Non-conveyance of patients: Challenges to decision-making in emergency care

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. Published by Sciedu P ess 31 cns.sciedup ess.com Clinical Nu sing S udies 2016, Vol. 4, No. 4 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 32 ISSN 2324-7940 E-ISSN 2324-7959 cns.sciedup ess.com Clinical Nu sing S udies 2016, Vol. 4, No. 4 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 Published by Sciedu P ess 33 cns.sciedup ess.com Clinical Nu sing S udies 2016, Vol. 4, No. 4 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 34 ISSN 2324-7940 E-ISSN 2324-7959 cns.sciedup ess.com Clinical Nu sing S udies 2016, Vol. 4, No. 4 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 Published by Sciedu P ess 35 cns.sciedup ess.com Clinical Nu sing S udies 2016, Vol. 4, No. 4 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 . REFERENCES [1] Campeau A. Why pa amedics equi e " heo ies-o -p ac ice". Aus- alas J Pa amed. 2008; 6(2). A ailable om: h p:// o.ecu.edu .au/jephc/ ol6/iss2/3 [2] Snooks HA, Kea sley N, Dale J, e al. Gaps be ween policy, p o- ocols and p ac ice: a quali a i e s udy o he iews and p ac ice o eme gency ambulance s a conce ning he ca e o pa ien s wi h non-u gen needs. Qual Sa Heal h Ca e. 2005 Aug; 14(4): 251-7. h p://dx.doi.o g/10.1136/qshc.2004.012195 [3] Bigham BL, Buick JE, B ooks SC, e al. 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