A qualitative exploration of restraint decisions made by paramedics and advanced paramedics when managing patients presenting with acute behavioural disturbance (ABD) in the pre-hospital setting.

: (Alternative Format Thesis)

Abstract

Acute behavioural disturbance (ABD), also known as ‘excited delirium’, is a serious emergency. Patients presenting with ABD may present to paramedics and advanced paramedic (APs) and may require restraint. However, little is known about how these clinicians make restraint decisions in practice. This thesis explores how paramedics and APs make such decisions, to identify opportunities to improve clinical practice.

An exploratory, qualitative approach was utilised in this research. Twenty ambulance clinicians from a single ambulance service participated in two sample groups: a key informant group consisting of seven APs and a heterogeneity sample group consisting of 13 paramedics. A total of 17 semi-structured individual interviews and one focus group were undertaken. The resulting data was analysed using reflexive thematic analysis informed by critical realism. This involved several phases of analysis, beginning with familiarisation with the data, followed by coding and then the identification of patterns and development of candidate themes, followed by theme refinement and writing up.

Analysis of the data identified that ABD presentations were associated with complexity and ambiguity. This was linked to a perceived mismatch of clinical and legal education and training, identification of ABD patients and subsequent certainty of treatment planning. Paramedics and APs experience vulnerability concerning decision-making, with ABD presentations perceived to be high-risk in terms of both patient harm and risk of professional detriment. The relationships between professionals at incident scenes and need to characterise cases as medical rather than as law enforcement incidents were also identified as a key influences on decision-making.

The results of this research indicate that paramedics and APs would benefit from education which acknowledges the context of interprofessional relationships, as well as clinical and legal issues related to ABD and the agitated patient. These findings broaden our understanding of paramedic decision-making and highlight the need to shift away from traditional notions of atomised individual-level processes and recognise the relevance of social contexts in decision-making.

Date of Award	10 Dec 2025
Original language	English
Awarding Institution	University of Bath
Supervisor	Leda Blackwood (Supervisor) & Timothy Edwards (Supervisor)