Non-conveyance and autonomy: How organisational contexts influence ambulance clinicians’ practice in mental health crises – A qualitative study

Study design and theory

Data were analysed using Braun and Clarke's reflexive thematic analysis (RTA), ²⁹ adopting an inductive data-driven orientation. Coding and theme development were grounded in ACs accounts while recognising the researcher's active, interpretative role in knowledge production. ²⁹ In the discussion, Schein and Schein's theory of organisational culture ³⁰ was applied with a critical realist perspective.^31,32 From a critical realist standpoint, a mind-independent reality exists, while understandings of that reality are shaped through personal, social, historical, and cultural contexts. ³¹ Consistent with this stance, our inferential move relied on retroduction – reasoning from observed patterns to the underlying generative mechanisms that would have to exist for those patterns to occur. To operationalise this logic, we drew on Schein and Schein`s (2017) account of organisational culture as the collective learning and shared experiences of a group, that develop through addressing challenges of adaptation and integration. They conceptualise culture at three interrelated levels: artefacts – visible, tangible manifestations such as routines, protocols, physical layout and documented practices; espoused values – the stated beliefs, priorities and goals leaders and members claim to follow; and basic underlying assumptions – deep, often unconscious beliefs that actually guide behaviour. ³⁰ Bringing these perspectives together enabled an analytic focus on the meaning-making processes through which clinicians interpret and respond to organisational demands and constraints.

Group interviews were chosen because the shared storytelling and interaction among participants can stimulate recall, clarify perspectives, and generate deeper insights into both individual and collective experiences. ³³ A semi-structured approach was selected to enable open exploration of relevant topics while ensuring that all groups discussed the same topics. ³⁴ We prioritised breadth in clinical contexts and participant characteristics to yield rich and varied perspectives. Eight interviews were planned for reasons of feasibility and were judged to have generated rich data and well-developed insights to address the research aim, supporting interpretations that move beyond descriptions to offer theoretically informed explanations of clinicians’ experiences, as suggested by Braun and Clarke. ³⁵

Researchers’ positionality and reflexivity

The first author, who conducted the interviews and led the analysis, is a nurse and a paramedic with more than 20 years of experience in the ambulance services. Professional encounters with patients experiencing mental health difficulties motivated the present study and sensitised the interpretative lens applied during analysis. Reflexive journaling and collaborative discussions with co-authors and an advisory board were used to examine how prior experience and assumptions might influence coding decisions and theme development.

This project was supported by an advisory board comprising individuals with lived experience of mental health challenges, substance abuse and caregiving, alongside ACs, legal and psychiatric professionals. The PhD supervisors contributed complementary expertise in sociology, nursing, and general practice. All co-authors took part in advisory board meetings, and together, they have provided critique, guidance and insight which have informed the project's design, recruitment, analysis, and interpretation. We believe this collaborative approach enhances the project's validity and ensures its relevance. ³⁶

Recruitment and interviews

A convenience sample of ACs was recruited using the snowball method. Members of the advisory board helped us engage with the ambulance station managers, clinical ambulance development staff, and ‘local ambulance champions’. These individuals played a key role in the study by distributing invitations to ACs, recruiting participants to the group interviews, and coordinating the scheduling and locations for the interviews.

The interviews were conducted between December 2022 and June 2023 at or in close proximity to the local ambulance station. The interviews were facilitated by the first author and limited to two hours. The interviews were recorded using the Nettskjema-diktafon app. ³⁷ Nettskjema was used as a mediator to store the audio recordings directly on the safe storage in Tjenester for Sensitive Data (Services for sensitive data). ³⁸ Some ambulance services were able to compensate their employees using time reserved for clinical development in their shift schedule. Other respondents participated in their free time.

Participants

We aimed to include participants who were ACs with ≥2 years’ experience and for groups to consist of 4–8 participants and sought to include participants with diverse educational backgrounds. In practice, group interviews included 4–11 participants per session, with experience spanning 0–30 years. One session included a temporary substitute with no prior AC experience. We retained this participant to preserve the naturalistic context of the on-duty team, consistent with our critical realist emphasis on real-world organisational conditions. Two sessions included one participant (each) who also held a management role.

Ethics

The Regional Committees for Medical and Health Research Ethics (reference 516477/REK South-East) deemed that the study was outside the scope of the Health Research Act. The Norwegian Centre for Research Data (reference 903381), the Data Protection Officer at each local health trust (not included for confidentiality reasons), and the management of each ambulance service granted their approval of the study. All respondents voluntarily provided signed informed consent declarations and were encouraged to treat the information disclosed in the interview as confidential. The interviews were transcribed verbatim by the first author and deidentified during the transcription process.

Data analysis

Coding was done inductively with iterative movement between the data, codes and candidate themes. The first author undertook coding and theme construction, with input from the co-authors and the advisory board at multiple stages. NVivo 12 software 1.7.2 (1560) was used to manage and code data. ³⁹ Quotations are labelled by two numerals, the first denotes the group interview and the second the participant (e.g. Resp. 1-2).

The theoretical lens of Schein and Schein's (2017) theory of organisational culture was applied in the discussion to contextualise findings, consistent with our inductive approach.

Experienced challenges in mental healthcare assignments

Consequences for on-scene practice and care trajectories

Implication – solving the mission, not the problem

In their everyday work, ACs respond to both interfacility transfers – moving patients between locations – and emergency calls initiated through the emergency medical number or by healthcare professionals requesting on-scene assessment or treatment. ²⁸ Across all groups, participants discussed their approaches to handling or resolving the calls, sometimes referred to as ‘missions’, particularly those involving patients experiencing a mental health crisis. Many ACs expressed that during these calls, they often felt unable to provide direct assistance. Instead, they viewed their primary role as conveying patients to physicians to assess and determine whether hospital admission was required. One respondent explained their approach as follows:

Resp. 2-1: No, we’re not solving the problem [of the person being mentally ill], and we’re really not supposed to solve it either, because we don’t have that training, you know, or the authority for it. Basically, our job is just to pick someone up and drive them to the people who can actually do something about it, in one way or another.

Organisational culture's influence on ambulance clinicians’ practices

To better understand the underlying drivers of ACs’ practices, we will now discuss our results through the lens of Schein and Schein's (30) theory of organisational culture, within a critical realist perspective, which we argue can illuminate how organisational cultural mechanisms shape ACs’ reliance on conveyance of patients to specialised clinicians.

Schein and Schein ³⁰ argue that shared assumptions, values, and norms can develop within groups as they adapt to internal and external challenges. These cultural elements become embedded in daily practices, shaping members’ perceptions, attitudes, and behaviours – often without conscious awareness. From a critical realist perspective, such embedded cultural elements can be understood as generative mechanisms that produce the observed practices. Participants reported feeling unprepared to manage mental health cases, relying instead on experience, intuition, and informal knowledge rather than formal training, findings consistent with previous research.^10,14,41,42 ACs’ reliance on conveyance appears as an adaptive response to organisational gaps in training and support that, over time, has crystallised into a default norm. Thus, frequent conveyance can be seen as a group-level coping strategy compensating for limited confidence and knowledge in how to manage mental health calls. This raises critical questions about the contextual and organisational factors that continually reproduce these clinical practices.

Conveyance practises

In many countries, patients experiencing mental health crises are directed to the emergency department (ED), where they often face long waiting times and a stressful environment poorly suited to their needs.^14,42 Respondents described how in Norway, ambulance services typically convey patients with mental health needs to their GP. When GPs are unavailable, the out-of-hours service becomes the default option. This pattern was primarily attributed to challenges in referring patients to other appropriate primary healthcare resources and points to insufficient collaboration and misaligned pathways between municipal primary healthcare services and ambulance services, as noted in previous research.^42,43

While conveyance to the ED or out-of-hours primary care may satisfy ACs’ need to transfer responsibility to other clinicians, these services frequently do not address patients’ broader psychosocial needs, such as financial insecurity, housing instability, lack of social support and safeguarding concerns. These services’ primary mandate is to provide immediate emergency care to meet the population's urgent medical needs. ²⁰ Consequently, conveyance may provide a resolution for the ACs but does not necessarily provide the most appropriate or therapeutic pathway for patients in mental health crises. Numerous studies emphasise the need for improved interagency referral processes and the development of alternative, tailored care pathways for individuals experiencing mental health illness.^{14,20,42–45} Although person-centred alternatives to emergency department care have been shown to offer safe and valuable support, ⁴⁶ their availability varies widely. Such variation is produced by local municipal provision and inter-organisational arrangements; where alternatives do exist, their referral pathways must be accessible and operational for ambulance services. ⁴⁷

The role of organisational culture in shaping non-conveyance practices

A systematic review by Ebben et al. ¹⁹ reported wide variations in non-conveyance rates across studies from multiple countries, ranging from 3.7% to 93.7%. They show how the factors influencing decisions of non-conveyance are multifaceted and associated with the clinician, the patient and their relatives, the healthcare system or processes, as well as the availability of supportive tools.^46,48–61 Professional factors include competencies, where additional training increased non-conveyance rates,^52,62 risk assessment, fear of litigation,^59,60 experience and intuition, ⁶¹ and pragmatism (conveyance being an easy option compared to non-conveyance). ⁶¹ Patient factors include health status,^{46,53,55,58,60,63,64} specific conditions such as resolved or minor injuries,^46,53,58 and refusals..^46,58 Patient wishes and best interests also play a role. ⁵⁷ Organisational factors include access to GPs or alternative care^46,59 and availability of patient information, with a lack thereof leading to less appropriate care. ⁵⁴ Supportive tools such as online medical control or high-risk cards increased conveyance in high-risk or refusing patients.^49–51

Our findings align with this complex picture. Respondents emphasised the significant responsibility of being the last healthcare professionals to interact with patients left on-scene, echoing the study of Rees et al. ⁶⁵ In some cases, decisions to convey were motivated both by concern for patient welfare and by a desire to safeguard themselves against the potential consequences of adverse outcomes. This defensive practice was intensified where managerial support was perceived as weak, consistent with Knowles et al.'s study. ²⁴ Similarly, the present findings show that lack of support may reinforce risk-averse practices and that managerial attitudes vary between promoting person-centred non-conveyance and preferring a more risk-averse approach.

Our results and theoretical orientation in interpreting the results can shed light on these processes and suggest potential causal connections. We have shown how artefacts, espoused values and basic underlying assumptions might shape how leadership priorities, measurement systems, incident response and shared narratives become embedded as relatively enduring mechanisms. On this basis, these cultural elements function as generative mechanisms (e.g. historical emphasis on conveyance, managerial risk aversion, weak interagency pathways, limited training) that produce and reproduce the observed non-conveyance patterns. ³¹

Balancing autonomy, risk, and organisational pressures in non-conveyance practices

Drawing explicitly on Schein and Schein's organisational culture model ³⁰ and a critical realist stance,^30,31 we have considered how organisational culture, through its mechanisms and underlying assumptions, shapes the balancing of autonomy, risk, and organisational culture in non-conveyance practices. We have shown that organisational culture likely affects clinical practises and thereby non-conveyance decisions. Here, we explicate how those cultural elements may influence the extent to which ambulance clinicians enable patients’ self-determination, potentially constraining autonomy when conveyance is treated as the safer option.

As mentioned above, autonomy in our context refers to a person's ability, right and opportunity to make informed decisions about their care and life, which presupposes decision-making capacity.^66,67 Assessment of a patient's capacity typically accompanies a clinical evaluation. ⁶⁸ In our data, respondents did not refer to the four core abilities of capacity: understand, reason, appreciate relevant information, and communicate a choice.^66,67 Instead, assessments of capacity appeared to rely on whether patients were perceived to have sufficient insight into what was considered to be in their best interests, with references to confusion, reduced awareness, or dementia serving as indicators of incapacity. Furthermore, respondents reported difficulties with making judgments regarding decision-making capacity, consistent with other studies that documented limited tools, templates and training to support these complex assessments.^25,69–72 When clinicians encounter patients in high-risk situations who refuse the help offered by ACs (e.g. self-harm or suicidal behaviour), legal frameworks allow interventions when imminent danger exists, and in Norway, clinicians must act in the patient's best interest when there is imminent risk of harm. ⁷³ Applying Schein's levels (artefacts, espoused values and basic underlying assumptions) and retroduction from our empirical observations, we interpret practices such as persuasion, lies, tricks and coercion to ensure conveyance^7,65 as, at least in part, stemming from interacting cultural and organisational mechanisms. Their experience of leadership priorities, weak managerial support, scarce training and limited referral pathways shape how clinicians interpret risk and what counts as acceptable actions in response. Barghout et al. (2025) ‘Elements of Guidance for Emergency Medical Services Clinicians’ shows that managing patients’ refusal of conveyance involves many practical steps beyond capacity assessment. It involves risk evaluation, persuasive communication, escalation to medical oversight, and meticulous documentation, underscoring that autonomy in the field is negotiated through multiple, context-dependent practises. The medicolegal landscape also matters. The risk of liability is generally low for using reasonable force to convey a patient out of genuine concern, but substantially higher if a patient left on-scene later experiences an adverse outcome. ⁷⁴

Taken together, these findings indicate that organisational culture plays a significant role in shaping clinicians’ everyday practices around refusal and conveyance, with important ethical implications. Without managerial attention to the cultural and structural supports for autonomy, patients’ self-determination may be unduly compromised even when legal criteria for intervention are not met.