Ambulance clinicians’ experiences of enforcing coercion: Insights from open-ended responses through the lens of social identity theory

Ambulance clinicians may have to apply coercion while delivering healthcare. However, coercion is a source of stress for all involved. Challenges include unclear legislation, lack of training, equipment, support, not least ethical dilemmas. This paper explores factors influencing ambulance clinicians’ experiences of exercising coercion. An anonymous online survey was conducted between Oct 2021 and Nov 2022. During a six months period, 488 ambulance clinicians reported using coercion, and 431 answered a free-text response question about their experience. Using Graneheim & Lundman's analysis of qualitative content, 376 answers were analyzed. Three overarching themes were identified. First, ambulance clinicians reflected on what constitutes healthcare and how they perceive their professional role, including the idea that coercion can, in some cases, be a legitimate form of healthcare; at the same time, clinicians expressed concern about patients’ experiences, and described feelings of powerlessness. Second, participants highlighted encounters and situations that they found especially distressing, often due to ethical ambiguity. Third, the experience of exercising coercion was shaped by various contextual and structural conditions concerning equipment, legislation, insufficient training and expertise, as well as the complex impact of police involvement during critical incidents and lack of support. Social identity theory was used to understand how the described challenges influenced the use of coercion and shaped ambulance clinicians’ professional identity at the individual, service, and societal levels. This identity was challenged across all levels. Clinicians often found themselves in situations where they felt morally conflicted, underprepared, and isolated from the wider healthcare system. These findings underline the need for integrated strategies that address coercion through a multi-level lens. Clinical implications include the implementation of structured ethical reflection, improved training, adequate equipment, and clear, context-specific guidelines. Such efforts can strengthen ethical competence, reduce moral distress, and align prehospital practice with broader health-led efforts to minimize coercion.