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 [
]. Consequently, the ambulance service is likely to be affected as an older population has been shown to increase the demand for ambulances [
[2]- Andrew E.
- Nehme Z.
- Cameron P.
- Smith K.
Drivers of increasing emergency ambulance demand.
]. 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]- Santoni G.
- Angleman S.
- Welmer A.K.
- Mangialasche F.
- Marengoni A.
- Fratiglioni L.
Age-related variation in health status after age 60.
]. 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 [
], the European Union reports 80.4 years [
] and Sweden 84.3 years for women and 80.6 years for men [
[6]Swedish National Board of Welfare
Vård och omsorg för äldre. Lägesrapport 2022. [Care for older people.
]. However, Swedish prognostic demographics indicate a 76% increase of individuals aged ≥ 80 years by the year 2040 [
[6]Swedish National Board of Welfare
Vård och omsorg för äldre. Lägesrapport 2022. [Care for older people.
]. Research reveals that ambulance service assignments frequently involve older persons [
7- Cantwell K.
- Morgans A.
- Smith K.
- Livingston M.
- Dietze P.
Differences in emergency ambulance demand between older adults living in residential aged care facilities and those living in the community in Melbourne, Australia.
,
8- Hjalmarsson A.
- Holmberg M.
- Asp M.
- Östlund G.
- Nilsson K.W.
- Kerstis B.
Characteristic patterns of emergency ambulance assignments for older adults compared with adults requiring emergency care at home in Sweden: a total population study.
] and older patients also constitute a significant part of those who are discharged at the scene [
[9]- Lederman J.
- Lindström V.
- Elmqvist C.
- Löfvenmark C.
- Ljunggren G.
- Djärv T.
Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: a cohort analysis.
]. This is potentially challenging, as older persons are often considered vulnerable [
10- Barrientos C.
- Holmberg M.
The care of patients assessed as not in need of emergency ambulance care - Registered nurses' lived experiences.
,
11- Ferreira J.B.B.
- Santos L.L.D.
- Ribeiro L.C.
- Rodrigues Fracon B.R.
- Wong S.
Vulnerability and primary health care: an integrative literature review.
]. 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]railty in older people: a principle-based concept analysis.
].
In general, patients who call for an ambulance have been found to experience an acute illness, thus in need of urgent medical attention [
13- Ahl C.
- Nyström M.
- Jansson L.
Making up one's mind:--patients' experiences of calling an ambulance.
,
14- Ahlenius M.
- Lindström V.
- Vincente V.
Patients’ experience of being badly treated in the ambulance service: a qualitative study of deviation reports in Sweden.
,
15- Rantala A.
- Ekwall A.
- Forsberg A.
The meaning of being triaged to non-emergency ambulance care as experienced by patients.
]. 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]- van der Kluit M.J.
- Dijkstra G.J.
- de Rooij S.E.
The decision-making process for unplanned admission to hospital unveiled in hospitalised older adults: a qualitative study.
]. 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]- Rantala A.
- Ekwall A.
- Forsberg A.
The meaning of being triaged to non-emergency ambulance care as experienced by patients.
].
n order to embrace co-created healthcare, the ambulance service has to balance a complex whole comprising both medical science and caring science [
17- Gugiu M.R.
- McKenna K.D.
- Platt T.E.
- Panchal A.R.
Technicians ftNRoEM. A proposed theoretical framework for clinical judgment in EMS.
,
18The EXPAND-Model: a hermeneutical application of a lifeworld-led prehospital emergency nursing care.
,
19- Wireklint Sundström B.
- Bremer A.
- Lindström V.
- Vicente V.
Caring science research in the ambulance services: an integrative systematic review.
]. However, research in the ambulance service context usually stems from a positivistic paradigm with studies that adopt an objective medical, disease-oriented perspective [
20- Cassignol A.
- Markarian T.
- Cotte J.
- Marmin J.
- Nguyen C.
- Cardinale M.
- et al.
Evaluation and comparison of different prehospital triage scores of trauma patients on in-hospital mortality.
,
21- Hirlekar G.
- Jonsson M.
- Karlsson T.
- Hollenberg J.
- Albertsson P.
- Herlitz J.
Analysis of data for comorbidity and survival in out-of-hospital cardiac arrest.
]. The encounter and caring relationship are often described from a caregiver perspective [
22- Backman T.
- Juuso P.
- Borg R.
- Engström A.
Ambulance nurses' experiences of deciding a patient does not require ambulance care.
,
23- Höglund E.
- Schroder A.
- Möller M.
- Andersson-Hagiwara M.
- Ohlsson-Nevo E.
The ambulance nurse experiences of non-conveying patients.
,
24- Oosterwold J.
- Sagel D.
- Berben S.
- Roodbol P.
- Broekhuis M.
Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review.
], 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]- Schenell R.
- Strang S.
- Henoch I.
- Ozanne A.
Struggling for a dignified life: the meaning of self-determination in palliative phase in residential care.
].
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]Dignity in bodily care at the end of life in a nursing home: an ethnographic study.
]. On the other hand, older patients often present a more complex picture of symptoms due to age-related physiological deterioration [
[34]Dynamics of stability: the physiologic basis of functional health and frailty.
], including psychosocial problems, as well as reduced cognitive ability and self-esteem [
[35]- Eckerblad J.
- Theander K.
- Ekdahl A.
- Jaarsma T.
- Hellström I.
To adjust and endure: a qualitative study of symptom burden in older people with multimorbidity.
]. 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. [
[36]- Dahlberg K.
- Dahlberg HN M.
Relective lifeworld research.
] concerning the carer-patient encounter, it is argued that there is a gap in understanding as a result of e.g., patients’ previous experiences [
[36]- Dahlberg K.
- Dahlberg HN M.
Relective lifeworld research.
], indicating a need to increase older patients’ participation in decision-making [
[37]Ethical conflicts in patient relationships: Experiences of ambulance nursing students.
].
The ambulance clinicians’ competence has been found to be reassuring for patients [
38- Togher F.J.
- O'Cathain A.
- Phung V.H.
- Turner J.
- Siriwardena A.N.
Reassurance as a key outcome valued by emergency ambulance service users: a qualitative interview study.
,
39- van Doorn S.C.M.
- Verhalle R.C.
- Ebben R.H.A.
- Frost D.M.
- Vloet L.C.M.
- de Brouwer C.P.M.
The experience of non-conveyance following emergency medical service triage from the perspective of patients and their relatives: a qualitative study.
]. Bearing in mind the vulnerability of older patients in ambulance encounters [
[40]- Tohira H.
- Masters S.
- Ngo H.
- Bailey P.
- Ball S.
- Finn J.
- et al.
Descriptive study of ambulance attendances for older adults with and without dementia in Western Australia.
], 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]Trust in nurse-patient relationships: a literature review.
]. Older patients’ frailty often gives rise to multiple issues, including psychosocial problems and reduced cognitive ability [
[35]- Eckerblad J.
- Theander K.
- Ekdahl A.
- Jaarsma T.
- Hellström I.
To adjust and endure: a qualitative study of symptom burden in older people with multimorbidity.
]. 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]- Holmberg M.
- Forslund K.
- Wahlberg A.
- Fagerberg I.
To surrender in dependence of another: the relationship with the ambulance clinicians as experienced by patients.
]. 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]- Venesoja A.
- Castren M.
- Tella S.
- Lindström V.
Patients' perceptions of safety in emergency medical services: an interview study.
]. By being accessible and polite, ambulance clinicians made older patients feel seen as a person, which is in line with previous knowledge [
15- Rantala A.
- Ekwall A.
- Forsberg A.
The meaning of being triaged to non-emergency ambulance care as experienced by patients.
,
44Practising the ethics of person-centred care balancing ethical conviction and moral obligations.
] 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]- Rantala A.
- Ekwall A.
- Forsberg A.
The meaning of being triaged to non-emergency ambulance care as experienced by patients.
], 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]- Ahlenius M.
- Lindström V.
- Vincente V.
Patients’ experience of being badly treated in the ambulance service: a qualitative study of deviation reports in Sweden.
].
Methodological considerations
The four quality criteria for ensuring trustworthiness in qualitative research developed by Lincoln and Guba [
[45]Naturalistic inquiry. Beverly Hills.
] 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 [
[36]- Dahlberg K.
- Dahlberg HN M.
Relective lifeworld research.
] and provided feedback to the authors.
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.
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 ProofCopyright
© 2023 The Author(s). Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.