Clinical decision making has been studied in medicine over the last few decades (Norman, 2005). Jensen et al (2009) noted that very little evaluation has been conducted in the paramedic population. This article highlights the need for the study of clinical decision making which forms a vital part of the paramedic's practice.
According to Parsons and O'Brien (2011), clinical decision making can be considered as a process of applying knowledge and skills to a clinical situation. The dichotomy between the clinical and non-clinical environment creates challenges. In the non-clinical environment, this process is a vital part of paramedical life that often takes place in settings which are unpredictable (Shaban, 2005). Lord (2003) suggested that clinical environments, e.g. emergency departments, increase the likelihood that clinicians will have access to expert opinion, medical records and advanced diagnostic tests. The assessment and management of patients in the non-clinical setting, however, is usually characterised by independent and time critical factors and where access to similar support systems and medical technology is potentially unavailable (Lord, 2003). In this situation, the role of a paramedic is a complex one, as they have to gather, assess, evaluate and synthesise information that relates to a patient's presentation before deciding on appropriate treatment (Saunders, 2005; Caroline, 2008). Throughout this decision-making process, paramedics must continuously evaluate and decide on the extent to which they are making the correct decisions about a particular patient.
Parsons and O'Brien (2011) proposed that paramedics adopt a two stage process to clinical decision making. The first stage refers to concept formation whereby relevant data regarding a patient's presentation is collated and forms the basis of the paramedic's initial assessment. During the second stage, the data is synthesised and evaluated to formulate a working diagnosis. This process is dependent on the ability of paramedics to have an understanding of a range of the signs and symptoms of conditions and has been found to be significantly influenced by prior knowledge and clinical experience (Wyatt, 2003). Challenges arise when paramedics respond to mental health emergencies because of the potential ambiguous nature of how the patient may present, insufficient background information and inadequate support (Shaban, 2005; Roberts, 2009; Townsend and Luck, 2009). Yellowlees (1998, cited in Parsons and O'Brien, 2011) stated that unlike clinical based settings, the emphasis is often on clarifying what the patient's major concerns are before attending to any physical needs. In crisis situations, this is not always possible or appropriate, as the goal is often focused on identifying and responding to immediate risk issues that may exist. When paramedics provide non-clinical mental health care, a number of areas must be explored. These key areas surround the medical, psychiatric, environmental and legal aspects of a patient's presentation. To achieve this, paramedics perform a number of specific assessments, including a primary survey of the patient's basic physiological status, a brief mental health assessment and risk assessment (Saunders, 2005).
Wyatt (2003) purported that for novice paramedics, clinical decision-making judgements were heavily influenced by organisational protocols and guidelines. Wyatt (2003) found that as paramedics became more experienced, they were found to rely much less on established protocols and guidelines and developed an increasing degree of autonomy and confidence when managing clinical presentations. These findings suggested that over time, prior clinical experience has the potential to significantly improve the ability of paramedics to engage in skilled and independent clinical decision making.
Reflective practice
According to Sibson (2009), the theory and practice of reflective practice is increasing amongst paramedics, with a greater awareness of the benefits of reflection to everyday practice.
Reflection involves learning from experience (Ghaye and Lillyman, 2010). Fade (2003: 4) states that ‘reflection involves describing, analysing and evaluating our thoughts, assumptions, beliefs, theory base and actions.’ It is common practice to only think of reflection as looking back on an event or scenario; however, it can be broken down into three components (Fade, 2003):
Very simply, a reflection is an image of something. Mirrors of course provide reflections; therefore, placing a literal mirror to an event can facilitate exploration of a view or perspective that would otherwise be missed. Reflective practice has been defined by Spalding (2004: 50) as a ‘process of examining and exploring issues in an attempt to improve and shape activities.’ In the context of the reflective practitioner, reflection may assist in an increased awareness of the necessity to question the validity of actions within practice. Quite simply, reflection is about learning and developing from experience, resulting in a changed perspective. Through reflection, the paramedic can obtain the greatest benefits from his or her actions and continue along the path of professional development; for example, examination of how communication with a patient could have been improved to help his/her understanding of treatment. It also focuses on a positive incident that resulted in a good outcome. Reflective practice therefore is of relevance to paramedics who have an extremely challenging and demanding role to play in patient care. Sibson (2009: 121) adds: ‘Care is delivered in an environment without walls, no two cases being the same, each day presenting with different challenges. This is the front line of care delivery and too little attention has been paid previously to the potential learning opportunities that stem from this environment.’
Although there are a number of reflective models, Sibson (2009) points out that they contain similar characteristics, namely description, evaluation, analysis and critique. Some models are simpler than others and as a health care practitioner, it is important to be familiar with a range and to use the ones that you feel best suit your needs in terms of reflective practice. For the novice practitioner, the Gibbs (1988) reflective cycle is frequently recommended. This is largely due to its relatively simple structure and flow of tasks and is therefore easy to apply and use as a framework for a piece of reflective work within a group (Sibson, 2009).
A case study is always a helpful tool in facilitating clinical decision making and reflective skills. The following example case study concerns an elderly man who has fallen:
Stage 1
What anticipatory (prospective) reflections might you come up with based on the 999 call?
Stage 2
On arrival
What additional information do you require?
Stage 3
Additional information
Our findings are as follows:
What additional information do you now need to inform your actions?
Stage 4
On observation
Is there anything else you need to know?
Stage 5
How will you proceed from here?
Conclusions
Clinical decision making and reflection are essential skills for any health care professional to possess in that they underpin and enhance practice by providing a robust framework for structuring one's thinking and subsequent actions.