
A s udy con i med ha app op ia ely ained
pa amedics wi h ex ended skills can p o ide ca e ha is a
leas as sa e as he s anda d ca e p o ided by eme gency med-
ical se ices and eme gency depa men s.
[17]
O he s udies
claim ha pa amedics canno always sa ely decide, which
pa ien s o ans e o hospi al.
[18,19]
S ill, o be able o pe -
o m as well as possible, ca e p o ide s need o ha e he igh
in o ma ion
[16]
and ocused guidelines o suppo hei deci-
sion making.
[20]
Suppo and aining a e needed o inc ease
ca e p o ide s’ con idence, and wi h app op ia e aining, i
is possible o ea e en aged pa ien s a home sa ely.[17]
Pu pose o he s udy
This s udy deals wi h non-con eyance o pa ien s ollowing
a endance by an ambulance c ew. The s udy was conduc ed
om he pe spec i e o eme gency ca e p o ide s, who ep-
esen ed a ious p o essional backg ounds. All pa icipan s
will be e e ed o as “ca e p o ide s” hence o h. The s udy
aims a gene a ing new knowledge o decision-making in
eme gency ca e si ua ions, o be used in con inuing oca-
ional o p o essional educa ion and in de eloping ca e qual-
i y. The new knowledge can also alle ia e decision-making
on whe he o no o con ey a pa ien o hospi al.
The esea ch ques ions we e: (1) How di icul was i o ca e
p o ide s o make decisions on non-con eyance; (2) Wha
we e he ca e p o ide s’ easons o no anspo ing pa ien s
o hospi al; (3) Which ac o s ela ed o non-con eyance
did he ca e p o ide s ind challenging a e he immedia e
eme gency ca e si ua ion?
2. METHOD
2.1 Resea ch design and sample
The da a collec ed o his esea ch was mainly quali a i e
and desc ip i e. Responden s we e eme gency ca e p o ide s
o a hospi al dis ic in Finland in Sep embe –Oc obe 2014.
A new ques ionnai e based on li e a u e was de eloped and
es ed o his pu pose.
[21]
The ques ionnai e was sen o all
eme gency ca e p o ide s o he hospi al dis ic , ha is o
nu ses, eme gency nu ses, p ac ical nu ses and eme gency
medical echnicians (N = 142). The esponse a e was 53%
(n = 71). The ques ionnai e was sen elec onically, as a link
o an e-mail. Ca e p o ide s eplied elec onically o he
in es iga o di ec ly. They emained anonymous. This pape
complemen s and is a con inua ion o esul s epo ed in ou
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ea lie a icle, which deals wi h eme gency ca e p o ide s’
clinical skills.[21]
2.2 Ins umen
The ques ionnai e, de eloped o his s udy, was based on ea -
lie esea ch and li e a u e. I was cons uc ed by an expe
panel consis ing o ou esea che s. The elec onic ques ion-
nai e was es ed wi h eme gency ca e p o ide s (n = 17) in
June-July 2014. As no amendmen s we e equi ed, his da a
was included in he ac ual s udy.
[22–24]
The ques ionnai e
s a ed wi h 8 backg ound ques ions. Responden s we e hen
asked whe he hey had expe ienced di icul y in making non-
con eyance decisions. A mul iple choice ques ion was used
wi h he op ions 1 = no, 2 = yes, and 3 = canno say. Finally,
ca e p o ide s we e p esen ed wi h wo open ques ions, ask-
ing hem o desc ibe he easons o no anspo ing pa ien s
o hospi al and any challenging ac o s o issues ela ed o
non-con eyance, expe ienced a e he immedia e eme gency
ca e si ua ion. The esul s sec ion o his pape includes
ca e p o ide s’ backg ound in o ma ion, hei esponse o
he i em on di icul y o making non-con eyance decisions,
hei easons o non-con eyance and he challenges hey had
expe ienced a e he immedia e eme gency ca e si ua ion
had passed.
2.3 Validi y and eliabili y
The alidi y o his esea ch was add essed by means o he
p ima y alidi y c i e ia as syn hesized by Whi emo e e
al.
[25]
o quali a i e esea ch. These c i e ia in ol e c ed-
ibili y, au hen ici y, c i icali y and in eg i y. C edibili y o
he quali a i e analysis means ha he eade can us ha
he in e p e a ions a e us wo hy and e lec he expe ience
o pa icipan s o he con ex . Au hen ici y, which is closely
linked o c edibili y, means eaching pa icipan s’ li ed and
pe cei ed meanings and expe iences and po aying mul i-
ple, some imes con lic ing eali ies. C i icali y e e s o he
in es iga o s’ e o o c i ically app aise hei own solu ions,
in e p e a ions, assump ions and he e ec o hei knowl-
edge backg ound. Finally, o ensu e alid in e p e a ions
g ounded wi hin da a, in eg i y should be sough h ough
sel - e lec ion and a sel -c i ical app oach.[24,25]
The c edibili y and au hen ici y o his esea ch was ensu ed
by collec ing da a om eme gency ca e p o ide s in ol ed in
p ac ical ca e wo k. Responden s had i s -hand expe ience
and concep ions o he challenges ela ed o decision-making.
Thei uni o mi y o opinion was exp essed in nume ous e -
e ences o he challenges in decision-making, epo ed bo h
quan i a i ely and quali a i ely. The c i icali y and in eg i y
o he esea ch was secu ed by epea ed examina ion o in e -
p e a ions and ca e ul epo ing o he esea ch p ocess. The
whole esea ch eam pa icipa ed in da a analysis, which in-
c eased he eliabili y o he esul s. The connec ion be ween
da a and in e p e a ion was demons a ed by quan i a i e
da a on he challenges and by a de ailed desc ip ion o he
analysis.
The eliabili y o he s udy may be limi ed by he ac ha
da a we e collec ed in a single hospi al dis ic . Despi e a
mo i a ing co e le e and eminde s he esponse a e was
ela i ely low, 53%, as is o en he case in e-mail enqui ies.
Ha ing o open a sepa a e link o access he ques ionnai e
may ha e been one eason o he low esponse a e. I is also
possible ha his pa icula a ge g oup was i ed o a ious
enqui ies and epea ed da a collec ion.[26–28]
2.4 E hical conside a ions
A en ion was paid o esponsible conduc o esea ch and
esea ch e hics h oughou he s udy.
[24,29,30]
The s udy plan
passed he e hical e iew p ocess, and pe mission o conduc
he s udy was g an ed by he hospi al. Ca e p o ide s we e
in o med o he pu pose o he s udy, olun a y pa icipa ion
and anonymi y be o e gi ing hei in o med consen . They
had he possibili y o wi hd aw a any ime, and consen o
decline did no a ec hei wo k in any way. The esea ch e-
sul s a e epo ed hones ly, neu ally and o he in es iga o ’s
bes unde s anding.
[31,32]
Indi idual ca e p o ide s’ exp es-
sions canno by iden i ied. The esea ch eam will s o e he
da a elec onically un il all esea ch p ojec s ha e been ended
and epo ed on.
2.5 Da a analysis
The backg ound da a we e analyzed using SPSS o Win-
dows 22. The esul s sec ion s a s wi h he ca e p o ide s’
backg ound in o ma ion: age, sex, quali ica ion, cu en posi-
ion, ype o employmen and wo k expe ience in he cu en
posi ion, in eme gency ca e and in heal h se ices. These
backg ound ac o s a e gi en in equencies, pe cen ages,
means and anges. The esponden s’ age da a we e eclassi-
ied o analysis. The connec ion be ween ca e p o ide s’ sex
and di icul y o he non-con eyance decision was analyzed
using c oss abula ion.
Induc i e con en analyses was used o analyze he quali-
a i e da a,
[33,34]
wi h he objec i e o cons uc ing a sys-
ema ic, condensed desc ip ion o he phenomenon unde
s udy.
[31]
Wo ds, ph ases and hough s exp essed h ough
se e al clauses we e hough o as uni s o be analyzed.
O iginal exp essions we e selec ed, lis ed and educed, al-
hough some o he exp essions we e so sho ha hey
could no be educed. In he nex s age, he educed exp es-
sions we e g ouped oge he as sub-ca ego ies and named
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using con en -cha ac e is ic wo ds. The sub-ca ego ies we e
hen g ouped unde highe o de ca ego ies and desc ip i e
headings. These ca ego ies ep esen he in es iga o ’s con-
s uc ed explana ion o he phenomenon unde s udy.
[34–36]
The numbe o exp essions o a ious ca ego ies is also
epo ed in he esul s below.
3. RESULTS
The non-con eyance si ua ion, expe ienced by ca e p o ide s
a e he immedia e eme gency ca e si ua ion, comp ised he
ca e p o ide ’s decision-making ela ed o non-con eyance,
hei easons o no anspo ing he pa ien o hospi al and
he challenges expe ienced by ca e p o ide s in he si ua ion.
3.1 Backg ound In o ma ion
Ca e p o ide s’ backg ound in o ma ion is gi en in Table
1. Thei mean age was 34 yea s. The younges pe son was
19 and he oldes 58. The e was an equal numbe o women
and men (n = 71, 50%). Mo e han hal o he esponden s
wo ked in basic-le el eme gency ca e (n = 93, 65.5%) and he
es in ad anced-le el eme gency se ices (n = 49, 34.5%).
Mos ca e p o ide s had a egis e ed nu sing quali ica ion
(60.6%), while he mino i y (39.4%) held oca ional quali i-
ca ions in p ac ical nu sing o pa amedics. Mos esponden s
(74.6%) had a pe manen wo k con ac and he es (25.4%)
a ixed- e m con ac .
Table 1. Pa icipan s’ backg ound in o ma ion
Backg ound in o ma ion N %
Sex
• Female 71 50.0
• Male 71 50.0
Age
• Unde 25 23 16.2
• 25-34 55 38.7
• 35-44 40 28.2
• O e 45 24 16.9
Cu en wo kplace
• Basic-le el eme gency ca e 93 65.5
• Ad anced eme gency ca e 49 34.5
Quali ica ion
• P ac ical nu se, EMT 56 39.4
• Nu se 86 60.6
Type o employmen
• Pe manen 106 74.6
• Fixed e m 36 25.4
No e. EMT = eme gen medical echnician
In addi ion o he da a shown in Table 2, he s udy e ealed
ha mos esponden s (77.3%) had wo ked less han 2 yea s
in hei cu en posi ion. Thei mean ime in hei cu en
wo k was 1.9 yea s, wi h he ange om 0.3 mon hs o 13
yea s. They had an a e age o 8.3 yea s’ expe ience o wo k-
ing in eme gency ca e se ices ( ange 0.5-34 yea s) and an
a e age o 10 yea s’ expe ience o wo king in he heal h
se ice ( ange 0-34 yea s).
Table 2. Ca e p o ide s’ expe ience o hei cu en wo k, eme gency ca e and heal h se ice by occupa ional g oup
Backg ound in o ma ion
P ac ical nu ses, EMT
Nu ses
N
%
N
%
Expe ience o cu en wo k
• unde 1.5 yea s
16
29.1
17
19.8
• 1.5-2.4 yea s
31
56.4
45
52.3
• 2.5 yea s o mo e
8
14.5
24
27.9
Expe ience o eme gency ca e
• unde 3 yea s
19
33.9
33
38.4
• 3-8 yea s
16
28.6
29
33.7
• o e 8 yea s
21
37.5
24
27.9
Expe ience o heal h se ice
• unde 3 yea s
14
26.0
11
12.8
• 3-8 yea s
16
29.6
39
45.3
• o e 8 yea s
24
44.4
36
41.9
No e. EMT = eme gen medical echnician
Table 3 e eals ha 19% (n = 27) o ca e p o ide s ound
i di icul o make a decision no o anspo he pa ien o
hospi al, whe eas app oxima ely wo hi ds o hem (n = 95)
did no conside he non-con eyance decision di icul and
14% (n = 20) chose he op ion canno say.
The in es iga o s did no disco e any s a is ically signi i-
can di e ences be ween a ious g oups as ega ds he back-
g ound a iables. Table 4 shows he esul s o men and
women. A sligh ly la ge p opo ion o women (24%) com-
pa ed o men (14%) ound i di icul o make decisions abou
non-con eyance. Simila ly, he e we e mino di e ences in
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he esul s be ween hose wo king in basic eme gency ca e
(21.5%) and hose employed in ad anced eme gency ca e
(15.2%). Finally, an analysis conduc ed o occupa ional
g oups e ealed ha 25% o eme gency medical echnicians,
23% o p ac ical nu ses and 16% o nu ses conside ed he
non-con eyance decision di icul .
Table 3. Ca e p o ide s’ di icul y o making
non-con eyance decisions
F equency
Pe cen
Valid Pe cen age
No
95
66.9
66.9
Yes
27
19.0
19.0
Canno say
20
14.1
14.1
To al
142
100.0
100.0
3.2 Reasons o non-con eyance
The eques o lis easons o no anspo ing he pa ien
o hospi al yielded a o al o 257 exp essions, classi ied and
p esen ed in Table 5.
Acco ding o ca e p o ide s, hei decision no o anspo
he pa ien o hospi al was based on hei assessmen o ca e
needs and, mos commonly, on he conclusion ha he pa ien
did no equi e eme gency ea men o anspo o hospi al
(121 exp essions). The pa ien equi ed nei he anspo by
ambulance no eme gency p ocedu es o cons an obse a-
ion. I was o en decided ha he pa ien could wai un il
he ollowing day and con ac he local heal h cen e . Ca e
p o ide s epo ed ha hey o en ad ised pa ien s o use
hei own ehicles o ha e amily membe s accompany hem
(e.g. o a heal h cen e ). In some cases, pos poning he ea -
men by a ew hou s seemed a be e solu ion han a longe ,
nigh ime anspo by ambulance. Se e al ca e p o ide s
also main ained ha some imes hei decision no o anspo
he pa ien was due o ci izens’ oo low a h eshold o call
o help. Pa ien s seemed o expec ha an ambulance would
always con ey hem o hospi al.
Table 4. Ca e p o ide s’ di icul y o making a non-con eyance decision by sex
Sex
To al
Female
Male
Di icul y o non-con eyance decision
No
Coun
43
52
95
% wi hin sex
60.6%
73.2%
66.9%
Yes
Coun
17
10
27
% wi hin sex
23.9%
14.1%
19.0%
Canno say
Coun
11
9
20
% wi hin sex
15.5%
12.7%
14.1%
To al
Coun
71
71
142
% wi hin sex
100.0%
100.0%
100.0%
Table 5. Reasons o non-con eyance
Gene ic ca ego y
Sub-ca ego y
Assessmen o ca e needs
• No need o con eyance o eme gency ca e
• La e isi o a heal h cen e
• Pa ien is no le alone a home
Pa ien ea ed on si e
• Adequa e ea men on si e
• Mino inju y, disease o symp om
• Ch onic o p olonged complain /old complain
Psychosocial easons
• Loneliness
• Insecu i y
• Social easons
• Lack o common sense o basic li e skills
The pa ien is no an eme gency ca e clien
• D ugs o alcohol
• Unnecessa y elephone calls
• Re usal o be anspo ed
• Pa ien is a clien o he police
• Pa ien canno be ound
• Ambulance is no used o anspo he pa ien
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Adequa e ea men on si e was ano he common eason
o non-con eyance (28 exp essions). In hese cases, ca e
p o ide s el ha hey had been able o adminis e adequa e
ca e on si e, so ha i was sa e o he pa ien o s ay a home.
The si ua ions men ioned in ol ed pain alle ia ion ( o ex-
ample o back pain), nose bleeds, gluing wounds, li ing and
examining pa ien s who had allen and ea ing low blood
suga s and sho ness o b ea h. Secondly, pa ien s o en had
mino physical inju ies o symp oms (18 exp essions). Ex-
amples gi en by esponden s included mild hype ension o
e e , mino wounds, gas i is, ansien a acks, lu, dia -
hea, alls (wi hou inju y) and la yngi is. Thi dly, ch onic
o p olonged condi ions we e also men ioned as a eason
o non-con eyance (26 exp essions). In hese cases, he
pa ien ’s complain was no acu e o had no de e io a ed
signi ican ly, so no eme gency ea men was equi ed. The
symp oms had pe sis ed o weeks o mon hs. The examples
gi en by ca e p o ide s in ol ed p olonged s omach com-
plain s, cons ipa ion, poo gene al condi ion, p olonged lu
and ch onic back pain.
Responden s also epo ed ha psychosocial easons some-
imes esul ed in non-con eyance. The pa ien ’s loneliness
was men ioned in 9 exp essions. Some imes pa ien s had
called o an ambulance, because hey had el us a ed,
hoping o help o a p olonged complain , o because hey
had el insecu e abou hei coping a home. In some cases,
pa ien s had called o help o social easons. Fo example,
a lonely elde ly pe son o an in oxica ed clien had wished
o someone o alk o. Finally, i was sugges ed ha lack
o common sense o basic li e skills some imes esul ed in
unnecessa y calls.
Las , esponden s o en el ha he pa ien was no an eme -
gency ca e clien and did no equi e anspo o hospi-
al. Use s o d ugs and alcohol we e men ioned speci ically
(22 exp essions). S ongly in oxica ed pe sons some imes
called an ambulance, because hey wan ed immedia e eha-
bili a ion o had un ou o d ink. Pe sons, who e used o be
anspo ed by ambulance, we e clien s o he police o could
no be ound, we e no conside ed eme gency ca e clien s
ei he . Some imes clien s we e no con eyed o hospi al by
ambulance bu by ano he means o anspo .
3.3 Challenges ela ed o non-con eyance
As a esponse o he las ques ion ca e p o ide s epo ed,
which issues o ac o s ela ed o non-con eyance hey had
ound challenging a e he eme gency ca e si ua ion. A o al
o 192 exp essions we e ob ained.
Table 6. Challenges ela ed o non-con eyance
Gene ic ca ego y
Sub-ca ego y
Di icul y o eaching mu ual unde s anding
• No mu ual unde s anding o non-con eyance wi h he pa ien and amily membe
• No need o eme gency ca e o con eyance
• P oblems in anspo
• Pa ien equi es special a en ion
Pa ien ’s coping a home
• Insecu i y abou pa ien ’s coping a home
• Ca e p o ide ’s esponsibili y o non-con eyance decision
• Home ca e assis ance
Co-ope a ion be ween p o essionals
• Co-ope a ion wi h he eme gency clinic doc o
• Telephone consul a ion
Table 6 summa izes he challenges ela ed o he non-
con eyance decision. Acco ding o ca e p o ide s, he di i-
cul y o eaching mu ual unde s anding was he mos chal-
lenging ac o (72 exp essions). The pa ien and/o amily
membe did no always ag ee wi h he non-con eyance de-
cision; he pa ien and/o amily membe had a di e en
opinion compa ed o he ca e p o ide s’ opinion. Some-
imes pa ien s o amily membe s did no unde s and why
he pa ien was no con eyed o ca e. Some o hem hough
ha pa ien s anspo ed by ambulance we e ea ed as e
and could a oid queuing a he eme gency clinic. Some pa-
ien s, especially olde pe sons, and amily membe s had
he misconcep ion ha an ambulance always anspo ed he
pa ien o hospi al. Some o hem hough ha he des ina-
ion would always be a cen al hospi al, a he han a mino
hospi al o heal h cen e. Ca e p o ide s epo ed ha ing el
p essu ized o anspo he pa ien ; some imes con eyance
was demanded, al hough he pa ien ’s condi ion clea ly did
no equi e hospi al ca e. Responden s also men ioned ha
eaching a mu ual unde s anding was di icul wi h pa ien s,
who equi ed special a en ion. Con used pa ien s, use s o
in oxican s and agg essi e pa ien s we e lis ed as examples.
Wo ying abou he pa ien ’s coping a home was ano he
challenge men ioned by ca e p o ide s (21 exp essions). The
pa ien did no necessa y equi e hospi al ca e, bu espon-
36 ISSN 2324-7940 E-ISSN 2324-7959
cns.sciedup ess.com Clinical Nu sing S udies 2016, Vol. 4, No. 4
den s we e insecu e abou he pa ien ’s coping a home o he -
wise. Especially lea ing alone-li ing o old pe sons a home
was some imes conside ed p oblema ic. Ca e p o ide s also
commen ed on hei esponsibili y o non-con eyance de-
cisions. Some o hem exp essed hei insecu i y ega ding
he decisions (9 exp essions) and he ange o esponsibili y
om assessmen and examina ion o he pa ien o diagnos-
ics and non-con eyance decisions. Si ua ions, in which
he e was a possibili y o he pa ien making ano he ele-
phone call o help, caused insecu i y in ca e p o ide s, as
did he conce n ha he pa ien migh no unde s and he
home ca e and ollow-up ins uc ions (24 exp essions) o
migh no ecei e adequa e assis ance om he home help
se ice. Pa ien s wi h ambiguous symp oms (6 exp essions)
we e ano he sou ce o insecu i y; i was no always possible
o ind a clea explana ion o he illness o he pa ien was
a so-called bo de line case. Wo y and ea abou making
an inco ec decision when lea ing he pa ien a home was
men ioned (13 exp essions); he pa ien migh de e io a e de-
spi e ca e ul examina ion and ea men . A ew esponden s
commen ed ha in case o insecu i y, i was be e o con ey
he pa ien o hospi al.
One mo e a ea in which challenges we e epo ed in his
s udy in ol ed he co-ope a ion be ween p o essionals. Ca e
p o ide s co-ope a ed wi h doc o s o he eme gency clinic,
consul ing hem by elephone. Some imes ca e p o ide s
el ha he doc o did no concen a e su icien ly on he
cu en si ua ion (9 exp essions). Secondly, ca e p o ide s
we e no always ce ain i he doc o had en e ed on o he
pa ien ’s eco ds he in o ma ion ha he ambulance c ew
had eques ed ca e ins uc ions.
4. DISCUSSION
Eme gency ca e p o ide s equi e a wide ange o compe en-
cies o be able o encoun e acu ely ill pa ien s and p o ide
high quali y eme gency ca e.
[13,17]
In his s udy, mos ca e
p o ide s (70%) did no conside i di icul o decide abou
he pa ien ’s non-con eyance o hospi al. The decisions we e
sligh ly mo e di icul o ca e p o ide s wo king in basic
le el eme gency se ices han o hose in ad anced le el
eme gency ca e. Women also ound i mo e di icul o decide
abou he pa ien ’s anspo han men. I has been p oposed
ha ca e p o ide s should ha e mo e possibili y o decide
abou non-con eyance.
[6]
This s udy indica es ha such a
de elopmen migh well be possible.
Pa ien s a e no con eyed o hospi al ca e o a a ie y o ea-
sons. This s udy e ealed ha non-con eyance was based on
a ca e needs assessmen o on adequa e ea men p o ided
on si e. Some imes he easons we e psychosocial o i was
decided ha he pa ien was no a clien o eme gency ca e
se ices. The mos common eason, acco ding o espon-
den s o his s udy, was ca e p o ide s’ assessmen o he
pa ien ’s si ua ion.
[16]
As ega ds psychosocial easons as a
backg ound o non-con eyance, he indings a e consis en
wi h ea lie esea ch, which s a es ha he eme gency eam is
some imes only called “ o be on he sa e side”. In many cases
he pa ien does no equi e anspo o hospi al
[12,20]
o can-
no be conside ed a clien o eme gency ca e se ices. As in
ea lie esea ch,
[12,15]
i was ound in his s udy ha pa ien s
some imes e used anspo a ion o could no be ound. The
s udy con i ms ha eme gency ca e p o ide s assess hei
pa ien s’ eme gency ca e needs and decide abou sui able
anspo on si e.
[8]
S ill, non- anspo guidelines and p ac i-
cal ac ion models o suppo decision-making and sa e ca e
a e also equi ed, as has been ecommended be o e.[20]
Today, ca e p o ide s encoun e a g ea e a ie y o pa ien
g oups han be o e.
[6,12]
In his s udy, eaching a mu ual un-
de s anding be ween he ca e p o ide , pa ien and/o amily
membe ega ding non-con eyance was ound o be he mos
demanding challenge. The inding is in ha mony wi h ea lie
p oposi ions ha decisions on anspo can be commonly ne-
go ia ed, bu a e also p one o challenges.
[15]
Ca e p o ide s’
conce n ha he pa ien migh no cope a home was an-
o he challenge highligh ed in his s udy. The inding b ings
in o mind he impo ance o gaining co ec and adequa e
pa ien in o ma ion o suppo decision-making.
[16]
Ea lie ,
a doc o ’s assessmen and decision has been desc ibed as
he eason o non- anspo a ion.
[12]
I has also been e-
pea edly con i med ha eme gency ca e p o ide s’ wo k is
cha ac e ized by hu y and s ess.
[3]
This s udy adds o he
inding by p esen ing one mo e challenge: p oblems in mul i-
p o essional co-ope a ion, linked o limi ed ime and he
ca e p o ide s’ insecu i y, whe he doc o s ha e always paid
adequa e a en ion o pa ien s and i hey ha e co ec ly doc-
umen ed he ambulance c ew’s eques s o ca e ins uc ions.
5. CONCLUSIONS
Eme gency ca e p o ide s ha e a a ie y o easons o no
anspo ing pa ien s o hospi al ca e and hey ace mul i-
ple challenges in he si ua ion ela ed o non- anspo a ion,
al hough mos esponden s in his s udy did no ind non-
con eyance decisions di icul . This esea ch sugges s ha
ca e p o ide s’ skills in assessing ca e needs and making
decisions based on he assessmen a e essen ial when ha ing
o decide whe he he pa ien should be anspo ed. The
ca e p o ide s in his s udy possess good sel - epo ed skills
in ecognizing non-u gen ca e needs. The s udy u he in-
dica es ha eaching a mu ual unde s anding be ween he
pa ien and ca e p o ide can be he g ea es challenge linked
o he non-con eyance si ua ion. The indings can be used o
Published by Sciedu P ess 37
cns.sciedup ess.com Clinical Nu sing S udies 2016, Vol. 4, No. 4
de elop eme gency ca e u he by imp o ing ca e p o ide s’
compe ence by u he aining and h ough eme gency p ac-
ice.
CONFLICTS OF INTEREST DISCLOSURE
The au ho s decla e hey ha e no con lic s o in e es .
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