Mental health and mental illness in paramedic practice: A warrant for research and inquiry into accounts of paramedic clinical judgment and decison-making

This paper is the first in a series that heralds a study examining paramedic accounts and constructs of judgment and decision-making (JDM) of mental health and mental illness. Providing an introduction and background to the evolving study, the paper will establish a warrant for the research and scope of the research agenda and methods of inquiry. Background to the Research The provision of appropriate mental health services for Australians is an urgent national health priority. The National Mental Health Report 2000 cites that almost one in five (18%) Australians suffers from a mental disorder, and that 3% of the total population live with a serious psychiatric disorder at any one point in time[1]. Fundamental changes to health-care policy in Australia and around the world have led to an increase in the extent to which emergency personnel come into contact with patients experiencing mental health problems [2, 3]. The launch of the National Mental Health Policy by the Australian Health Ministers in 1992 provided the stimulus for significant changes to psychiatric services within the Australian health-care system[4]. Mainstreaming of services was a central feature of these changes, shifting the provision of traditional psychiatric care from dedicated institutions to integration and co-location with mainstream general health services and community settings. Such changes to mental health service delivery have been problematic for health-care workers across many disciplines. The decentralisation of mental heath services has resulted in increased attendance at emergency departments and to emergency medical services by patients with mental health problems, something well documented in Australia and around the world [2, 4, 5]. Some facilities have reported a 10-fold increase of the number of patients presenting to the Emergency Department (ED) with mental health problems in 10 years [6]. Health care workers from a variety of disciplines have reported perceiving themselves as lacking the skills and expertise to provide appropriate care and treatment to this client group [1, 4, 5, 7, 8]. Such events and factors have meant that health-care workers, particularly community health and emergency personnel, are increasingly required to manage a variety of patients mental health problems, often complex and chronic in nature [1-4, 6]. In Queensland, legislation has recently undergone major revision in line with national and international reform in the provision of mental health services. The Mental Health Act 2000 (Qld) (MHA)[9] is, broadly speaking, the major legislative instrument regulating involuntary treatment and protection of people who have mental illnesses in Queensland. The MHA provides for the involuntary assessment, treatment, and protection of persons experiencing a mental illness while at the same time safeguarding their rights. While the MHA focuses on Journal of Emergency Primary Health Care (JEPHC), Vol.2, Issue 3-4, 2004 Author(s): Ramon Shaban the aspects of mental illness that cannot be dealt with in other legislation, it does not specifically provide for voluntary treatment of mental illness. Voluntary treatment of mental illness is regarded in the same way as treatment for any other illness, with the protection of rights secured by other legislation. The MHA has been drafted to comply with the National Standards for Mental Health Services (1997), the United Nations Principles for the Protection of People with Mental Illness and for the Improvement of Mental Health Care (1997), and a model mental health legislation agreed to by all Australian states and territories. The MHA also reflects contemporary clinical practice, international, national, and state policy directions, and broad community expectations. An important aim of the MHA is to reduce the stigma associated with mental illness. The MHA provides for the involuntary assessment, treatment, and protection of persons (whether adults or minors) who have mental illness while at the same time safeguarding their rights. Emergency provisions under the MHA exist for police officers, paramedics, and psychiatrists. Pursuant to section 33(1) of the MHA, a paramedic (or a police officer) may make an emergency examination order for involuntary admission where the officer ‘reasonably believes’ that: (a) a person has a mental illness; and (b) because of the person’s illness there is an imminent risk of significant physical harm being sustained by the person or someone else; and (c) proceeding under Division 2 (Justice’s examination order) would cause dangerous delay and significantly increase the risk and harm to the person or someone else; and (d) there is no less restrictive way of ensuring the person is assessed[9]. The MHA defines mental illness as ‘a condition characterised by a clinically significant disturbance of thought, mood, perception or memory’. The MHA further defines ‘belief’ as a ‘reasonable belief’, which is characterised as a ‘belief on grounds that are reasonable in the circumstances’. An emergency examination order is dependent on the belief of the paramedic that the patient meets all of the criteria set out in section 33(1) of the MHA. The emergency examination order made by a paramedic or police officer is critically informed by a determination, or a judgment of the paramedic or police officer, that satisfies the criteria for involuntary admission. In the event that an individual does not satisfy the criteria for involuntary assessment, the provisions of the MHA do not apply. The Research Problem Paramedics are required to undertake rigorous, thorough, and complete assessment of their patients, often in difficult or emergency situations. Paramedic assessment of mental status is essential in determining the appropriate treatment for patients presenting with a mental illness. The introduction of new Queensland mental health legislation precipitated widespread industrial concern within the Queensland Ambulance Service (QAS) regarding the ability of paramedics to comply with explicit legislative requirements, citing poor education in mental illness and assessment techniques. The QAS prepared and distributed an in-service education program on the new MHA, which was designed primarily to orientate paramedics to the administrative functions of the MHA to meet their statutory and professional obligations. Its introduction was problematic. Paramedics expressed concern voiced through the union about the quality of existing education of its members and the ability of paramedics to satisfy legislative requirements owing to limited education and training in mental illness historically. Paramedics at the time expressed concern for their preparedness to manage mental illness in practice given the prevailing policy frameworks and contexts. The introduction of this education program signalled the existence of other issues in this context, and provided an opportunity to examine the relationship between theory and practice in paramedics’ judgment and decision-making (JDM). Importantly, it has highlighted the dearth of knowledge and research, substantiated by a literature search, about paramedic knowledge, judgment, and clinical decision-making in the context of mental health, mental illness, and mental health assessments. Journal of Emergency Primary Health Care (JEPHC), Vol.2, Issue 3-4, 2004 Author(s): Ramon Shaban Six key themes are discussed that establish the warrant and justification for the research. 1. Industrial Relations and Action The introduction of new legislation governing the practice of paramedics of the Queensland Ambulance Service (QAS) has precipitated significant industry concern about the ability of paramedics to satisfy legislative requirements citing insufficient education and training in mental illness. These concerns are mirrored in the related literature that examines mental health assessment and management practices in medicine, nursing, and the allied health professions. The related literature of studies into the nursing and medical professions illustrates that generally the recognition and care of mental illness is limited [2-5, 7, 8]. This literature demonstrates the problematic nature of knowledge, recognition, and management of mental illness by health-care professionals, and that further education and training of such professionals is required. To date there has been no published study found that specifically examined paramedic mental health knowledge, judgment, and decision-making practices nationally or internationally. 2. Statutory and Legislative Obligations The style and working provisions of the various mental health Acts worldwide have attracted intense criticism in the international literature. In particular, the major area of concern relates to the conditions in which clinical judgments that precipitate involuntary assessments are made. Holdsworth and Dodgson [10] report that the Mental Health Act (2004) (UK) seriously impairs the clinical reasoning practices of individuals who act under provisions of the legislation in clinical or practical settings. Stating that the use of criteria that are based on frequentist statistical analysis excludes the ability of the clinician to use information idiosyncratic to the individual in making clinical judgments, Holdsworth and Dodgson [10] argue that legislation of this nature over-values statistical frequency of clinical risk assessment and under-values idiosyncratic qualitative information, which is much more difficult to explicate, represent, or qualify. The use of objective statistical frequency assessments in determining clinical risk without concomitant weight or consideration to idiosyncratic qualitative judgments has been strongly criticised [11]. The workings of Australian mental health Acts are yet to be examined in the published literature and will be examined in detail in this study. 3. Paramedic Clinical Practice and Clinical Practice Policy In order to improve clinica