Expertise among health professionals is a widely researched area of study. One particularly important reason for this emphasis is that a common occupational characteristic of fully recognized professions is continuing development of domain specific knowledge from within the professions. The importance of this point is emphasized by Goodwin (1994), who describes expert level knowledge as a crucial element for distinguishing one profession from another.
Efforts to identify the general nature of expertise have been extensive (Polanyi, 1966; Larkin et al, 1980; Dreyfus and Dreyfus, 1986; Perkins and Salomon, 1989; Schmidt et al. 1990; Bereiter and Scardamalia, 1993; Ericsson and Charness, 1994; Guthrie, 1995; Tiberius et al. 1998; Guest et al. 2001). However, much of this literature suggests that expertise is in fact very domain-specific and this has led to considerable research into expertise within specific disciplines.
To date, for paramedics, this research focuses on the performance of discrete medical procedures. However, the nature of paramedic practice is not limited to a series of discrete procedures. While it is certainly true that paramedics frequently perform risky emergency medical procedures, what sets paramedics apart from other healthcare providers is the setting in which they practice. Paramedics must ‘fit’ medical procedures into their work context and consequently, paramedics practice a unique type of care where medical procedures are intertwined with the social context of the prehospital environment.
This care is provided outside of any formal institution, which means in plain language that paramedics practice ‘in the street’ and perform in ‘a context rife with chaotic, dangerous, and often uncontrollable elements with which hospital-based practitioners need not contend’ (Nelson, 1997). Given the challenges inherent in this practice context, one particularly important aspect of paramedic work is the ability to manage an emergency scene, and so it is not surprising that competence in this area has become a highly prized ability within the occupation. This is reflected in Metz's observation that for paramedics, ‘the measure of a man or woman doing paramedic work is always decided at the scene’ (1981: 93).
An electronic review of the following EMS–related databases revealed only one study dealing with scene management (Campeau, 2009): Academic Emergency Medicine, New England Journal of Medicine, Journal of the American Medical Association, Canadian Journal of Emergency Medicine, Emergency Medical Journal; and none focusing on expert level performance in this area of practice.
The absence of published studies on this topic means that knowledge of how patient care can be operationalized at a high performance level at the scene (in contrast to other areas of paramedic practice) has not yet been informed by research. This qualitative study from Ontario, Canada is intended to help fill this knowledge gap by generating a theory-of-practice at the substantive level (Merton, 1996) of what comprises expert paramedic scene-management. Such an inquiry can provide important insights into the real determinants of field performance.
Methodology
In order to understand what expert paramedics do at emergency scenes from the paramedics’ point of view, this inquiry focused on the level of the individual practitioner (micro). The socio-psychological perspective offered by symbolic interactionism (SI) was selected as appropriate for this situation, consistent with Charon's (2007) view that SI is known for the strengths of its micro level studies of individuals. SI's basic assumptions are that behaviour is based on the meanings that we create when we interpret our symbolic (including language) interactions with others (Blumer, 1969).
In order to maintain consistency between theory and method (Guba and Lincoln, 1994), a grounded theory methodology (GTM) was used. Crooks (2001) characterizes GTM as a qualitative research method based on the SI perspective, because grounded theory relies on the same basic assumptions as SI.
Glaser and Strauss (1967) originally generated GTM as a general methodology for developing theory. Starting with data such as this is commonly compiled through interviews, researchers systematically use constant comparison between data and emerging concepts as a means of identifying progressively more abstract descriptions of the phenomena being studied. Eventually a theory that explains all of the data is conceptualized. The constant comparison feature is so important to GTM that it is ‘often referred to as the constant comparative method’ (Strauss and Corbin, 1994: 273).
When considering the application of SI in health care settings, Crooks observes that SI is an excellent choice for exploratory research and ‘ideal for health related investigations when salient variables in the health-illness situation have yet to be identified’ (2001: 12). More specifically, in discussing which theoretical perspective is most appropriate for investigating expertise in nursing, Bonner (2003) recommends SI and GTM as appropriate and preferable. Bonner and Walker's research into the expertise of nephrology nurses provides a particularly relevant example of the successful use of SI ‘to uncover the acquisition and the essence of expertise’ (2004: 211) as this area of nursing practice had, similar to expert paramedic scene-management, not been previously explored.
Study design
The study needed to involve paramedics from a variety of backgrounds and ranges of competency. To focus on these requirements, a variety of criteria for determining the eligibility of participants were used. First, all of the paramedics held current legislated paramedic qualifications (Ambulance Act, 2000). Second, paramedics were selected from rural, sub-urban, and urban areas. Finally, three categories of paramedic competence were created:
This type of situation is a relatively common dilemma faced by medical researchers and it is certainly true that many different approaches have been used to define experts (Ericsson, 2006). This is particularly relevant for a relatively young field such as paramedicine where the nature of expertise is just beginning to be explored. In an insightful examination of the problem of defining expertise, Hoffman (1996) acknowledges the use of imperfect research definitions but also maintains that this has not prevented the discovery of important knowledge. Consequently, and consistent with other medical research into the nature of expertise, an operational proxy (Norman et al, 2006) for expertise was used with the following rationale.
Rationale
In the study's location (Ontario, Canada), selected hospitals are staffed by emergency physicians and programme directors who oversee, for quality assurance purposes (e.g. evaluating compliance with and deviations from standards of practice), the performance of paramedics. Some of these paramedics are selected by base hospitals to also work as instructors on a part-time basis, delivering continuing and upgrading medical education programs to other paramedics.
Instructor preparation involves attending regular ‘train-the-trainer’ sessions convened by base hospitals and meeting physician standards for assuring that instructors are highly competent in the course(s) content. As a result of this training, feedback from students regarding the instructors, informal day-to-day interaction, and knowledge about instructor compliance and deviations from patient care standards (when they are working as paramedics), base hospitals have knowledge about the overall competencies of these instructors as practicing paramedics. Drawing on this knowledge, base hospitals identified those instructors who they considered expert paramedics and since there was no direct measure of overall expertise or specifically scene-management expertise available, these instructors were selected as experts.
On a voluntary basis, a total of 24 paramedics participated in private, semi-structured interviews lasting from one to three hours in duration. Seven novice, nine experienced, and eight expert level paramedics were interviewed during three rounds of interviews.
Participants were asked open-ended questions about situations that they believed comprised emergencies. They were asked about how they made decisions and managed these scenes, including how they interacted with other people and dealt with physical circumstances.
Audiotapes were used to record the interviews and the tapes were transcribed to facilitate thematic analysis. The study was approved by a university ethics review board and data were collected with written consent.
Limitations
Perspective on the use of a proxy may be informed by considering that difficulties in defining expertise for research purposes can be significant (Mieg, 2006) and due to operational situations, most studies into medical reasoning use loose definitions of expertise (Norman et al, 2006). Also, voluntary participation in research brings with it the potential for bias.
Conclusion
This report has explained the methodology and rationale for researching the nature of an important, yet to-date unexplored area of paramedic practice: expertise in managing emergency scenes. A subsequent article will describe the study's findings and the paramedic kairotope theory of expert paramedic scene-management in detail. Consideration should be given to using similar methodologies for researching other aspects of the social context of paramedic practice.