In the prehospital environment, paramedics are required to make daily clinical decisions, often rapidly, to ensure the provision of appropriate treatment and care. Decisions made by paramedics have a major impact on the lives, clinical outcomes, safety, health and wellbeing of their patients. This renders clinical decision-making capabilities an integral part of paramedic practice.
Paramedics must recognise that decision making is not the same as problem solving; however, the two are interchangeable in that one complements the other. Decision making is defined by Dowie (1993) as the assessment of the alternative and argues that such decisions are based on assessments of the future, with ethical and legal considerations. Problem solving on the other hand is a systematic process that focuses on analysing a difficult process, after which a decision will be reached (Cork, 2012).
The subject of how paramedics make decisions is being covered more frequently in the literature; however, it is still largely unexplored when compared with other health professions. Decision making in a clinical context has however been heavily studied by many authors over the last 50 years, and each seems to offer different terminology to describe the same concept. What was described as clinical reasoning by Carnevelli et al (1984) was described as clinical decision making by Field (1987) and clinical judgment by Thompson and Dowding (2009).
With the introduction of the Newly Qualified Paramedic Framework, it has never been more pertinent to examine the decision-making process encountered by paramedics. All newly qualified paramedics (NQPs) are now expected to undertake 24 months of consolidation and produce a portfolio which ‘will evidence autonomous decision-making based on sound clinical judgment’ (NHS Employers, 2017), suggesting that the NQP framework itself indirectly supports Benner's (1984) theory of intuitive decision making.
Theories and models
Decision making is a complex process (Standing, 2010) and decisions made by paramedics are based on a variety of information sources such as experience, knowledge, experience of others, research and other available evidence (Thompson and Dowding, 2009). There are many theories and models which underpin how clinicians go through a decision-making process based on the information that is available to them. The problem as described by Jensen et al (2009) is that paramedics are often making decisions with very limited information such as from partial or incomplete patient history, and limited support or resources.
There are three theories based around decision making with each decision falling into either ‘normative’, ‘descriptive’ or ‘prescriptive’; although Nixon (2013) claims that distinction of the theories in practice is unclear.
Normative theories
Normative theories are standards of evaluation and where there appears to be no obvious conclusion (Baron, 2012), decisions are thereby drawn from philosophical and mathematical argument (Baron, 2004).
Descriptive theories
Descriptive theory tries to explain how and why people make decisions (Baron, 2012) based on real life, and what people actually do or have done when making decisions (Nixon, 2013).
Prescriptive theories
Prescriptive decision making is the theoretical aspect of normative and the observational aspect of descriptive (Nixon, 2013). Larrick (2004) describes prescriptive judgmental theories as being an imperative tool for redesign or improvement.
Frameworks
There are two key opposing intangible frameworks, into which all models of judgement fit. Intuitive and analytical frameworks each underpin the clinical decision-making process.
Intuitive
Intuition as a decisive model is described by Benner and Tanner (1987) as how decisions are reached without a need to understand rationale, suggesting that experts in practice can use hunches to formulate decisions. Benner (1984) documented five stages to skill acquisition and on the basis of this, the intuitive decisions reached by experts were substantially different to those reached by novices.
An example put into context by Nixon (2013) describes an incident of a pale and clammy patient suffering severe and sudden onset back pain. Using Benner's (1984) framework, an expert paramedic would use intuition and immediately form a judgement of aortic dissection. A competent or novice paramedic on the other hand would seek to analyse evidence/clinical observations and observe the patient before reaching a clinical decision.
Benner's (1984) belief is that intuition is an essential part of clinical decision making and is linked clearly to expertise. Banning (2008) however argues that intuition is based on guess work and personal opinion—thus taking the normative approach towards the intuitive framework.
In connection with the intuitive approach, pattern recognition is regularly used to describe the decision-making process (Benner et al, 1996). The practitioner uses previously attained knowledge, experience and terminology to recognise a pattern of events in order to form a judgement (Buckingham and Adams, 2000).
This is most commonly evidenced with the current 999 emergency ambulance triage system and is arguably the most frequently used decision-making tool used by paramedics. An example of this is the term ‘thunderclap headache’, which immediately suggests cerebral haemorrhage (National Institute for Health and Care Excellence (NICE), 2015). As this term and condition are commonly associated together, the NHS (2018) advises that an emergency ambulance will be dispatched.
Gigerenzer and Todd (1999) documented that by using the intuitive or pattern recognition tool to make decisions, clinicians are at risk of forming a bias and allure to the possibility that poor decisions are created within the intuitive process.
Analytical
Cohen et al (1972) created the Garbage Can model, which indicates that decisions are made and used and then reused again. This is a model created for organisational decisions rather than those made at individual level. The analytical frameworks are based on rationalistic perspective and assume that the person making the decision has a logical, cognitive thought process and is able to study and analyse an actual decision-making framework at the time it is required (Daft, 2009). Beach and Connolly (2005) recognise that this is not always achievable and identify limitations of rationality when there is limited available information.
Most clinical situations encountered in prehospital practice will require a combination of analytical and intuitive frameworks to form clinical decisions (Nixon, 2013). However, Cork (2012) recognises that when attending to complex incidents, paramedics will need to take a broader approach to clinical justification and a combination of frameworks will not be appropriate. Nixon (2013) also highlights that when dealing with emergencies, paramedics cannot often afford the time to study and follow analytical models, and therefore indicates the intuitive process is most commonly best practice.
Professional issues
Barriers are important to acknowledge when analysing decision making as the effects of the decision can be significant. One of the main barriers at an operational level explained by Sullivan and Decker (2005) is in the shortcuts professionals are willing to take. By taking shortcuts, the amount of attainable information is limited, which also limits the quality and alternatives which are generated and considered.
While the paramedic profession along with all other healthcare providers are governed by clinical guidelines, the autonomy that paramedics are given leaves them more susceptible to litigation, complaints and unnecessary conveyance to hospital. Complaints against health professionals are rising with paramedics forming the second most common profession to enter fitness-to-practise cases by the Health and Care Professions Council (HCPC) (Gallagher, 2018). Romano (2018) agrees that it is therefore understandable why paramedics fear discharging patients and making decisions like this on scene despite not having a clinical need to convey to hospital.
Rarely are decisions analysed in any depth when a positive outcome has been achieved; the analysis therefore only forms part of the reflection process following poor decision making or poor judgments. By engaging in this way of practice, Cork (2012) argues that practitioners are denying themselves the opportunity to enhance learning based on positive decisions. This implies therefore that a greater focus be placed on the recognition of good decisions, on a platform deemed suitable by the clinician.
Decision making and education
According to Bloom's (1956) Taxonomy, diagnosis is an analytical skill which requires significant critical thinking to employ correctly. Cognitive functions involved in decision making are shown in Bloom's (1956) theoretical model. Using Bloom's Taxonomy, to make a competent clinical decision a clinician must be able to:
Traditionally, most paramedics in England are educated to Diploma level (HCPC, 2018) and work as autonomous practitioners who are accountable for their own decisions and actions (HCPC, 2008). Cockram and Hicks (2012) document that critical thinking is usually not required or assessed at diploma level, and question how paramedics and nurses can graduate without a level of thinking that requires knowledge and comprehension to critically analyse and evaluate decisions—comments which are supported by Bloom's (1956) theoretical model. However, with the paramedic profession moving towards a degree-based qualification, it is argued within the literature that students should be taught decision-making models and how to think critically to form a competent clinical decision (Cockram and Hicks, 2012).
A dangerous imbalance can develop between confidence and competence without objective decision making. Despite the suggestion that the intuitive framework is best suited to the paramedic profession and considering the criticism this process receives, it is reasonable to highlight that more work needs to be done to ensure paramedics have a framework that is fit for practice and will not easily allow for such heavy criticism. Arguably, such a framework could prove an essential tool to support how an NQP will evidence autonomous decision making.