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Making up one’s mind: – Patients’ experiences of calling an ambulance
Accident and Emergency Nursing (2006) 14, 11–19
Accident and Emergency Nursing www.elsevierhealth.com/journals/aaen
Making up one’s mind: – Patients’ experiences of calling an ambulance ¨m (Assistant Caroline Ahl MSc, RN (Doctoral Student) a,b,*, Maria Nystro a b Professor) , Lilian Jansson (Assistant Professor) a b
˚s, SE-501, 90 Bora ˚s, Sweden School of Health Sciences, University Collage of Bora ˚ University, SE-90 187 Umea ˚, Sweden Department of Nursing, Umea
Received 30 June 2005; accepted 1 October 2005
KEYWORDS
Summary The issue of the inappropriate use of ambulance transport and care has mainly been studied from the professionals’ and caregivers’ perspective, with few studies focusing on the patient and his/her experiences. To further understand whether patients use ambulance care in an inappropriate manner and, if so, why, it is important to obtain an overall picture of the patients’ existential situation at the time they call an ambulance. The aim of this study was to analyse and describe patients’ experiences related to the decision to call an ambulance and the wait for it to arrive. The design was explorative, and twenty informants aged between 34 and 82 years were interviewed. Qualitative content analyses were performed. The findings showed that calling for an ambulance is a major decision that is preceded by hesitation and attempts to handle the situation by oneself. Our conclusion is that the definition of inappropriate use of valuable health care resources should not be based solely on the professionals’ point of view but also take account of the patients’ reactions when they experience a threat to their life and health. c 2005 Elsevier Ltd. All rights reserved.
Patient experience; Prehospital emergency care; Ambulance; Content analysis
Introduction
Prehospital emergency care is care and treatment provided at the scene of an accident or acute and sudden illness, in an ambulance, emergency vehicle or helicopter. It also includes the interval between the receipt of a call by the emergency call centre * Corresponding author. Tel.: +46 33 435 4379. E-mail address: [email protected] (C. Ahl).
and the hand-over of the patient to the receiving unit. Today, ambulance care is thus a general term for both the transport and specialized treatment for sick and injured patients. Ambulance care can also be defined as the examination, care and treatment carried out in connection with the transportation of patients. It has improved both in quality and quantity, in the areas of staff competence, the development of vehicles, sickbay and medical technical equipment. Today, most ambulances are equipped
0965-2302/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.aaen.2005.10.002
12 to provide qualified care for seriously ill or injured patients. Swedish health legislation states that ambulance care is a part of the public health and medical service and should be able to provide adequate care in a personalized and humane manner (Suserud et al., 2003a,b). Recently, many researchers have highlighted the fact that ambulance care is used in a way for which it was not intended (Billittier et al., 1996; Clark and Fitzgerald, 1999; Gardner, 1990; Gratton et al., 2003; Hauswald and Jambrosic, 2004; Pallazzo et al., 1998; Rademaker et al., 1987; Richards and Ferrall, 1999). These studies reflect the professionals’ view that there are many calls to the emergency call centres that do not require an emergency response. Those studies also reveal that the number of non-urgent cases managed by ambulance care has increased. Accordingly, some studies have focused on the inappropriate use of valuable health care resources and the overuse of ambulance care, which is considered a major problem. A recent study by Hja ¨lte et al. (submitted) reveals that ambulance personnel in Sweden estimate that every third journey is unnecessary. The results of the study suggest that efficiency in the care of seriously ill and injured patients would increase if unnecessary ambulance journeys could be avoided. Hence, assessment of the need for ambulance and emergency care must be made. In many cases, patients, emergency call centres and caregivers assess the need for ambulance/emergency care differently (Hauswald, 2002; Silvestri et al., 2002). From the professionals’ point of view, too many people use ambulance and emergency care in an inappropriate way, and the emergency departments are filled by non-urgent patients (Gill and Riley, 1996; Malone, 1995; Murphy, 1998; Walsh, 1994). From the patients’ point of view, the problems are quite different (Nairn et al., 2004). Olsson and Hangasi (2001) suggest that patients who frequently use emergency care make strong efforts to cope with the perceived threat and try to maintain their autonomy. It is the feeling of powerlessness that compels them to seek help. At present, there are few studies focusing on the patient and his/her experiences of prehospital care. However, Pallazzo et al. (1998) interviewed 300 patients about the reason for calling an ambulance. According to the criterion set by the study, i.e., having used ambulance care within the past three months, 50% of the patients were considered to have been in need of an ambulance. Approximately 60% of these patients believed that they were in a serious or life-threatening condition; 16% did not know whom to call when they needed
C. Ahl et al. help and a further 16% were not aware of any other way of getting to a hospital. The remaining 8% decided to call an ambulance because they wanted to avoid having to wait at the emergency department. Mattiasson and Andersson (1995) found that staff attitudes to patient autonomy are crucial for patients’ ability to act autonomously and take responsibility for their own decisions. Hence, it is obvious that medical staff play a key role in supporting or limiting patients’ rights in health care. The issue of inappropriate use of ambulance transport has mainly been studied from the caregivers’ perspective. To further understand whether or not patients use ambulance care in an inappropriate manner, and why, it is important to obtain an overall picture of the patients’ existential situation at the time they call an ambulance. Thus, the aim of the present study is to analyze and describe patients’ experiences related to the decision to call an ambulance and when waiting for it to arrive.
Method Design and participants The design of the study is explorative for the purpose of describing patients’ experiences. Twenty patients participated, 12 women and 8 men, aged between 34 and 82 years, who had experienced ambulance care in towns and rural areas of southern Sweden. The informants were selected in order to achieve a large variation in age, gender, emergency priorities and medical diagnosis. A general criterion was that the informants had used ambulance care within the past three months. Their medical diagnosis/symptoms were heart disease, asthma and/or respiratory problems, trauma/traffic accident, diabetes and musculoskeletal pain. In addition, several other conditions occurred, e.g., mental illness, postoperative complications, abdominal pain and conditions related to chronic illness. The informants were selected by the officer in charge of each ambulance station in accordance with the above-mentioned criterion and ambulance patient records. A letter was sent to the informants asking them whether they were interested in participating in the project, after which they were contacted by telephone to arrange a time and place for the interview. Written information about the study was provided and all participants were assured of confidentiality. The analysis was conducted with the intention of protecting the integrity of all respondents. The study was approved by the Ethics Committee at the Medical Faculty, Gothenburg University (reg. no. 186-00).
Making up one’s mind: – Patients’ experiences of calling an ambulance
Procedure and interviews The interviews took place at the informants’ home, often at the kitchen table. Each interview began with a short presentation of the researcher and the study. The general impression was that the informants seemed willing to participate in the study; they answered the questions spontaneously and appeared to be pleased and satisfied with their role as interviewees. They were encouraged to share their experiences of the situation in which they decided to call an ambulance. They were also asked to describe the care they received. These data will be analysed and presented in a future study. All interviews started with the same question: Could you please describe the events that made you decide to call an ambulance? In connection with the informants’ narratives, follow-up questions such as What do you mean?, Can you explain a bit more?, How did you feel? etc., were asked in order to clarify the content of the interview (Mischler, 1986). The interviews were characterized by openness and pliability on the part of the interviewer and lasted between 30 and 90 minutes. All interviews were taperecorded and transcribed verbatim.
Analysis Qualitative content analysis of the transcribed interviews was performed. The method is described by Graneheim and Lundman (2003), among others. A text always involves multiple meanings and there is always some degree of interpretation when approaching a text. Therefore, a qualitative content analysis deals with interpretation. The interpretations can vary in depth and level of abstraction (Graneheim and Lundman, 2003). As a first step, each interview was read through several times, bearing in mind the aim of the study, in order to obtain a sense of the whole. The second step, the structural analysis, consisted of dividing the text into meaning units. The meaning units were then condensed and categorized. The third step in the analysis was to identify themes, i.e., threads of an underlying meaning by means of abstraction, meaning units, subcategories or categories. Reflections and further interpretations of the relationship between the themes in the findings are presented in the discussion.
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table form, after which they are described and illustrated by quotations from the interviews.
Theme 1: Making up one’s mind Prehospital care begins with the patients’ decision to call an ambulance. This is a major decision for many people and, quite often, persons other than the patient him/herself are involved in the decision-making process. However, sudden illness and the insight that one cannot handle the situation does not always lead to immediate contact with the emergency call center. Often, the decision to call an ambulance is preceded by deliberation with oneself and/or others (see Table 1). Must get immediate help The need for help derives from the feeling of being very ill and experiencing the situation as intolerable. The patients themselves are sometimes aware of the need for an ambulance, but in many cases someone else, a relative or a friend, realizes that the patient cannot handle the situation any longer. To experience the situation as intolerable. The request for an ambulance results from an urgent need for help. It is no longer possible to handle the situation by oneself – strength fails and it is necessary to get help from someone else. I just felt that I had to get help. I couldn’t take any more and I lost consciousness when I lay down. I should call an ambulance I thought, then I might get help. Several informants waited, struggled, hesitated and tried to handle the situation for quite a while. But once they became fully convinced that a medical examination was urgent, they did not hesitate to call an ambulance. Their only concern was how to obtain treatment so that their suffering would cease. When I realized that I could not manage it on my own, I woke up my wife who called an ambulance. . .It was a desperate feeling. . . it was almost as I didn’t care what happened. . . Do whatever you want as long as it stops. However, the decision to call an ambulance is often connected to a sense of relief and, once taken, the symptoms often abate somewhat. Then the waiting starts.
Findings
The stress and pain began to ease when I knew that the ambulance was on its way.
The findings are reported as two themes, making up one’s mind and waiting for help. Categories and subcategories of each theme are presented in
An intolerable situation can also lead to various actions associated with one’s family, work or other important activities. Some informants revealed
14 Table 1
C. Ahl et al. Theme 1: Making up one’s mind
Categories
Subcategories
Must get immediate help
To experience the situation as intolerable Someone else points out the urgent need for help
To realise that other options have been exhausted
To overcome one’s own hesitancy To realise one’s limitations
Ambulance, the safest and most secure form of transport
To feel the transport is fast and safe To receive immediate access to care
To emphasize the need for care
that before calling an ambulance they phoned clients, cancelled or re-scheduled meetings or prepared themselves in some other way for the unexpected situation. However, such delays can affect patients’ outcome and treatment, although the respondents did not seem to be aware of this fact. The first thing that came into my mind when I felt the pain was. . . ‘‘I have to work’’ and then I remembered. . .I was supposed to cut wood, as I was just about to change over to heating with wood, so instead I called a person who delivers oil and arranged with him to fill the oil tank. . .then I called the ambulance because I was in such agony. Someone else points out the urgent need for help. Some informants did not realize the seriousness of the situation. In such cases, there was someone with the patient, a close relative or a neighbour, who, in the end, made the decision to call an ambulance. Sometimes, a nurse at the health information hotline, to whom many people turn in the first instance, was the one who advised that an ambulance should be called. Everything happened so suddenly, so I called the health information hotline and she (the nurse) said that the condition can deteriorate very quickly and I should call an ambulance – No, I said, I don’t think I need an ambulance but I have someone who can drive me. No, she said, it can deteriorate rapidly, so call an ambulance.
To realise that other options have been exhausted Most of the informants described efforts to manage the situation on their own. Initially, they tried to wait and see if the situation would improve. They hesitated to call an ambulance, despite realizing that they needed help and instead sought alternative solutions and wanted to obtain treatment by other means. In the end, when there were no options left, the ambulance became the only alternative.
To overcome one’s own hesitancy. Hesitation and anxiety caused by concern that others may consider they took advantage of the ambulance service made almost all informants seek other alternatives and options. The informants stated that they would not call an ambulance unless there was an urgent need. It is not the easiest solution, but in the end, it is the only one. This makes the decision easier. (What does one think when calling an ambulance?) What will the neighbours think? Because an ambulance is an ambulance, it isn’t seen as a means of transport but rather. . .Now something has happened. I don’t see it like that but I think many people do. (Apart from wondering what your neighbours will think, how do you feel yourself about having to call an ambulance?) Any time I needed an ambulance I probably felt so sick that I could not have managed without it otherwise I would rather take my car or call a taxi. The hesitancy includes feelings of being exposed to something unpleasant ‘‘to be vulnerable and to need help’’. One informant’s description of the situation is that ‘‘there is too much publicity’’. There is also a feeling of not wanting to be a burden. One doesn’t want to cause any unnecessary trouble or expense to the health services. To realize one’s limitations. To call an ambulance was not an easy decision for the majority of the informants. They considered alternative ways of getting to hospital either by their own means or with help from others. Relatives, friends or neighbours can help the sick person to understand that there are no other alternatives, i.e., the situation demands an ambulance. In this respect, one must accept one’s own limitations and recognize the advantages of an ambulance. There are also indications that the patient does not want to cause trouble or be a burden on his/her relatives, despite the gravity of the condition. In the latter situation, the ambulance can be seen as a neutral way of helping the
Making up one’s mind: – Patients’ experiences of calling an ambulance patient without him/her becoming a burden on relatives or other people. Therefore, to realize one’s limitations deals with both the individual and his/ her context. I could have gone in my car, I could maybe have taken a taxi, no I would have taken my car, but then someone would have had to drive me there in my car, and put the wheelchair into the car, I would have made a lot of work for my relatives, which I don’t think is right. Although upon reflection, the patients realized that the only and best solution was to call an ambulance, they nevertheless felt it was frightening and sometimes embarrassing to make the call. An ambulance signifies drama, the ambulance is always a bit dramatic, something that may attract the neighbours’ attention. The informants stated that they did not wish to be the subject of attention, which is another reason why they hesitated to call an ambulance. This is especially relevant when there are children involved or near by. Ambulance, the safest and most secure form of transport Despite the fact that the informants were reluctant to call an ambulance, they stated that it was a reliable and safe way of getting to hospital when they were incapable of making the journey on their own. Since other vehicles make way for an ambulance, the journey to hospital is smooth and safe. Some also described the ambulance as the fastest way to receive treatment. To feel that the transport is fast and safe. When the informants needed help and all other alternatives had been exhausted, the general opinion was that the ambulance is a safe and fast way of reaching the hospital. This is connected to the patients’ intolerable and acute experiences but also to safety, partly because an ambulance provides safe transportation, e.g., ambulances are given the right of way by other drivers (a right laid down by law in Sweden), and partly because of the relief the informants experienced when the caregivers arrived and treatment began. To be able to get there quickly, without having to drive yourself. No, I wouldn’t have been able to drive. I would have been a danger in the traffic. Ambulances are really great. . . they turn on the siren and are given the right of way. To receive immediate access to care. When the ambulance and caregivers arrive, the informants are sure of getting immediate help and adequate treatment. However, some informants were surprised and to some extent frustrated by the fact
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that they were treated at the scene instead of being immediately transported to a hospital. One of them said: ‘‘I just wanted to go’’. However, treatment in an ambulance is mainly seen as a guarantee of receiving immediate attention and high priority upon arrival at a hospital. If you get into an ambulance you are, yes, then you are almost in hospital. My sister has driven me sometimes but then one has to sit in the waiting room. You don’t want that when you are throwing up and feeling generally poorly. (You mean that if you call an ambulance, you will receive attention more quickly?) Yes, that is my experience anyway. To emphasize the need for care Even if the situation is not urgent, the ambulance means immediate or at least the ‘‘promise’’ of treatment. To be in need of an ambulance emphasizes a need for care, even if it has more to do with transport to a hospital than advanced forms of medical treatment. From a patient perspective, to need an ambulance means ‘‘more treatment than transportation’’. (But the time you went from U-city to X-city, your primary need was transport?) Yes, transport. (There wasn’t much treatment on that occasion?) No, there wasn’t, there wasn’t. . .On the other hand, it was due to the fact that I was ill. . .so there was care involved. ..so it was, yes, it was care. (Was it care?) It wasn’t just transport. (It was not transport?) Well, they took care of me then and put me on a stretcher, they checked the whole time that I was all right so it sure was more care than transport. It is also significant that the ambulance emphasizes the need of care in the eyes of others, which several informants pointed out. Some people would not be able to call an ambulance so easily. (Why do you think that?) I think many people believe you have to be dying before calling an ambulance.
Theme 2: Waiting for help While waiting for the ambulance, feelings of fear and anxiety can occur, and in some cases feelings of loneliness and helplessness are also present. The decision and the wait mean that patients have handed over responsibility to someone else, i.e.
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C. Ahl et al.
they rely on the caregivers to assume responsibility for them (see Table 2).
To experience the wait as long The time that passes before deciding to call for help can vary, but once the decision is made, there is a desire to receive immediate help. Several informants described the wait for an ambulance as very long although they later realised that this was not the case. ‘‘It could have been a minute; it could have been an hour’’. The waiting sometimes includes feelings of being neglected and alone. They just wanted to get to the hospital immediately. When the caregivers arrived, the patients received care and attention, which led to feelings of relief. I felt that it took a long time for them to arrive although I realized afterwards that it didn’t take that long. I remember saying to myself the whole time: aren’t they coming soon? I was in such pain that all I wanted was help. You experience the time as incredibly long until the ambulance arrives but then it is obvious that it wasn’t long. That time was difficult, because I just wanted to go, I didn’t want to be at home. To be alone with one’s feelings To be alone with one’s feelings implies fear and loneliness. In addition, the wait reinforces these feelings. Fear can also be experienced when one looks back and reflects upon the situation. To be anxious and afraid. Some informants described experiencing anxiety and fear while waiting. It concerned relatives or close friends, but also fear that the ambulance would not reach them in time or fail to find their house. In addition, fear also increases the desire to get to the hospital as quickly as possible. This was expressed by an informant in the following way: ‘‘I was afraid and I just wanted to go . . .go. . .I didn’t want to be at home and that is why I became so frustrated when we didn’t go
Table 2
immediately’’. However, several informants described how fear gave way to relief and calm when the ambulance and medical team arrived. Will they get here in time, will I get there in time, but once you are in the ambulance and you see their equipment and all that. . ., well you are in safe hands. To feel neglected and alone. Besides anxiety and fear, the informants also felt neglected, alone and in some way vulnerable, but once the ambulance had arrived, they experienced a sense of relief. In addition, some informants described being alone both in their decision making and while waiting for the ambulance. I was in such pain that the only thing I wanted was to get help and when you don’t have anyone to talk to at home you feel isolated but it was a relief when they came and I became a bit calmer and they did what they could. To avoid responsibility To be in need of help and calling an ambulance means handing over responsibility to someone else. Hence, there is a sense of freedom and relief at handing over responsibility as well as a feeling of trust and security in allowing someone else to take over what you cannot handle yourself. To put your life in the hands of someone else becomes natural. To feel relief. As previously mentioned, when all decisions and the call to the emergency number have been made, the informants described a sense of relief. They felt free of responsibility, as they had handed it over to someone else. Knowing that the ambulance is on its way and that someone else will take over responsibility was described as feelings of relief and calm. It feels good once you have made the decision and phoned for an ambulance. They know that something is wrong. . .now I don’t have to take further responsibility. . .It is about letting go, now I no longer have to be in control.
Waiting for help
Categories
Subcategories
To experience the wait as long To be alone with one’s feelings
To be anxious and afraid To feel neglected and alone
To avoid responsibility
To feel relief To experience a sense of safety and trust
Making up one’s mind: – Patients’ experiences of calling an ambulance To experience a sense of safety and trust. Even before the ambulance arrives, there is a sense of security and trust that help is on the way. The decision-making may have taken a long time, but the informants can now hand over responsibility to and trust in the ambulance personnel. The informants reported that the personnel at the emergency call centre and the caregivers in the ambulance can strengthen patients’ feeling of safety and trust, partly because the patients know that someone is coming and because they can speak to them on the phone before the ambulance arrives. I felt so ill that I thought I was about to become unconscious, but knowing that someone is on the way meant that I was not worried, as I knew they would find me.
Discussion The purpose of this study was to describe patients’ experiences related to their decision to call and wait for an ambulance. The findings are more nuanced and partly contradict those of previous studies, in which researchers revealed indications of overuse/misuse in all cases where patients have assessed ambulance care as necessary (Billittier et al., 1996; Clark and Fitzgerald, 1999; Gardner, 1990; Gratton et al., 2003; Pallazzo et al., 1998; Rademaker et al., 1987; Richards and Ferrall, 1999). The analysis of the interviews shows that there are various considerations in the patients’ decision to call an ambulance that have not been previously highlighted, thus the findings of the present study contribute new knowledge. Many of the respondents seem to have made a great effort to manage the situation themselves before taking the decision to call an ambulance. People who face unexpected situations and suddenly fall ill express their experience in various ways, such as fear, anxiety, insecurity and irrational behaviour (Bowman, 2001). Most people strive for independence, to have control over the expected and the unexpected, despite the fact that they are seriously ill (Olsson and Hangasi, 2001). The informants in this study stated that they also tried to manage on their own, despite being in obvious need of help. Initially, the patient may even refuse help in order to maintain control of his/her situation. Some studies (Hauswald, 2002; Silvestri et al., 2002) argue that the excessive use of ambulances, and therefore misuse of the emergency services, is a growing problem. Our findings moderate such conclusions and can be seen as a complement to the overall picture of patients who tend to be cau-
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tious and hesitant before calling an ambulance. Their cautiousness and hesitancy are expressed in various ways such as loss of control, feelings of not being able to cope with the situation and negative attention caused by the arrival of an ambulance. Sometimes, the patients act in a way that may be perceived as inconsistent with the need for an ambulance, for example, standing in the hallway ready to go when the ambulance arrives. Our findings show, however, that most patients would have preferred to seek care on their own had they been able to do so, a result which can also be found in Billittier et al. (1996), Pallazzo et al. (1998) and Thuresson et al. (2005). At the same time, they appear to recognize the advantages of the ambulance. Patients consider their options either alone or in consultation with relatives. They reflect upon different strategies, hesitate and try to find solutions, even though they may be seriously ill, which can have devastating consequences for their future care and treatment. This delay is also reported in Kristofferzon et al. (2003) and Thuresson et al. (2005) and may be interpreted as reluctance to admit vulnerability and dependence. Calling an ambulance is experienced as an inability to ‘‘be in control of yourself and your illness’’. Accordingly, the illness becomes everybody’s concern. On the other hand, the hesitancy and fear also relate to the anxiety of being a burden on the health care services or not being believed by caregivers. The findings also show that some patients presume that the ambulance legitimizes their need for care. Having assessed their situation, they came to the conclusion that they needed help and were incapable of coping with the situation on their own. The ambulance seemed, thus, to be perceived as a promise of help. Moreover, the patients appear to believe that they gain easier access to medical care when they arrive in an ambulance. According to Marinovich et al. (2004), the patients may be correct in this conclusion. Patients who arrive at the emergency department in an ambulance use significantly more resources than their walk-in counterparts. These patients are often elderly people and women who usually arrive after office hours. The results of this study also indicate that these patients need more time at the emergency department and often have to be admitted to hospital. However, this study also agrees to some extent with previous investigations claiming that patients overuse/misuse the ambulance service due to ignorance and for reasons of convenience. There seems to be a great risk of not being prioritized at the emergency department despite troublesome
18 symptoms. Consequently, the informants seemed to think that the risk was less if they arrived in an ambulance. In order to gain a better understanding of the problem, it should be pointed out that low priority may result in a wait of up to twelve hours, despite the fact that the patient is in pain or has a high temperature (Nystro ¨m et al., 2003). Patients try to cope with illness in different ways and for varying lengths of time before calling an ambulance. Once the decision is made, the variation in the interviews disappears, and the statements express similar experiences/sentiments. The patients are now convinced of their need for help. Waiting for an ambulance involves the belief that help is on its way and something is about to happen; but at the same time it evokes feelings of loneliness and reveals the patients’ vulnerability and dependence. At the moment the decision to call an ambulance is made, the patient places himself/herself, all responsibility and decision making, in someone else’s hands. The patient relinquishes everything in order to feel trust and security. At this moment, there is a dramatic change in the informants’ demeanour. Their hesitancy and attempts to manage the situation on their own disappear. Knowing that an ambulance is on its way is reassuring. In some cases, the symptoms decrease to the extent that the patients manage to plan their sick leave, pack a suitcase and wait for the arrival of the ambulance. Accordingly, ambulance personnel appear to base their opinion about inappropriate use of ambulance care on patients who appear fully capable of making plans for their hospital stay. Hence, our study, which describes patients’ considerations in choosing an ambulance, is a valuable complement to other studies in the field. In addition, we must also take into consideration the fact that the person who makes the emergency call, be it a patient or a relative, cannot always explain the patient’s exact needs and symptoms. Consequently, an ambulance may be dispatched even though the assessment of the situation is uncertain. Morse and O’Brien (1995) describe the effects of sudden illness on people’s ability to communicate. Pain and anxiety caused by sudden illness may, thus, lead to an incorrect assessment of the situation, resulting in unnecessary use of ambulance care. The patient, however, should not be blamed for this.
Conclusion According to the findings of this study the definition of inappropriate use of valuable health care resources should not only be based on the profes-
C. Ahl et al. sional point of view. Professionals may not be aware of the situation leading to the decision to call an ambulance, since some symptoms decrease while waiting. It seems fair to assume that professional judgment should consider both medical knowledge and patients’ reactions when they experience threat to their health and life.
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Making up one’s mind: – Patients’ experiences of calling an ambulance Murphy, W.A., 1998. Inappropriate attenders at accident and emergency departments: definition, incidence and reason for attendance. Family Practice 15 (1), 23–32. Nairn, S., Whotton, E., Marshal, C., Roberts, M., Swann, G., 2004. The patient experience in emergency departments: a review of the literature. Accident and Emergency Nursing 12, 159–165. Nystro ¨m, M., Dahlberg, K., Carlsson, G., 2003. Non-caring encounters at an ECU – a life-world hermeneutic analysis of an efficiency driven organization. Journal of Nursing Studies 40, 761–769. Olsson, M., Hangasi, H., 2001. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emergency Medicine 18, 430–434. Pallazzo, F.F., Warner, O.J., Harron, M., Sadana, A., 1998. Misuse of the London ambulance service: how much and why? Journal Accident Emergency Medicine 15, 368–370. Rademaker, W.A., Powell, G., Read, H.J., 1987. Inappropriate use and unmet need in paramedic and nonparamedic ambulance systems. Annals of Emergency Medicine 16 (5), 553– 556.
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Richards, R.J., Ferrall, J.S., 1999. Inappropriate use of emergency medical service transport: Comparison of provider and patient perspective. Emergency Medicine 6 (1), 14–20. Silvestri, S., Rothrock, G.S., Dennedy, D., Ladde, J., Bryant, M., Pagane, J., 2002. Can paramedics accurately identify patients who do not require emergency department care? Prehospital Emergency Care 6 (4), 387–389. Suserud, B.-O., Bruce, K., Dahlberg, K., 2003a. Initial assessment in ambulance nursing – part one. Emergency Nurse 10 (10), 13–17. Suserud, B.-O., Bruce, K., Dahlberg, K., 2003b. Ambulance nursing – The nurse assessment – part two. Emergency Nurse 11 (1), 14–18. Thuresson, M., Berglin, J.M., Lindahl, B., Svensson, L., Zedigh, C., Herlitz, J., 2005. Symtoms and type of symtoms onset in acute coronary syndrome in relation to ST – elevation, gender, age and history of diabetes. American Heart Journal 150 (2), 234–242. Walsh, M., 1994. A study of the attitudes of A & E staff towards patients. Accident and Emergency Nursing 2, 27–32.
Accident and Emergency Nursing www.elsevierhealth.com/journals/aaen
Making up one’s mind: – Patients’ experiences of calling an ambulance ¨m (Assistant Caroline Ahl MSc, RN (Doctoral Student) a,b,*, Maria Nystro a b Professor) , Lilian Jansson (Assistant Professor) a b
˚s, SE-501, 90 Bora ˚s, Sweden School of Health Sciences, University Collage of Bora ˚ University, SE-90 187 Umea ˚, Sweden Department of Nursing, Umea
Received 30 June 2005; accepted 1 October 2005
KEYWORDS
Summary The issue of the inappropriate use of ambulance transport and care has mainly been studied from the professionals’ and caregivers’ perspective, with few studies focusing on the patient and his/her experiences. To further understand whether patients use ambulance care in an inappropriate manner and, if so, why, it is important to obtain an overall picture of the patients’ existential situation at the time they call an ambulance. The aim of this study was to analyse and describe patients’ experiences related to the decision to call an ambulance and the wait for it to arrive. The design was explorative, and twenty informants aged between 34 and 82 years were interviewed. Qualitative content analyses were performed. The findings showed that calling for an ambulance is a major decision that is preceded by hesitation and attempts to handle the situation by oneself. Our conclusion is that the definition of inappropriate use of valuable health care resources should not be based solely on the professionals’ point of view but also take account of the patients’ reactions when they experience a threat to their life and health. c 2005 Elsevier Ltd. All rights reserved.
Patient experience; Prehospital emergency care; Ambulance; Content analysis
Introduction
Prehospital emergency care is care and treatment provided at the scene of an accident or acute and sudden illness, in an ambulance, emergency vehicle or helicopter. It also includes the interval between the receipt of a call by the emergency call centre * Corresponding author. Tel.: +46 33 435 4379. E-mail address: [email protected] (C. Ahl).
and the hand-over of the patient to the receiving unit. Today, ambulance care is thus a general term for both the transport and specialized treatment for sick and injured patients. Ambulance care can also be defined as the examination, care and treatment carried out in connection with the transportation of patients. It has improved both in quality and quantity, in the areas of staff competence, the development of vehicles, sickbay and medical technical equipment. Today, most ambulances are equipped
0965-2302/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.aaen.2005.10.002
12 to provide qualified care for seriously ill or injured patients. Swedish health legislation states that ambulance care is a part of the public health and medical service and should be able to provide adequate care in a personalized and humane manner (Suserud et al., 2003a,b). Recently, many researchers have highlighted the fact that ambulance care is used in a way for which it was not intended (Billittier et al., 1996; Clark and Fitzgerald, 1999; Gardner, 1990; Gratton et al., 2003; Hauswald and Jambrosic, 2004; Pallazzo et al., 1998; Rademaker et al., 1987; Richards and Ferrall, 1999). These studies reflect the professionals’ view that there are many calls to the emergency call centres that do not require an emergency response. Those studies also reveal that the number of non-urgent cases managed by ambulance care has increased. Accordingly, some studies have focused on the inappropriate use of valuable health care resources and the overuse of ambulance care, which is considered a major problem. A recent study by Hja ¨lte et al. (submitted) reveals that ambulance personnel in Sweden estimate that every third journey is unnecessary. The results of the study suggest that efficiency in the care of seriously ill and injured patients would increase if unnecessary ambulance journeys could be avoided. Hence, assessment of the need for ambulance and emergency care must be made. In many cases, patients, emergency call centres and caregivers assess the need for ambulance/emergency care differently (Hauswald, 2002; Silvestri et al., 2002). From the professionals’ point of view, too many people use ambulance and emergency care in an inappropriate way, and the emergency departments are filled by non-urgent patients (Gill and Riley, 1996; Malone, 1995; Murphy, 1998; Walsh, 1994). From the patients’ point of view, the problems are quite different (Nairn et al., 2004). Olsson and Hangasi (2001) suggest that patients who frequently use emergency care make strong efforts to cope with the perceived threat and try to maintain their autonomy. It is the feeling of powerlessness that compels them to seek help. At present, there are few studies focusing on the patient and his/her experiences of prehospital care. However, Pallazzo et al. (1998) interviewed 300 patients about the reason for calling an ambulance. According to the criterion set by the study, i.e., having used ambulance care within the past three months, 50% of the patients were considered to have been in need of an ambulance. Approximately 60% of these patients believed that they were in a serious or life-threatening condition; 16% did not know whom to call when they needed
C. Ahl et al. help and a further 16% were not aware of any other way of getting to a hospital. The remaining 8% decided to call an ambulance because they wanted to avoid having to wait at the emergency department. Mattiasson and Andersson (1995) found that staff attitudes to patient autonomy are crucial for patients’ ability to act autonomously and take responsibility for their own decisions. Hence, it is obvious that medical staff play a key role in supporting or limiting patients’ rights in health care. The issue of inappropriate use of ambulance transport has mainly been studied from the caregivers’ perspective. To further understand whether or not patients use ambulance care in an inappropriate manner, and why, it is important to obtain an overall picture of the patients’ existential situation at the time they call an ambulance. Thus, the aim of the present study is to analyze and describe patients’ experiences related to the decision to call an ambulance and when waiting for it to arrive.
Method Design and participants The design of the study is explorative for the purpose of describing patients’ experiences. Twenty patients participated, 12 women and 8 men, aged between 34 and 82 years, who had experienced ambulance care in towns and rural areas of southern Sweden. The informants were selected in order to achieve a large variation in age, gender, emergency priorities and medical diagnosis. A general criterion was that the informants had used ambulance care within the past three months. Their medical diagnosis/symptoms were heart disease, asthma and/or respiratory problems, trauma/traffic accident, diabetes and musculoskeletal pain. In addition, several other conditions occurred, e.g., mental illness, postoperative complications, abdominal pain and conditions related to chronic illness. The informants were selected by the officer in charge of each ambulance station in accordance with the above-mentioned criterion and ambulance patient records. A letter was sent to the informants asking them whether they were interested in participating in the project, after which they were contacted by telephone to arrange a time and place for the interview. Written information about the study was provided and all participants were assured of confidentiality. The analysis was conducted with the intention of protecting the integrity of all respondents. The study was approved by the Ethics Committee at the Medical Faculty, Gothenburg University (reg. no. 186-00).
Making up one’s mind: – Patients’ experiences of calling an ambulance
Procedure and interviews The interviews took place at the informants’ home, often at the kitchen table. Each interview began with a short presentation of the researcher and the study. The general impression was that the informants seemed willing to participate in the study; they answered the questions spontaneously and appeared to be pleased and satisfied with their role as interviewees. They were encouraged to share their experiences of the situation in which they decided to call an ambulance. They were also asked to describe the care they received. These data will be analysed and presented in a future study. All interviews started with the same question: Could you please describe the events that made you decide to call an ambulance? In connection with the informants’ narratives, follow-up questions such as What do you mean?, Can you explain a bit more?, How did you feel? etc., were asked in order to clarify the content of the interview (Mischler, 1986). The interviews were characterized by openness and pliability on the part of the interviewer and lasted between 30 and 90 minutes. All interviews were taperecorded and transcribed verbatim.
Analysis Qualitative content analysis of the transcribed interviews was performed. The method is described by Graneheim and Lundman (2003), among others. A text always involves multiple meanings and there is always some degree of interpretation when approaching a text. Therefore, a qualitative content analysis deals with interpretation. The interpretations can vary in depth and level of abstraction (Graneheim and Lundman, 2003). As a first step, each interview was read through several times, bearing in mind the aim of the study, in order to obtain a sense of the whole. The second step, the structural analysis, consisted of dividing the text into meaning units. The meaning units were then condensed and categorized. The third step in the analysis was to identify themes, i.e., threads of an underlying meaning by means of abstraction, meaning units, subcategories or categories. Reflections and further interpretations of the relationship between the themes in the findings are presented in the discussion.
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table form, after which they are described and illustrated by quotations from the interviews.
Theme 1: Making up one’s mind Prehospital care begins with the patients’ decision to call an ambulance. This is a major decision for many people and, quite often, persons other than the patient him/herself are involved in the decision-making process. However, sudden illness and the insight that one cannot handle the situation does not always lead to immediate contact with the emergency call center. Often, the decision to call an ambulance is preceded by deliberation with oneself and/or others (see Table 1). Must get immediate help The need for help derives from the feeling of being very ill and experiencing the situation as intolerable. The patients themselves are sometimes aware of the need for an ambulance, but in many cases someone else, a relative or a friend, realizes that the patient cannot handle the situation any longer. To experience the situation as intolerable. The request for an ambulance results from an urgent need for help. It is no longer possible to handle the situation by oneself – strength fails and it is necessary to get help from someone else. I just felt that I had to get help. I couldn’t take any more and I lost consciousness when I lay down. I should call an ambulance I thought, then I might get help. Several informants waited, struggled, hesitated and tried to handle the situation for quite a while. But once they became fully convinced that a medical examination was urgent, they did not hesitate to call an ambulance. Their only concern was how to obtain treatment so that their suffering would cease. When I realized that I could not manage it on my own, I woke up my wife who called an ambulance. . .It was a desperate feeling. . . it was almost as I didn’t care what happened. . . Do whatever you want as long as it stops. However, the decision to call an ambulance is often connected to a sense of relief and, once taken, the symptoms often abate somewhat. Then the waiting starts.
Findings
The stress and pain began to ease when I knew that the ambulance was on its way.
The findings are reported as two themes, making up one’s mind and waiting for help. Categories and subcategories of each theme are presented in
An intolerable situation can also lead to various actions associated with one’s family, work or other important activities. Some informants revealed
14 Table 1
C. Ahl et al. Theme 1: Making up one’s mind
Categories
Subcategories
Must get immediate help
To experience the situation as intolerable Someone else points out the urgent need for help
To realise that other options have been exhausted
To overcome one’s own hesitancy To realise one’s limitations
Ambulance, the safest and most secure form of transport
To feel the transport is fast and safe To receive immediate access to care
To emphasize the need for care
that before calling an ambulance they phoned clients, cancelled or re-scheduled meetings or prepared themselves in some other way for the unexpected situation. However, such delays can affect patients’ outcome and treatment, although the respondents did not seem to be aware of this fact. The first thing that came into my mind when I felt the pain was. . . ‘‘I have to work’’ and then I remembered. . .I was supposed to cut wood, as I was just about to change over to heating with wood, so instead I called a person who delivers oil and arranged with him to fill the oil tank. . .then I called the ambulance because I was in such agony. Someone else points out the urgent need for help. Some informants did not realize the seriousness of the situation. In such cases, there was someone with the patient, a close relative or a neighbour, who, in the end, made the decision to call an ambulance. Sometimes, a nurse at the health information hotline, to whom many people turn in the first instance, was the one who advised that an ambulance should be called. Everything happened so suddenly, so I called the health information hotline and she (the nurse) said that the condition can deteriorate very quickly and I should call an ambulance – No, I said, I don’t think I need an ambulance but I have someone who can drive me. No, she said, it can deteriorate rapidly, so call an ambulance.
To realise that other options have been exhausted Most of the informants described efforts to manage the situation on their own. Initially, they tried to wait and see if the situation would improve. They hesitated to call an ambulance, despite realizing that they needed help and instead sought alternative solutions and wanted to obtain treatment by other means. In the end, when there were no options left, the ambulance became the only alternative.
To overcome one’s own hesitancy. Hesitation and anxiety caused by concern that others may consider they took advantage of the ambulance service made almost all informants seek other alternatives and options. The informants stated that they would not call an ambulance unless there was an urgent need. It is not the easiest solution, but in the end, it is the only one. This makes the decision easier. (What does one think when calling an ambulance?) What will the neighbours think? Because an ambulance is an ambulance, it isn’t seen as a means of transport but rather. . .Now something has happened. I don’t see it like that but I think many people do. (Apart from wondering what your neighbours will think, how do you feel yourself about having to call an ambulance?) Any time I needed an ambulance I probably felt so sick that I could not have managed without it otherwise I would rather take my car or call a taxi. The hesitancy includes feelings of being exposed to something unpleasant ‘‘to be vulnerable and to need help’’. One informant’s description of the situation is that ‘‘there is too much publicity’’. There is also a feeling of not wanting to be a burden. One doesn’t want to cause any unnecessary trouble or expense to the health services. To realize one’s limitations. To call an ambulance was not an easy decision for the majority of the informants. They considered alternative ways of getting to hospital either by their own means or with help from others. Relatives, friends or neighbours can help the sick person to understand that there are no other alternatives, i.e., the situation demands an ambulance. In this respect, one must accept one’s own limitations and recognize the advantages of an ambulance. There are also indications that the patient does not want to cause trouble or be a burden on his/her relatives, despite the gravity of the condition. In the latter situation, the ambulance can be seen as a neutral way of helping the
Making up one’s mind: – Patients’ experiences of calling an ambulance patient without him/her becoming a burden on relatives or other people. Therefore, to realize one’s limitations deals with both the individual and his/ her context. I could have gone in my car, I could maybe have taken a taxi, no I would have taken my car, but then someone would have had to drive me there in my car, and put the wheelchair into the car, I would have made a lot of work for my relatives, which I don’t think is right. Although upon reflection, the patients realized that the only and best solution was to call an ambulance, they nevertheless felt it was frightening and sometimes embarrassing to make the call. An ambulance signifies drama, the ambulance is always a bit dramatic, something that may attract the neighbours’ attention. The informants stated that they did not wish to be the subject of attention, which is another reason why they hesitated to call an ambulance. This is especially relevant when there are children involved or near by. Ambulance, the safest and most secure form of transport Despite the fact that the informants were reluctant to call an ambulance, they stated that it was a reliable and safe way of getting to hospital when they were incapable of making the journey on their own. Since other vehicles make way for an ambulance, the journey to hospital is smooth and safe. Some also described the ambulance as the fastest way to receive treatment. To feel that the transport is fast and safe. When the informants needed help and all other alternatives had been exhausted, the general opinion was that the ambulance is a safe and fast way of reaching the hospital. This is connected to the patients’ intolerable and acute experiences but also to safety, partly because an ambulance provides safe transportation, e.g., ambulances are given the right of way by other drivers (a right laid down by law in Sweden), and partly because of the relief the informants experienced when the caregivers arrived and treatment began. To be able to get there quickly, without having to drive yourself. No, I wouldn’t have been able to drive. I would have been a danger in the traffic. Ambulances are really great. . . they turn on the siren and are given the right of way. To receive immediate access to care. When the ambulance and caregivers arrive, the informants are sure of getting immediate help and adequate treatment. However, some informants were surprised and to some extent frustrated by the fact
15
that they were treated at the scene instead of being immediately transported to a hospital. One of them said: ‘‘I just wanted to go’’. However, treatment in an ambulance is mainly seen as a guarantee of receiving immediate attention and high priority upon arrival at a hospital. If you get into an ambulance you are, yes, then you are almost in hospital. My sister has driven me sometimes but then one has to sit in the waiting room. You don’t want that when you are throwing up and feeling generally poorly. (You mean that if you call an ambulance, you will receive attention more quickly?) Yes, that is my experience anyway. To emphasize the need for care Even if the situation is not urgent, the ambulance means immediate or at least the ‘‘promise’’ of treatment. To be in need of an ambulance emphasizes a need for care, even if it has more to do with transport to a hospital than advanced forms of medical treatment. From a patient perspective, to need an ambulance means ‘‘more treatment than transportation’’. (But the time you went from U-city to X-city, your primary need was transport?) Yes, transport. (There wasn’t much treatment on that occasion?) No, there wasn’t, there wasn’t. . .On the other hand, it was due to the fact that I was ill. . .so there was care involved. ..so it was, yes, it was care. (Was it care?) It wasn’t just transport. (It was not transport?) Well, they took care of me then and put me on a stretcher, they checked the whole time that I was all right so it sure was more care than transport. It is also significant that the ambulance emphasizes the need of care in the eyes of others, which several informants pointed out. Some people would not be able to call an ambulance so easily. (Why do you think that?) I think many people believe you have to be dying before calling an ambulance.
Theme 2: Waiting for help While waiting for the ambulance, feelings of fear and anxiety can occur, and in some cases feelings of loneliness and helplessness are also present. The decision and the wait mean that patients have handed over responsibility to someone else, i.e.
16
C. Ahl et al.
they rely on the caregivers to assume responsibility for them (see Table 2).
To experience the wait as long The time that passes before deciding to call for help can vary, but once the decision is made, there is a desire to receive immediate help. Several informants described the wait for an ambulance as very long although they later realised that this was not the case. ‘‘It could have been a minute; it could have been an hour’’. The waiting sometimes includes feelings of being neglected and alone. They just wanted to get to the hospital immediately. When the caregivers arrived, the patients received care and attention, which led to feelings of relief. I felt that it took a long time for them to arrive although I realized afterwards that it didn’t take that long. I remember saying to myself the whole time: aren’t they coming soon? I was in such pain that all I wanted was help. You experience the time as incredibly long until the ambulance arrives but then it is obvious that it wasn’t long. That time was difficult, because I just wanted to go, I didn’t want to be at home. To be alone with one’s feelings To be alone with one’s feelings implies fear and loneliness. In addition, the wait reinforces these feelings. Fear can also be experienced when one looks back and reflects upon the situation. To be anxious and afraid. Some informants described experiencing anxiety and fear while waiting. It concerned relatives or close friends, but also fear that the ambulance would not reach them in time or fail to find their house. In addition, fear also increases the desire to get to the hospital as quickly as possible. This was expressed by an informant in the following way: ‘‘I was afraid and I just wanted to go . . .go. . .I didn’t want to be at home and that is why I became so frustrated when we didn’t go
Table 2
immediately’’. However, several informants described how fear gave way to relief and calm when the ambulance and medical team arrived. Will they get here in time, will I get there in time, but once you are in the ambulance and you see their equipment and all that. . ., well you are in safe hands. To feel neglected and alone. Besides anxiety and fear, the informants also felt neglected, alone and in some way vulnerable, but once the ambulance had arrived, they experienced a sense of relief. In addition, some informants described being alone both in their decision making and while waiting for the ambulance. I was in such pain that the only thing I wanted was to get help and when you don’t have anyone to talk to at home you feel isolated but it was a relief when they came and I became a bit calmer and they did what they could. To avoid responsibility To be in need of help and calling an ambulance means handing over responsibility to someone else. Hence, there is a sense of freedom and relief at handing over responsibility as well as a feeling of trust and security in allowing someone else to take over what you cannot handle yourself. To put your life in the hands of someone else becomes natural. To feel relief. As previously mentioned, when all decisions and the call to the emergency number have been made, the informants described a sense of relief. They felt free of responsibility, as they had handed it over to someone else. Knowing that the ambulance is on its way and that someone else will take over responsibility was described as feelings of relief and calm. It feels good once you have made the decision and phoned for an ambulance. They know that something is wrong. . .now I don’t have to take further responsibility. . .It is about letting go, now I no longer have to be in control.
Waiting for help
Categories
Subcategories
To experience the wait as long To be alone with one’s feelings
To be anxious and afraid To feel neglected and alone
To avoid responsibility
To feel relief To experience a sense of safety and trust
Making up one’s mind: – Patients’ experiences of calling an ambulance To experience a sense of safety and trust. Even before the ambulance arrives, there is a sense of security and trust that help is on the way. The decision-making may have taken a long time, but the informants can now hand over responsibility to and trust in the ambulance personnel. The informants reported that the personnel at the emergency call centre and the caregivers in the ambulance can strengthen patients’ feeling of safety and trust, partly because the patients know that someone is coming and because they can speak to them on the phone before the ambulance arrives. I felt so ill that I thought I was about to become unconscious, but knowing that someone is on the way meant that I was not worried, as I knew they would find me.
Discussion The purpose of this study was to describe patients’ experiences related to their decision to call and wait for an ambulance. The findings are more nuanced and partly contradict those of previous studies, in which researchers revealed indications of overuse/misuse in all cases where patients have assessed ambulance care as necessary (Billittier et al., 1996; Clark and Fitzgerald, 1999; Gardner, 1990; Gratton et al., 2003; Pallazzo et al., 1998; Rademaker et al., 1987; Richards and Ferrall, 1999). The analysis of the interviews shows that there are various considerations in the patients’ decision to call an ambulance that have not been previously highlighted, thus the findings of the present study contribute new knowledge. Many of the respondents seem to have made a great effort to manage the situation themselves before taking the decision to call an ambulance. People who face unexpected situations and suddenly fall ill express their experience in various ways, such as fear, anxiety, insecurity and irrational behaviour (Bowman, 2001). Most people strive for independence, to have control over the expected and the unexpected, despite the fact that they are seriously ill (Olsson and Hangasi, 2001). The informants in this study stated that they also tried to manage on their own, despite being in obvious need of help. Initially, the patient may even refuse help in order to maintain control of his/her situation. Some studies (Hauswald, 2002; Silvestri et al., 2002) argue that the excessive use of ambulances, and therefore misuse of the emergency services, is a growing problem. Our findings moderate such conclusions and can be seen as a complement to the overall picture of patients who tend to be cau-
17
tious and hesitant before calling an ambulance. Their cautiousness and hesitancy are expressed in various ways such as loss of control, feelings of not being able to cope with the situation and negative attention caused by the arrival of an ambulance. Sometimes, the patients act in a way that may be perceived as inconsistent with the need for an ambulance, for example, standing in the hallway ready to go when the ambulance arrives. Our findings show, however, that most patients would have preferred to seek care on their own had they been able to do so, a result which can also be found in Billittier et al. (1996), Pallazzo et al. (1998) and Thuresson et al. (2005). At the same time, they appear to recognize the advantages of the ambulance. Patients consider their options either alone or in consultation with relatives. They reflect upon different strategies, hesitate and try to find solutions, even though they may be seriously ill, which can have devastating consequences for their future care and treatment. This delay is also reported in Kristofferzon et al. (2003) and Thuresson et al. (2005) and may be interpreted as reluctance to admit vulnerability and dependence. Calling an ambulance is experienced as an inability to ‘‘be in control of yourself and your illness’’. Accordingly, the illness becomes everybody’s concern. On the other hand, the hesitancy and fear also relate to the anxiety of being a burden on the health care services or not being believed by caregivers. The findings also show that some patients presume that the ambulance legitimizes their need for care. Having assessed their situation, they came to the conclusion that they needed help and were incapable of coping with the situation on their own. The ambulance seemed, thus, to be perceived as a promise of help. Moreover, the patients appear to believe that they gain easier access to medical care when they arrive in an ambulance. According to Marinovich et al. (2004), the patients may be correct in this conclusion. Patients who arrive at the emergency department in an ambulance use significantly more resources than their walk-in counterparts. These patients are often elderly people and women who usually arrive after office hours. The results of this study also indicate that these patients need more time at the emergency department and often have to be admitted to hospital. However, this study also agrees to some extent with previous investigations claiming that patients overuse/misuse the ambulance service due to ignorance and for reasons of convenience. There seems to be a great risk of not being prioritized at the emergency department despite troublesome
18 symptoms. Consequently, the informants seemed to think that the risk was less if they arrived in an ambulance. In order to gain a better understanding of the problem, it should be pointed out that low priority may result in a wait of up to twelve hours, despite the fact that the patient is in pain or has a high temperature (Nystro ¨m et al., 2003). Patients try to cope with illness in different ways and for varying lengths of time before calling an ambulance. Once the decision is made, the variation in the interviews disappears, and the statements express similar experiences/sentiments. The patients are now convinced of their need for help. Waiting for an ambulance involves the belief that help is on its way and something is about to happen; but at the same time it evokes feelings of loneliness and reveals the patients’ vulnerability and dependence. At the moment the decision to call an ambulance is made, the patient places himself/herself, all responsibility and decision making, in someone else’s hands. The patient relinquishes everything in order to feel trust and security. At this moment, there is a dramatic change in the informants’ demeanour. Their hesitancy and attempts to manage the situation on their own disappear. Knowing that an ambulance is on its way is reassuring. In some cases, the symptoms decrease to the extent that the patients manage to plan their sick leave, pack a suitcase and wait for the arrival of the ambulance. Accordingly, ambulance personnel appear to base their opinion about inappropriate use of ambulance care on patients who appear fully capable of making plans for their hospital stay. Hence, our study, which describes patients’ considerations in choosing an ambulance, is a valuable complement to other studies in the field. In addition, we must also take into consideration the fact that the person who makes the emergency call, be it a patient or a relative, cannot always explain the patient’s exact needs and symptoms. Consequently, an ambulance may be dispatched even though the assessment of the situation is uncertain. Morse and O’Brien (1995) describe the effects of sudden illness on people’s ability to communicate. Pain and anxiety caused by sudden illness may, thus, lead to an incorrect assessment of the situation, resulting in unnecessary use of ambulance care. The patient, however, should not be blamed for this.
Conclusion According to the findings of this study the definition of inappropriate use of valuable health care resources should not only be based on the profes-
C. Ahl et al. sional point of view. Professionals may not be aware of the situation leading to the decision to call an ambulance, since some symptoms decrease while waiting. It seems fair to assume that professional judgment should consider both medical knowledge and patients’ reactions when they experience threat to their health and life.
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