Abstract
Background
As worldwide life expectancy increases, the Swedish Ambulance Service is likely to be affected by the demographic shift towards a larger proportion of older persons. An older population tends to increase the demand for ambulances, indicating a need to illuminate older patients’ perspective. Thus, the aim of this study was to explore older patients’ perceptions of the Swedish Ambulance Service.
Methods
This interview study employed a descriptive qualitative design with a phenomenographic approach in accordance with Dahlgren and Fallsberg.
Results
Three main descriptive categories emerged to describe the underlying conceptions in the interviews; A double-edged encounter, Trust is created by perceived competence, and Safety through accessibility in vulnerable situations.
Conclusion
Older patients described trust in ambulance clinicians as a prerequisite for feeling safe enough to share their feelings and allow a bodily examination. However, they also criticized the care provided because they questioned the need for certain actions.
Keywords
Introduction
People worldwide are living longer and experiencing better health than ever before. Demographic projections indicate that one in every six persons will be 60 years or over by the year 2030, potentially giving rise to challenges in terms of health care resources [
[1]
]. Consequently, the ambulance service is likely to be affected as an older population has been shown to increase the demand for ambulances [World Health Organisation. Ageing and health [Internet] WHO Fact Sheets; 2022 [cited 2022 Oct 22] available from: 〈https://www.who.int/news-room/fact-sheets/detail/ageing-and-health〉.
[2]
]. It has been demonstrated that older patients have increasing medical care needs from about the age of 70, followed by a transitional period from about age 80–85, when major health changes often take place [[3]
]. This indicates a need to illuminate older patients’ perspective, which is the rationale behind this study.While the global life expectancy in 2020 was 71.0 years [
[4]
], the European Union reports 80.4 years [United Nations. World Population Prospects 2022. Summary of results. [cited 2023 Jan 20] available from 〈https://www.un.org/development/desa/pd/content/World-Population-Prospects-2022〉.
[5]
] and Sweden 84.3 years for women and 80.6 years for men [European Union (Eurostat). Life expectancy across EU regions in 2020 [cited 2023 Jan 19] available from: 〈https://ec.europa.eu/eurostat/web/products-eurostat-news/-/ddn-20220427–1]〉.
[6]
]. However, Swedish prognostic demographics indicate a 76% increase of individuals aged ≥ 80 years by the year 2040 [[6]
]. Research reveals that ambulance service assignments frequently involve older persons [7
, 8
] and older patients also constitute a significant part of those who are discharged at the scene [[9]
]. This is potentially challenging, as older persons are often considered vulnerable [10
, 11
]. Many older persons suffer from comorbidities and can be described as frail, which implies a reduced physical, mental, and social capacity to handle external stressors, i.e., when afflicted by acute illness [[12]
].In general, patients who call for an ambulance have been found to experience an acute illness, thus in need of urgent medical attention [
13
, 14
, 15
]. The situation prior to calling for an ambulance is described by patients as a struggle at home, which gradually becomes unbearable as fear takes over and no other choices exist [[16]
]. In the encounter with the ambulance clinicians, patients feel confirmed and empowered when ambulance clinicians take time to talk and ensure that the patient understands the information [[15]
].n order to embrace co-created healthcare, the ambulance service has to balance a complex whole comprising both medical science and caring science [
17
, 18
, 19
]. However, research in the ambulance service context usually stems from a positivistic paradigm with studies that adopt an objective medical, disease-oriented perspective [20
, 21
]. The encounter and caring relationship are often described from a caregiver perspective [22
, 23
, 24
], which may create an unbalanced portrayal of the ambulance context that overshadows the patients’ viewpoints. Therefore, it is particularly important to further illuminate older patients’ perceptions, as a prerequisite for care is self-determination and adherence to individual needs [[25]
].Aim
The aim of this study was to explore older patients’ perceptions of the Swedish Ambulance Service.
Methods
Methods and design
This study employed a descriptive qualitative design with a phenomenographic approach [
26
, 27
]. Phenomenography aims to highlight qualitatively different variations in how persons perceive their surroundings or a phenomenon, rather than the phenomenon itself [[27]
]. As phenomenographical research results may enable healthcare professionals to better comprehend and care for individuals’ various needs [[27]
], the method was considered appropriate in relation to the aim of the study. The methodological reporting of this study follows the consolidated criteria for reporting qualitative research (COREQ) standard [[28]
].Setting and context
Globally, as in Sweden, the ambulance service has developed rapidly over the past decades in terms of its mission, equipment, and education. Since 2005, each ambulance in Sweden must be crewed by at least one registered nurse (RN). Due to the fact that each region is governing and thus responsible for the AS in its own geographical area [
[29]
], some of Sweden’s 21 regions require the RNs to have a specialist ambulance nurse education [[30]
]. In Sweden a RN has completed a three-year nursing program and all graduates receive a bachelor’s degree. RNs are thereafter eligible to apply to a one-year program that leads to a postgraduate diploma in specialist nursing and a master's degree for ambulance nurses [[31]
]. In the region in which the study was conducted, the ambulance clinicians act as a team consisting of specialist ambulance nurse together with a RN or an emergency medical technician (EMT), where the specialist ambulance nurse is responsible for the provision and quality of care.Svensk författningssamling, Högskolefördningen (SFS 1993:100) [Swedish Constitutional Assembly, Higher Education Ordinance] [cited 2022 May 10] available from: 〈http://www.riksdagen.se〉.
The participants were recruited in a region in southern Sweden with an area or 11,303 km2 and consisting of 1.4 million inhabitants who are served by 28 ambulance stations, annually handling some 158,000 ambulance assignments. The region, representing both rural and urban settings, as well as representing diversity in terms of socio-economic status, is divided into four districts of which two are operated by the region and two by a private contractor on behalf of the region. However, clinical guidelines, quality indicators, and staffing requirements are identical, irrespective of the mode of operation.
Selection and participants
A convenience sample was chosen in order to capture a variety of perceptions among older people who had previously encountered the ambulance service. The inclusion criteria were persons with experience of being an older patient in the ambulance service after the year 2005, Swedish speaking, and cognitively lucid. The Chairpersons of three Swedish patient associations were approached and asked to distribute study information to their members. In the information sheet, eligible study participants were encouraged to contact one of the authors via telephone or e-mail. After informed consent had been obtained, participants were recruited from the Swedish National Pensioners’ Organization, the Swedish Stroke Association, and the Swedish Heart and Lung Association, representing common medical conditions encountered by the ambulance service. The associations represented both urban and rural areas, as well as various socio-economic areas. Twenty informants were recruited, and the demographics are presented in Table 1.
Table 1Demographics of the participants (N = 20).
| Woman, n | 9 |
| Man, n | 11 |
| Age (median), years (range) | 77 (69–88) |
| Swedish National Pensioners’ Organization, n | 7 |
| Swedish Heart and Lung Association, n | 12 |
| Swedish Stroke Association, n | 1 |
Data collection
All interviews were conducted during September and October 2019. Two participants chose to be interviewed at the patient association facilities, while the others wished to be interviewed in their homes. The interviews started with the question “When I say ambulance care, what do you think of?”. Follow-up questions were posed to deepen the descriptions and conceptions of the ambulance service. In all, twenty interviews were conducted, which lasted 25 min on average (range 19 – 30 min). The interviews were audio-taped and transcribed verbatim.
Data analysis
In accordance with phenomenography presented by Dahlgren and Fallsberg [
[26]
], the participants’ statements were studied and systematized into qualitatively different conceptions. The analysis, initially conducted by two of the authors [C.F.and B.H.], began by reading all the data to become familiar with it. Next, meaning units describing the participants' understanding of the phenomenon were identified and condensed. A preliminary grouping of meaning units based on similarities and differences was performed, followed by analyzing the categories to reveal the participants’ underlying, qualitatively different conceptions of the ambulance service. The descriptive categories were grouped into ‘‘what’’ and ‘‘how’’ aspects [20
, 21
] and illustrated by selected quotations, numbered in line with the interviews.Ethical considerations
The ethical code of conduct was followed, and we adhered to the ethical guidelines issued by the Swedish Research Council. Consent, confidentiality, utility, and information were considered in line with the Declaration of Helsinki [
[32]
], as well as the Swedish ethical protocol and legislation. Thus, prior to the study, the participants received oral and written information about the study aim, procedures, and their right to withdraw at any time without explanation. Additionally, each participant gave informed written consent. The study was approved by the Regional Ethical Review Board in Lund, Sweden (Reference No. 2018/383).Results
The analysis revealed three main descriptive categories: A double-edged encounter, Trust is created by perceived competence, and Safety through accessibility in vulnerable situations.
A double-edged encounter
Older patients perceived care provided by the ambulance service as a double-edged encounter. On the one hand long-awaited and meaningful, on the other an encounter characterized by a sense of powerlessness. For older patients, the ambulance service is perceived meaningful due to its primary function as the first link in the care chain, where care can be started with the help of ambulance service equipment.
Older patients perceived that care is coordinated by communication between ambulance clinicians and hospital staff in preparation for their arrival at the hospital. However, they also perceived powerlessness in the encounter, which occurs when older patients do not understand the ambulance clinicians’ questions and actions, which sometimes appear superfluous and difficult to handle in an acute situation of, for example, pain.
I injured a vertebra in my neck/./ the carers did their bit as I see it, but. There were questions, "have you drunk anything? Have you eaten anything? You can take those questions when you come in. it's very annoying when you're in pain/./ They should do their job based on what they see and detect. Focus on that. (10)
In older patients’ perceptions, the time perspective was crucial in the initial encounter with the ambulance service. Primarily, the ambulance service is described as a fast-paced organization, while the older patients also understood that resources are limited, leading to possible delays. However, their perceptions of time varied as a result of individual differences associated with the reason for calling an ambulance and own worries that affected their perception of the time it took for an ambulance to arrive at the scene.
Of course sometimes when you are pacing up and down, waiting, that 1-minute feels like half an hour, but then when you look at the time, you see that it hasn’t been as long as you thought.so they have actually been quite quick. (13)
The older patients described the need to contact an ambulance as necessary in life-threatening situations. However, the sense of urgency varied between older patients depending on how they experienced, for example, pain. Therefore, the older person who called for help always described it as urgent, irrespective of the reason.
Trust is created by perceived competence
Older patients perceived trust as a result of ambulance clinicians’ personal and practical competence, which helps to normalize the situation, thereby enabling older patients to relax. The ambulance clinicians’ actions thus contributed to older patients daring to feel trust.
To surrender yourself. it’s. I sometimes think it is just fantastic that you can do that, right?. I almost become apathetic and just sort of think - Yes! They’ll sort it out. (19)
Older patients described ambulance clinicians’ competence as being energetic, having an inner drive, possessing good judgment, with a calm, methodical approach to the assessment and treatment of a range of common medical conditions. In addition, older patients perceived themselves as being seen as persons behind their medical condition. A polite approach was also highly valued in the encounter between an older patient and ambulance clinicians.
They come in and introduce themselves, and ask where I have pain. so that they know how to deal with me or at least not just throw me on a stretcher somewhere. (17)
Older patients perceived the ambulance clinicians’ ability to handle advanced medical equipment as a fundamental competence for the initiation of care in their home or in the ambulance. Furthermore, competence was perceived in terms of ambulance clinicians’ personal suitability, that is, self-confidence, experience in the profession, as well as high resistance to stress. In addition, the ambulance clinicians’ ability to inform about present and forthcoming care processes with insight and good pedagogy was described as helping older patients to understand the information. The caring competence was also described as including an ability to determine whether the older patients need to be transported and, if so, where. It could also mean that older patients are judged to be able to remain at home, which is perceived as positive.
Safety through accessibility in vulnerable situations
Due to its high degree of accessibility, older patients perceived the ambulance service as a safety net in a vulnerable situation. Regardless of whether the older patients live in sparsely populated areas or cities, the ambulance service can always be contacted when necessary.
Because we don’t. have hospitals and specialist doctors everywhere the ambulance service is just what is needed, a quick effort at different stages. then they are perfect, the ambulance service, because.they can actually transport people to where they need to be. (10)
Older patients described that the checking of vital signs and, for example, ECG examination, contributed to an experience of safety, even though the transport can be cramped and uncomfortable.
Accessibility in terms of e.g., calm communication from the ambulance clinicians was perceived to create a relationship that helps older patients to dare to entrust their feelings and experiences in a vulnerable situation. Thanks to the relationship, older patients described themselves as feeling comfortable and safe.
For a person who is stressed and like. it feels. you don’t want to open up either. properly. maybe you don’t say. exactly where you have pain or exactly how it feels. but if you feel comfortable with someone, then. you really open up. much more.you are quite exposed in that situation where you need to ring for help. (1)
Older patients perceived that the relationship with the ambulance clinicians made them confident enough to allow a bodily examination, thus facilitating an adequate assessment.
Discussion
Our results reveal that older patients perceived the encounter with the ambulance service as double-edged, as while they are eager to meet the ambulance clinicians, they simultaneously questioned the ambulance clinicians’ approach to them. This may be caused by older patients’ self-awareness, acquired through long life experience, potentially positioning in vulnerable situations [
[33]
]. On the other hand, older patients often present a more complex picture of symptoms due to age-related physiological deterioration [[34]
], including psychosocial problems, as well as reduced cognitive ability and self-esteem [[35]
]. This may prevent them from objecting to the ambulance clinicians’ actions, resulting in feelings of powerlessness in the encounter, especially when they do not understand the ambulance clinicians’ questions and actions. The purpose of the ambulance clinicians’ questions often concerns the handovers between the ambulance service and Emergency Department, indicating a possible lack of communication with older patients. In line with the thoughts of Dahlberg et al. [] concerning the carer-patient encounter, it is argued that there is a gap in understanding as a result of e.g., patients’ previous experiences [], indicating a need to increase older patients’ participation in decision-making [[37]
].The ambulance clinicians’ competence has been found to be reassuring for patients [
38
, 39
]. Bearing in mind the vulnerability of older patients in ambulance encounters [[40]
], our results show that older patients trust in the ambulance clinicians’ competence. This is important when receiving care, e.g., when older patients surrender their bodies for assessment and medical interventions. Not surprisingly, the carer-patient relationship is the foundation of nursing work, in which trust is described as essential. However, it is also a dynamic and ongoing process, implying that the caring relationship is fragile [[41]
]. Older patients’ frailty often gives rise to multiple issues, including psychosocial problems and reduced cognitive ability [[35]
]. In the ambulance service setting the often brief carer-patient relationship is described as a surrender from one’s own struggles to dependence on others and trust in the ambulance clinicians’ competence to manage the situation [[42]
]. In our results, older patients described their perceived frailty and state of dependency in relation to the ambulance clinicians’ competence. Thus, the ambulance clinicians’ education, experience, and personal skills are vital aspects of older patients’ perception of the ambulance service.During the encounter, older patients perceived a sense of safety in relation to the ambulance service's accessibility, vital sign assessment, use of medical technical equipment, and the ambulance clinicians' communication skills. These findings are consistent with previous research that described patients' feelings of safety when the well-equipped ambulance service arrived with competent ambulance clinicians who possessed social skills [
[43]
]. By being accessible and polite, ambulance clinicians made older patients feel seen as a person, which is in line with previous knowledge [15
, 44
] emphasizing the carer-patient relationship.Consequently, it is important to recognize that this trust in ambulance clinicians implies responsibility; the more vulnerable the patient, the greater the responsibility [
[15]
], not least in terms of accessibility. As a result, it is crucial for ambulance clinicians to establish a climate of openness and trustworthiness in the brief time they spend with the patient, avoiding situations in which patients feel mistreated and potentially suffer from the care provided [[14]
].Methodological considerations
The four quality criteria for ensuring trustworthiness in qualitative research developed by Lincoln and Guba [] were adhered to. The relatively short duration of the interviews is a potential threat to credibility, although the number of different perceptions that emerged indicates that the data were adequate. However, a total of 20 interviews were conducted to ensure adequate data and compensate for some of the shorter interviews. In order to ensure the confirmability and trustworthiness of the study, and to minimize the influence of preunderstandings, the analysis process comprised ongoing discussions within the research group. Another limitation affecting transferability might be that the study was performed in a single county in Sweden and that the sample only included Swedish speaking participants, thus failing to reflect the increasing ethnic diversity in Swedish healthcare. However, the participants were recruited in both rural and urban settings, as well as representing diversity in terms of socio-economic status. Finally, three external nursing science researchers vetted the manuscript according to the gold standard [] and provided feedback to the authors.
Conclusions and implications
Older patients described feeling safe due to the ambulance clinicians’ competence, while also regarding the ambulance service as a transport organization with the sole purpose of quickly taking them to a healthcare facility. Furthermore, their trust in ambulance clinicians is a prerequisite for feeling safe enough to share their feelings and allow a bodily examination. Simultaneously, older patients criticized and questioned the treatment provided due to lack of communication with ambulance clinicians. The results reveal older patients’ ambivalent perceptions of the ambulance service and the care provided by ambulance clinicians, highlighting the need for an increased focus on the care relationship. To promote older patients’ self-determination and avoid suffering caused by care, this criticism needs to be addressed by ambulance clinicians in regular open discussions as well as in introductory information for new employees, where older persons’ preferences and views are outlined.
Funding
This research received funding from the Kamprad Family Foundation for Entrepreneurship, Research & Charity (ref. no. 20180157).
CRediT authorship contribution statement
Conceptualization; AR. Data curation; AR, EH. Formal analysis; AR, CH, EH, BH. Funding acquisition; AR. Investigation; AR, EH. Methodology; AR, CF, EH, BH. Project administration; AR. Resources; AR. Supervision; AR. Validation; AR, AS, CF, EH, BH. Visualization; AR, CF, EH, BH. Writing – original draft; AR, AS. Writing – review & editing; AR, AS, CF, EH, BH. All authors read and approved the final manuscript.
Conflict of Interest
The authors delare that there are no conflict of interest.
Acknowledgements
We are grateful to the participants who took part in this research and acknowledge Sanna Thomsen, who facilitated the data collection.
Appendix A. Supplementary material
Supplementary material
Supplementary material
Supplementary material
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Article info
Publication history
Published online: February 08, 2023
Accepted:
January 31,
2023
Received in revised form:
January 31,
2023
Received:
November 6,
2022
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2023 The Author(s). Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.
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