Paramedics practice in an environment of constant change. The combined factors of an expanding scope of practice: increases in technology, advances in treatment and care and an extending evidence base, ensure that the paramedic is always kept busy. It is a requirement of professional registration that the paramedic copes with these changes and their effects on practice and strives to continuously develop their professional knowledge, expertise and competence (Health Professions Council (HPC), 2010).
Society has the right and expectation that the professionals responsible for the immediate care of the acutely sick and injured are competent, knowledgeable and up-to-date. Maintenance of a record of continuous personal development and experience is mandatory for all health care professionals and there is a requirement for all registered paramedics to record these activities in a profile of evidence. Each year, a sample of randomly selected registrants is required to submit a CPD profile to the HPC for audit by CPD assessors (HPC, 2010). The Council provide comprehensive information and advice concerning CPD, available through their website (http://tinyurl. com/69on62m). This includes the five standards for CPD (Table 1) and it is an aspect of the second of these that this article seeks to address.
| Registrants (health professionals registered with the HPC) must: | |
| 1 | Maintain a continuous, up-to-date and accurate record of their continuous professional development (CPD) activities |
| 2 | Demonstrate that their CPD activities are a mixture of learning activities relevant to current or future practice |
| 3 | Seek to ensure that their CPD has contributed to the quality of their practice and service delivery |
| 4 | Seek to ensure that their CPD has contributed to the quality of their practice and service delivery |
| 5 | Present a written profile containing evidence of their CPD upon request. |
The process of reflecting
Learning can be said to result from exposure to an experience. However, it is not the exposure alone which results in learning. It is in the process of reflecting on that experience and responding to it that the real learning really takes place. Indeed, without reflection on an experience, a practitioner may be in danger of continuing to make the same errors (Schön, 1983). This is the difference between the paramedic with 20 year’s experience and the paramedic with one year’s experience, repeated 20 times.
For example, a student paramedic attending an emergency call to an elderly male who has fallen in the street; the placement-educator points out the shortening and rotation in the leg that indicates a classic presentation of a fractured neck-of-femur. The student will internalize this experience and bring this knowledge forward to the next occasion they see ‘shortening and rotation’ of a leg. Learning has taken place through ‘pattern recognition’.
How much richer though, is the learning that then takes place from the student reflecting upon that experience; considering what they currently know, opening their minds to gaps in their knowledge and then reacting to this by seeking further information; finding out that not all neck-of-femur fractures present with shortening and rotation; that they vary in the way they present; the many implications for the sufferer and the short and long–term complications they might face.
Reflection is about using questions to retell a story. It is about answering these questions critically and, in doing so, improving one’s own clinical practice.
‘By three methods we may learn wisdom: first, by reflection, which is the noblest; second by imitation, which is the easiest; and third by experience, which is the bitterest’ (Confucius)
Boud et al (1985: 7) note, like Confucius, that experience alone is not sufficient for learning and pose the following questions: What is it that turns an experience into learning? What is it that specifically enables learners to gain the maximum benefit from the situations they find themselves in? How can they apply this experience in new contexts? They suggest that structured reflection is the key to learning from experience.
Reflection in emergency care
Emergency care is characterized by its diverse and unpredictable range of illness and injury and one of the attractions of the paramedic role is the limitless human and scientific knowledge that underpins practice. This ability to reflect upon clinical experiences opens the mind of the paramedic to a vast field of evidence based practice and medical knowledge. Emergency care is characterised by its diverse and unpredictable range of illness and injury and one of the attractions of the role is the limitless human and scientific knowledge that underpins practice.
There are many models for reflection, varying from the straightforward, through the puzzling and on to the very complex. Some have universal application and others are more focused on a profession/role. For an individual approaching formal reflection for the first time, the array of, sometimes conflicting, models can be quite bewildering.
The I.F.E.A.R model
Using a pragmatic approach, the best way to choose a model is to find one that you are comfortable applying and confident that it will help you to translate your clinical experiences into knowledge and learning:
‘It is not enough just to do, and neither is it enough just to think. Nor is it enough simply to do and think. Learning from experience must involve linking the doing and the thinking.’ (Gibbs, 1988:9)
A model which uses this approach has been developed for use by student paramedic scientists. The I.F.E.A.R model (Figure 1) is an adaptation of Gibbs’ (1988) well–known experiential learning cycle which itself was adapted from work by Kolb:
‘Learning is the process whereby knowledge is created through the transformation of experience’ (Kolb, 1984:38)
The expressive phrase, ‘through the transformation of experience’, clarifies that merely being exposed to an event does not guarantee learning. The I.F.E.A.R. model encourages the practitioner to consider five stages. At each of these stages they will ask themselves some questions (Table 2).
| Incident: | |
| 1. | Describe the incident; the emergency call |
| 2. | Describe your part in it |
| 3. | You might want to focus on a description of an experience that |
| seems significant in some way | |
| Feelings: | |
| 4. | What were your feelings during the incident/call? |
| 5. | What were your feelings immediately afterwards? |
| 6. | What made you feel this way? |
| 7. | How do you now feel about this experience? |
| Evaluation: | |
| 8. | What went well? |
| 9. | What didn’t go so well? |
| 10. | What were the consequences of your actions on the patient and others? |
| 11. | Did the patient have any unmet needs (PUNs)? |
| 12. | To what extent did you act for the best and in tune with your values |
| (ethics)? | |
| 13. | Does this situation connect with any other similar experiences? |
| Analysis: | |
| 14. | What did you earn from the incident or event? |
| 15. | What could you have done better? |
| 16. | Can you identify any practitioner (paramedic) educational needs (PENs)? |
| 17. | Was there anything you did not know? |
| Reaction: | |
| 18. | How will you meet the PENs? |
| 19. | Do you need to chat to a colleague or mentor? |
| 20. | Do you need to research something in books/journals? |
| 21. | Do you need to ask questions? |
| 22. | Do you need to read an article/book? |
| 23. | Do you need to attend a seminar/session/course? |
| 24. | How might you respond more effectively given this situation again? |
| Response: | |
| 25. | What did you find out in response to your reaction (educational needs? |
| 26. | Describe your new learning |
| 27. | What can you take forward and apply if faced with the same or |
| similar incidents? | |
Stage one: describing the incident
The first stage is describing the incident: the emergency call. This should outline why you were called, how the patient presented and details of your actions. This should not be overly descriptive but merely a summary of the clinical details.
Stage two: feelings
The second stage is feelings. Describe how you felt during the incident, how you felt immediately afterwards and how you feel now (upon reflection).
Stage three: evaluation of care
The third stage is the evaluation of care. Ask, did the patient have any unmet needs? Were they cared for and managed in a way that you would be happy to be treated?
Stage four: analysis
The fourth stage is analysing your clinical knowledge, non-clinical knowledge, skill, or attitude. Did you feel you had a full understanding of the condition you were managing? What were the gaps in your knowledge or skill base? It is here that the patient’s unmet needs (PUNs), identified in the evaluation, will direct the paramedic’s educational needs (PENs). Eve (2003), a GP first described ‘PUNs and DENs’ (where the ‘D’ stands for Doctor)) and identified this as a means for enabling GP reflection. It readily adapts for paramedic use.
Stage five: reaction and response
The fifth stage is your reaction and response to both the PUN and the PEN? Reaction is where you plan how you will address the missing clinical knowledge, non-clinical knowledge, skill, or attitude. Ask yourself ‘what do I need to do to make things better for the next time?’ It could be as simple as speaking to a work colleague or another healthcare professional or that you need to research the information required from books or professional journals. If the educational need is substantial, you might need to attend a seminar or short course.
Finally, you can write about the things you have found out in response to your identified educational needs. It is here that you describe what you have learned and show how this new knowledge will transform your future practice. This stage completes the cycle and you will be ready to practically apply this new knowledge, gained from reflecting on experience, at future emergency calls and incidents.
Conclusion
In practice, we have found that both experienced practitioners and student paramedics have been able to use these steps to shape their writing. For those new to writing reflective case studies, the questions help to provide the muse for overcoming the ‘blank-sheet-of-paper’ inertia that can accompany portfolio building.