Enhancing Safety and Mitigating Violence on Prehospital Mental Health Calls: For the Care Providers and Care Recipients

doi:10.7870/cjcmh-2023-014 Published by Canadian Periodical for Community Studies Inc. CANADIAN JOURNAL OF COMMUNITY MENTAL HEALTH, VOL. 42, NO. 2, 2023 Polly Ford-Jones, School of Health Policy and Management, York University, Toronto, Ontario. Polly Ford-Jones is now at Faculty of Health Sciences & Wellness, Humber Institute of Technology & Advanced Learning, Toronto. This research was supported by the Fieldwork Cost Fund (YUGSA) York University and Research Cost Fund (CUPE 3903) York University. This article is drawn from Dr. Ford-Jones’ dissertation for the completion of a Doctorate in Health Policy and Equity in the School of Health Policy and Management, York University, Toronto, Canada. Dr. Ford-Jones would like to thank her dissertation supervisor Dr. Tamara Daly and committee members Dr. Mary Wiktorowicz and Dr. Claudia Chaufan, all of York University. Also great thanks to the paramedics who shared their time, perspectives, and vulnerability in participating in this research, without which it would not be possible. Correspondence concerning this article should be addressed to Dr. Polly Ford-Jones, Faculty of Health Sciences and Wellness, 205 Humber College Blvd., Toronto, Ontario M8W5L7. Email: [email protected] Enhancing Safety and Mitigating Violence on Prehospital Mental Health Calls: For the Care Providers and Care Recipients Polly C. Ford-Jones York University ABSTRACT Violent encounters and safety concerns are common among paramedics attending to 911 emergency calls. These concerns are particularly salient for paramedics attending to mental health and substance use calls. This article draws on data from a qualitative case study. Findings include paramedics’ reported perceptions and experiences of violence experienced on mental health calls, success with de-escalation of those in distress, and paramedics challenging the notion that all individuals with mental distress are violent. The article explores tensions between attention to care providers’ and care recipients’ safety, the contexts in which this care takes place, and equity concerns related to appropriately managing mental health emergencies. Keywords: safety, violence, paramedicine, prehospital care, qualitative research RÉSUMÉ Les rencontres marquées par la violence et les problèmes de sécurité sont courantes au sein des paramédicaux responsables des appels d’urgence 911. Ces situations préoccupantes sont particulièrement critiques pour les paramédicaux lors des interventions liées à la santé mentale et l’usage de substances. Cet article met l’accent sur les données d’une étude de cas qualitative. Les résultats incluent les perceptions rapportées des paramédicaux et la violence rencontrée lors d’appels liés à la santé mentale, les succès quant à la baisse de tension auprès des personnes en détresse, et le défi des paramédicaux avec l’a priori Canadian Journal of Community Mental Health Downloaded from www.cjcmh.com by Queens University on 03/25/24 For personal use only. 18 CANADIAN JOURNAL OF COMMUNITY MENTAL HEALTH VOL. 42, NO. 2, 2023 selon lequel toutes les personnes aux prises avec un problème de santé mentale sont violentes. Cet article explore les tensions entre les considérations à l’endroit des fournisseurs de soins et la sécurité des personnes soignées, ainsi que les contextes dans lesquels ces soins sont prodigués, de même que les préoccupations de sécurité en lien avec la gestion appropriée des interventions d’urgence liées à la santé mentale. Mots clés : sécurité, violence, paramédicaux, soins préhospitaliers, recherche qualitative Violent encounters and safety concerns are relatively common occurrences in healthcare settings (Koritsas et al., 2008; Pourshaikhian et al., 2016). Experiences of violence by paramedics in the prehospital setting occur worldwide (Bigham et al., 2014; Pourshaikhian et al., 2016), with many paramedics reporting exposure to violence in Australia, the US, UK, South Africa, Sweden, France, and Canada (Maguire et al., 2018). The nature of paramedic work is unpredictable, as paramedics respond to 911 emergency calls in a variety of settings and unknown circumstances. In the Canadian setting, paramedics report verbal assault, intimidation, physical assault, sexual harassment, and sexual assault (Bigham et al., 2014; Mausz et al., 2021). Recently, the Paramedic Chiefs of Canada released a position statement identifying the high rate of exposure to violence by paramedics and supporting zero tolerance for physical and verbal assault on paramedics (Paramedic Chiefs of Canada, 2018). While much of the literature about paramedics’ experiences of violence does not refer solely to encounters with patients with mental health needs, there is often reference to people with substance use issues as being more frequent perpetrators of violence against paramedics (Pourshaikhian et al., 2016) and those in crisis and with mental health needs are often thought of as dangerous or violent (Garcia et al., 2020; Giandinoto et al., 2018; Pescosolido et al., 2019; Sowislo et al., 2017). People with mental health needs being perceived as dangerous has existed historically, (Hewitt, 2008), including portrayals of people with mental health needs in the media as violent, dangerous, and unpredictable (Garcia et al. 2020). These portrayals may have some association with increased beliefs about dangerousness and mental illness (Hewitt, 2008; Reavley et al., 2016; Sowislo et al. 2017). Despite this persistent and salient belief, evidence indicates that individuals with mental health concerns are, in fact, more likely to be the victims and not the perpetrators of violence (Boyd & Kerr, 2016; Reavley et al., 2016). Ultimately though, discourses of dangerousness and mental illness have had significant influence on the focus of contemporary mental health services, policies, and legislation (Boyd & Kerr, 2016; Hewitt, 2008; Pescosolido et al. 2019). This article explores the tensions between front line paramedics’ considerations for managing safety and violence when attending calls for those with mental distress and the violence and safety concerns frequently faced by those with mental health needs. “Mental distress” and “mental health needs” refer to the spectrum of calls attended to, ranging from some level of distress to acute crisis. I draw on findings of paramedics’ experiences with violent encounters during mental health calls, successful management, and de-escalation of mental health calls, as well as paramedics’ descriptions that many mental health calls do not involve safety concerns. These tensions are contextualized by the limitations faced by paramedic services in managing these calls (Ford-Jones & Daly, 2020a), as well as the larger mental health and social care systems, considering factors that may reduce safety concerns for both care providers and recipients alike. The analysis is conducted with a feminist political economy approach (Armstrong et al., 2001). This approach informed all Canadian Journal of Community Mental Health Downloaded from www.cjcmh.com by Queens University on 03/25/24 For personal use only. 19 ENHANCING SAFETY AND MITIGATING VIOLENCE ON PREHOSPITAL MENTAL HEALTH CALLS P. FORD-JONES aspects of the study including the research questions, choice of methods, observation, and data collection process as well as analysis. METHODS Data were collected in a single qualitative, ethnographic case study (Yin, 2014) of mental health and psychosocial care in paramedicine in Ontario, Canada. Data collection consisted of interviews, observation in paramedic services, and thematic document analysis. Field work was carried out between September 2017 and October 2018. Purposive sampling was used to select three paramedic services (case sub-units) based on difference. Case sub-unit 1 was primarily urban with some suburban and rural communities, with program level engagement for mental health calls; case sub-unit 2 was rural with no specific program level engagement with the issue of mental health calls; case sub-unit 3 was rural and suburban with some limited first response resources for mental health calls. In addition to the three paramedic services, interview participants were also identified through snowball sampling. In total, 46 interviewees participated in the study including frontline paramedics (n = 31), paramedic services management (n = 5), paramedic college educators (n = 5) and base hospital physicians and directors (n = 5) who oversee paramedic practice in Ontario. Work observations took place in the three paramedic services with multiple crews and on varied shifts (n ~ 90 hrs.). Among interviews and observations, more than nine paramedic services were represented. Observations of paramedic calls offered an understanding of paramedics’ daily work experiences and their perspectives as they encountered real life situations. Participant observation took place on an ambulance, at stations, entering hospitals and participation by the researcher was limited to carrying bags, conversing with staff, and documenting field notes. The inclusion of multiple sources of evidence and multiple perspectives in fieldwork allowed for triangulation of data to increase construct validity, and validate findings across sources (Yin, 2014). Interviews were digitally recorded lasting 20–60 minutes in length, and transcribed verbatim. In advance of the research, an initial list of themes was derived from the literature, and these were refined during coding. All transcripts and field notes were read through at least once prior to thematic coding which was performed with NVivo (NVivo for Mac Version 11) software. The process of coding, determining themes, and further analysis of themes was an iterative, repeated process, employing a constant comparative method (Glaser, 1965), carried out to the point that refinements were no longer adding substantial insights or content relevant to the research questions (Braun & Clark, 2022). As the researcher, I had prior and current experience as a practicing paramedic in Ontario—although not in or proximal to any of the services included in the study—and as a paramedic educator in the college system. I also had prior experience conducting ethnographic research, including observations outside of paramedicine. My positionality brought existing experience and prior assumptions to this work, as well as informing directions for exploration. I acknowledge this positionality in my role as researcher, as informing the development, data collection, and analysis of the findings. I experienced being both an “insider” in this research due to my familiarity with paramedicine, as well as an “outsider” when engaging with services, geographies, and populations with whom I had not worked (Arber, 2006). Canadian Journal of Community Mental Health Downloaded from www.cjcmh.com by Queens University on 03/25/24 For personal use only. 20 CANADIAN JOURNAL OF COMMUNITY MENTAL HEALTH VOL. 42, NO. 2, 2023 Informed, written consent was individually obtained from all participants, and the paramedic services and interview participants remain anonymous for confidentiality. Informed, written consent was obtained from interview participants, from the paramedics whom I shadowed for field observations, as well as from the paramedic services within which I observed. As with other ethnographic research, the process of obtaining consent for observational research in the field was not a single event but an ongoing process (Bailey, 2007; Murphy & Dingwall 2007; Pope, 2005). An observation protocol was developed and approved by the ethics committee. If a patient or family member indicated that they did not wish to have me present, or if the paramedic crew indicated that I ought not to be present for a given call, the protocol indicated I would return to the ambulance or not exit the ambulance. This situation did not arise during my observation shifts. Ethics approval was obtained from York University’s Research Ethics Board. FINDINGS In this study about mental health and psychosocial care in paramedicine in Ontario, issues concerning violence and safety emerged as an important theme. Within this theme, three main sub-themes emerged: paramedic perceptions and experiences of violence on mental health-related calls, paramedics describing successful de-escalation methods to mitigate violence, and descriptions that many mental health-related calls do not necessarily involve violence or safety issues. Paramedic Perceptions and Experiences of Violence During Mental Health Calls Concerns around safety and violence were described as foremost concerns for managing mental health calls due to what was perceived as the unpredictable behaviours of patients with mental health needs. Many paramedics spoke of safety concerns as their highest priority because of the perception that violence from those in crisis was common. Paramedics spoke of their own and police use of restraining measures, alongside the need for de-escalation in certain situations. Paramedics emphasized how much of their work is unpredictable because notwithstanding whatever call details they have received from dispatch, they often walk into situations to provide care lacking accurate knowledge, history, and context. Along with this, paramedics stated that they are often called in at a point of crisis when people are in distress or when patients’ family support has been exhausted. For instance, they may not know an individual’s particular triggers, what may further exacerbate their distress, or whether a person may have intent to harm themselves or anyone else. When I say difficult it’s because it’s unpredictable, and you don’t know them, so you’re walking into somebody who has a known mental health issue perhaps, and you don’t know what their triggers are, you don’t know if they’re violent, you don’t know if they have something in their bag that they can get at you with. You don’t know if they’re gonna be good, good, good…suddenly you’re in danger. (front-line paramedic, interview 001) Given this unpredictability, paramedics described their highest priority as how they address their own safety and take precautions to prepare for physical interactions or violence. And keeping in mind too that when you’re dealing with mental health, you don’t know how fast they’re going to ramp up. If they’re going to get violent, if they’ve got a tendency to get violent. So, you’ve got to Canadian Journal of Community Mental Health Downloaded from www.cjcmh.com by Queens University on 03/25/24 For personal use only. 21 ENHANCING SAFETY AND MITIGATING VIOLENCE ON PREHOSPITAL MENTAL HEALTH CALLS P. FORD-JONES think your safety, their safety, your partner’s safety, public safety depending on where you are. (front-line paramedic, interview 007) During field observations, several of the calls observed exemplified the unpredictability described in the interviews, where call details often provided little detail, but enough to alert the paramedics to the potential for a safety concern. The following description outlines the start of a call observed: We weren’t in the station too much longer before our crew got a call. The call came in with the details: 21-year-old male self-inflicted injury to arm, bleeding controlled, police also dispatched. We would be met in the lobby. Code 3 (urgent, but not lights and sirens). When we arrived scene, police were not there. As we exited the truck, we went up a set of stairs and were not met in the lobby—the crew radioed to dispatch that we had not been met and noted police were not there. The crew said they would knock on the door and if there was anything “off,” we would go and wait somewhere else. Given that the details involved a selfinflicted wound, the reality is that there could be a weapon on scene and we do not know any more details than that. Someone answered the door, the crew entered and left the door propped open. As we entered the apartment it smelled strongly of smoke and there were cigarettes still burning. I could hear voices down the apartment hallway. The two paramedics entered toward the patient, I waited behind them, close to the door. The woman asked if we would close the door—one of the medics said, no, we’re going to leave it open. I understood she did this so we would have a point of egress, given that this seemed to be a bit of an uncertain situation. (field notes) This call proceeded without incident, paramedics spoke calmly with the patient and bystanders, provided treatment, and the patient agreed to be transported to hospital. Police did not arrive until the ambulance was about to depart scene. The crew navigated the uncertainties of the call and seemed to have plans in place depending on what they encountered. In interview, paramedics also spoke of learning to prioritizing their safety in their training and carrying this out in their practice. The most important thing is that we make sure that we’re okay, first of all. Because we’re always taught in school scene safety. If you’re not okay, your patient is definitely not going to be okay and your partner is going to be worse…We keep the worst case scenario at the front of our mind and then we work our way backwards. So, typically, you know, it starts off at a distance, trying to…figure out what that person’s comfort level is, what’s the situation that’s going on, trying to do your full assessment and then kind of figure out what the chief complaint is and work from there…With personal safety always being at the front. (front-line paramedic, interview 030) Another paramedic discussed direct questioning of patients, about their intent to be aggressive or violent, and if they have a weapon and the steps they take when expecting a safety issue. The other part of it is always gonna be a safety part on my part …I have them restrained for safe travel, it also affords me an opportunity that if they get scared or anxious and feel that I’m a threat and want to use force against me, well they have to work at trying to get a seatbelt buckle undone too and by that time I can tell my partner to stop, I can exit the vehicle…I want to make sure that they don’t have any…items in their pockets that could be used as a physical threat towards me…whether it’s an actual knife, or whether it’s an everyday object that people don’t realize might be a threat, like a screw driver, and a pair of scissors or whatnot…And usually I’ll flat out ask somebody…“Do you think I’m a threat to you?” “Do you understand that I don’t want to hurt you and I don’t want you to hurt me?” … We’ve had police officers ride in the back with us before. We’ve had police officers just follow in the cruiser behind us…The most extremist cases are when we’ve had them physically tied down to the stretcher. Usually, I find that in many of those Canadian Journal of Community Mental Health Downloaded from www.cjcmh.com by Queens University on 03/25/24 For personal use only. 22 CANADIAN JOURNAL OF COMMUNITY MENTAL HEALTH VOL. 42, NO. 2, 2023 cases, it’s not only the mental health issue, the psychosis or whatever they have, but it’s been aggravated or precipitated by drug use as well. (front-line paramedic, interview 005) Paramedics indicated how patients are often very forthcoming when directly asked these questions. The Basic Life Support Patient Care Standards is the primary guiding document for paramedics providing care in Ontario and it outlines direct questioning for harm to self or to others. Additionally, the document provides some guidelines about managing aggression and police involvement on scene. The section entitled the “Mental Health Standard” is two and a half pages of the 120 pages of the Patient Care Standards document. In total, the directives around safety and aggressive patients comprise approximately 2 pages of the 2.5-page “Mental Health Standard” (Ministry of Health and Long-Term Care, 2018b). In further understanding where some of the concern for safety originates, a number of paramedics spoke to their experiences of interacting with individuals on mental health calls when they felt a threat to their safety. Situations across multiple paramedic services included paramedics encountering weapons on the scene and/ or perceiving a threat to their safety. One paramedic interviewed said they were currently working in the office at headquarters on modified duties and not on the road for regular duty as they had been on temporary leave following an incident on a mental health call when they were directly threatened with a weapon. Experiences such as this and others, which involve actual or threatened violence, demonstrate situations of very real concern with potentially serious impacts for both the patients and paramedics. The Role of De-Escalation When describing their management of mental health calls, paramedics frequently described methods involving careful communication through listening, assessment of body language, keeping physical space and distance, and efforts at minimizing the number of first responders on a scene. Sometimes it’s better to just listen to the people, right? Some people wanna talk too much and, they [the patient] don’t maybe wanna be told at that point right? Depending on where they’re at. You know, just… stay calm and be friendly, and you know, be caring. That’s, sometimes…all they need, is just someone to listen…I find that that usually helps, you don’t wanna start saying things that are gonna trigger them, you know? (front-line paramedic: interview 018) The importance of paramedics’ interpersonal skills was emphasized by multiple paramedics. They identified that strong interpersonal skills could in some circumstances be a determining factor in how a mental health call goes, and whether a situation may escalate to involve violence or aggression. Ultimately, with these mental health calls it boils down to your interpersonal relationships and how you speak with these people. (front-line paramedic: interview 030) Paramedics described that in most circumstances, communication and de-escalation were effective and it was rare for a call to escalate to a point of violence or aggression. Most [mental health calls] are typically managed through…communication… therapeutic communication whatever that is [laughs], on rare occasions attempts at de-escalation when there’s someone who’s agitated or violent, and on even rarer occasions sedation or pharmacological restraint or physical restraint in violent cases; but I say the vast majority of the time it’s simply conversation. (front-line paramedic/paramedic educator: interview 041) Canadian Journal of Community Mental Health Downloaded from www.cjcmh.com by Queens University on 03/25/24 For personal use only. 23 ENHANCING SAFETY AND MITIGATING VIOLENCE ON PREHOSPITAL MENTAL HEALTH CALLS P. FORD-JONES Paramedics spoke of their awareness that people in crisis may well already be on edge or agitated and that it was an important part of their role to prevent that from worsening and, if possible, to decrease it. Usually…you can…verbal Judo usually works very well to de-escalate and keep people calm. Because often another thing that you want to avoid is make the situation worse. They’re already on edge, they’re already hyper-vigilant…so you don’t want to get there and make it worse. And you end up sedating them where you could have just talked them into getting into the ambulance instead…Revisit your priorities. Like, if he wants to walk, let him walk rather than putting everybody on a stretcher, “You want to walk, that’s fine,” “You want a cigarette before we go, sure,” like, instead of being very hard… be more accommodating to avoid escalation. (manager in an Ontario paramedic service: interview 035) Additionally, regarding preventing escalation, paramedics spoke of a need to limit the first responders on scene who were not needed. They indicated that having multiple responders on scene in addition to the two paramedics could sometimes be overwhelming. Paramedics indicated that police presence on a scene could at times be very helpful as an additional resource for managing calls and safety concerns; however, this was not always the case. One paramedic described police presence as a “double edged sword” (frontline paramedic: interview 001), highlighting that police involvement does not always de-escalate a situation but in fact can increase tensions, and in turn, conceivably heighten the risk to jeopardize safety concerns. In terms of de-escalation paramedics described the importance of interpersonal skills, communication, and accommodating patients’ needs when feasible. Paramedics described using these methods prior to requesting police involvement, where possible, and described that these methods were largely successful in managing mental health calls without incident. Challenging Common Conceptions: “They’re not all violent” Several paramedics challenged the frequent assumption that mental health calls and individuals with mental health needs are dangerous and are presumed to be violent. They explained how the perception of violence and safety issues related to mental health are a problematic way of thinking about and managing mental health needs. Like somebody with anxiety isn’t somebody who’s dangerous necessarily…and they’re very lumped into the same thing, and you don’t want to treat people like they’re…you know, like a psychokiller when they’re just anxious, they’re very, very different… But when we talk mental health, it’s the same thing. It’s all lumped the same. We need to understand the difference. Like just because somebody…takes Zoloft, doesn’t mean that you can’t enter their house and they’re dangerous, right? (front-line paramedic: interview 006) Another paramedic acknowledged that often those being apprehended under the Mental Health Act (1990), are not all dangerous or criminals, nor should they be thought of as “crazy,” but some paramedics may assume this. Let’s be honest, we paint everybody with the same picture… you see somebody coming in in handcuffs, right? Behind their back, so you think, oh, they’re crazy… they’ve done something wrong, right? …They’ve broken the law… so you think, right away … oh, it’s a bad person. And just because you have a mental health issue doesn’t mean you’re a bad person. (front-line paramedic: interview 019) Several paramedics acknowledged that assumptions about people in crisis being aggressive or violent may actually be detrimental to the ways in which care is provided. Canadian Journal of Community Mental Health Downloaded from www.cjcmh.com by Queens University on 03/25/24 For personal use only. 24 CANADIAN JOURNAL OF COMMUNITY MENTAL HEALTH VOL. 42, NO. 2, 2023 They’re not all violent, yet when they have these response teams [including police involvement], they’re all wearing bullet proof vests and you know…what sort of message does that send, right away when you’re pulling up in a cruiser and you’ve two individuals with bullet proof vests walking towards you, just assuming that people are going to be violent when, I think sometimes that escalates issues instead of de-escalating them right away. (manager in an Ontario paramedic service: interview 034) One paramedic educator suggested that mainstream and media portrayals of those with mental health needs as violent instills fear in those responding to mental health calls. The educator described that in their teaching, they aim to counteract that narrative, and find common ground between the paramedic and the patient. They’re [paramedics] scared…I think there’s fear involved in interacting with someone who’s [experiencing] psychosis. And that comes from lack of understanding and lack of experience and all the media crap that, you know, crazy people have the strength of ten people and all that crap … Actually, they’re frightened. So helping to reframe that and build empathy I think is a good thing … But that fear is, as I try to tell them, the fear is the common thing that bonds them in that moment. They’re afraid and the person with the illness is afraid. They need to get by that so teaching them mindfulness and how to ground someone and how to bring someone present and how to communicate with someone that’s distressed and all of those … things, I think, is really helpful. (paramedic educator: interview 039) Tensions in Violence and Safety: The Example of Jill During observation, I observed a patient transfer in a rural setting, where an individual was being transferred by ambulance from a small community hospital to the regional psychiatric ward. The interaction involved a patient, Jill (pseudonym) who was reported to have been highly aggressive with medical staff in the past and was being restrained in hospital and for the transfer. The nurse stated the patient has been extremely aggressive, it took 10 staff to manage her, and that in the past she has injured nursing staff and had them off on injury. She has [an extensive mental health history]. Patient is currently in 4-point restraints on a stretcher and has already even been given Ativan, Haldol, midazolam “enough to take down a horse” as per staff and she is still able to stand. One paramedic went in to speak to her, very calmly and explain that she is being transferred to another hospital. The patient was saying “I have to pee.” Nursing staff state, no, she will have to wait, she is “not to be trusted.” The one medic hesitated but the other medic pointed out that we did not see what they [the hospital staff] had to deal with. [The transfer was scheduled for them to have an RN [registered nurse] transfer with them. The one medic pointed out that the patient had been quite calm with her until the RN got in the patient’s face, then she became more agitated.] It took 5 hospital staff and 3 paramedics to move the patient over from the hospital bed to the stretcher and get her back into 4-point restraints on the stretcher as the patient continued to slip out. The patient appeared to have a lot of size and power behind her and as per the medics, she did. During the process the RN administered more medication and took additional Haldol and Midazolam for the transfer. The patient said “stop giving me medication.” She was not loud and aggressive, she was just pushing and slipping her hands away, stating “I just want to go home.” It took approximately 30–40 minutes for the patient to be loaded into the back of the ambulance and fully restrained. More Ativan was administered while trying to load her in the back—she kept slipping her hands out of the restraints. She continued to struggle while being loaded into the back. Throughout the process she kept trying to rock the stretcher—with her size, it would be very possible for her to rock the stretcher and for it to fall over with her still attached. Staff were attempting to prevent her from rocking. (field notes, 2018) Canadian Journal of Community Mental Health Downloaded from www.cjcmh.com by Queens University on 03/25/24 For personal use only. 25 ENHANCING SAFETY AND MITIGATING VIOLENCE ON PREHOSPITAL MENTAL HEALTH CALLS P. FORD-JONES Despite the many healthcare providers present in this situation, it took significant time, energy, physical, and chemical restraint to carry out this transfer. None of the care providers at the sending hospital, were mental health workers of any kind, but rather ED, acute care staff, and paramedics. Physical and chemical restraints are not necessarily uncommon for patients with mental health needs in the prehospital and ED setting; however, this presented as a particularly challenging situation in which neither type of restraint seemed to be helping significantly. This situation illustrates a tension between concern for Jill who has expressed she does not want to be there, does not want to receive more medication, and who is in need of support and care, and the healthcare providers who report that they have already had significant physical struggles with the patient and are aware that she has caused significant physical injury to other healthcare providers in the past. Acknowledging the concerns for all involved, it seemed that perhaps there could be another way. DISCUSSION The themes of safety and violence presented as a significant piece of context in the data. These themes were salient during interviews, observation, and document analysis, and across multiple domains, such as paramedic guiding documents, police presence on scenes, security services at hospitals, paramedic training and dialogue. Both receiving care and providing care with considerations of safety and violence are important contexts for mental health calls and paramedicine. A feminist political economy analysis accounts for tensions between individual agency and structure—paramedics’ ability to manage mental health calls safely, and the constraints of the systems within which paramedics work (Armstrong et al., 2001). Constraints include limited training, few supportive resources for those with mental health needs, requirements to transport directly to ED rather than other supportive care options, time limitations, and existing response models (Ford-Jones & Daly, 2020a, 2020b). As such, the importance of working and caring conditions is highlighted as well as people’s everyday lived experiences and the resultant equity considerations that are warranted. The following sections present the tensions between the safety and needs of care providers and recipients, equity concerns related to narratives of safety and violence, and recommendations moving forward. Tensions Between Care Provider and Care Recipient Safety Mental health policy has become increasingly dominated by a focus on violence prevention and alleviation of public concerns about dangerousness from those with mental health needs in the community (Burstow, 2013; Burstow, 2018; Hewitt, 2008). This increased dominance of violence prevention discourse at the policy level has had implications at the service delivery level with substantial focus on risk assessment and management. These implications play out in the policies existing for those with mental health needs living in the community, role of police in apprehending individuals, as well as in attitudes and approaches to care provision in mental health settings (Burstow, 2013, 2018; Hewitt, 2008). In a meta-analysis of health professionals’ attitudes toward dangerousness and patients with comorbid mental and physical health conditions, Giandonoto et al. (2018) found those working in EDs, and other medical and hospital wards reported poor confidence in mental health care skills resulting in increased perceptions of dangerousness, and negative attitudes and stereotypes impacting quality of care for those with comorbid physical and mental health needs. Canadian Journal of Community Mental Health Downloaded from www.cjcmh.com by Queens University on 03/25/24 For personal use only.