Identifying approaches to practice education for paramedics continues to be an ongoing challenge. Appropriate tools for clinical educators/mentors and students alike should arguably reflect what paramedics actually do. The framework discussed within this comment article is grounded in previous research undertaken at the University of Oxford, Department of Education (Freeman-May, 2012).
About the research
The research employed in-depth interviews following recalled incidents to generate data from which deductions were made about the underlying capabilities and guiding principles of the work of experienced paramedics. Interviews were supplemented by a questionnaire and data were analysed using a range of theoretical lenses, such as practice theory. The findings from this work suggested that responding to a call can be described as following a sequential series of key activities that, in practice, merge into each other, often in an iterative way: information-gathering, managing situations and people, and treating patients. Such a description leads to an identification of expertise used in the early stages of responding to a call; for example, reducing and managing ambiguity through the use of situated knowledge to generate tentative hypotheses about the nature of the call and developing initial plans for action (Greeno, 1998). Such hypotheses are left open and modifiable in the light of new information actively sought by the expert practitioner and are guided by capabilities such as communication, planning and organising, problem-solving and decision-making, and learning from experience. Additionally, expert paramedic practice is characterised by high levels of resilience, flexibility and the patience to leave plans incomplete for further development in the heat of practice. The findings therefore characterise the expertise underpinning the work of experienced paramedics in a way that transcends attempts to describe paramedic practice through lists of skills, knowledge or competencies. In so doing, the work contributes to the evidence base about the knowledge and skill used by paramedics in practice, and how and where this is developed. It also provides a framework for learning and assessment which resonates with what paramedics do when responding to emergency calls.
A framework for learning and assessment in paramedic practice
The data from the study suggested that responding to an emergency call can be characterised by three central activities:
These activities appear to be underpinned by five key areas of capability that require high levels of knowledge, skill, personal qualities and understanding (Stephenson, 1998: 1–13; Eraut and Hirsh, 2007: 6):
The detailed findings from the research are outside of the scope of this comment article. However, a snapshot summary of the activity, ‘managing situations and people’ can be seen in the following section.
Management of situations and people
Decision-making for paramedics often occurs in a working environment that is ill-structured, complex and chaotic (e.g. Hamm, 1988). Paramedics need to be able to exert agency and work relationally with others—such as fellow professionals and carers or relatives of patients—at the boundaries of their practice (Daniels et al, 2007: 522; Edwards, 2010: 61–77). Often they need to take charge and organise situations while taking on board the views of others in a multi-agency context (Burn and Edwards, 2007: 397). When working with less experienced staff, they need to provide guidance. When working alone, they may need to improvise and, critically, know when to call for assistance. The requirement to manage situations and people emerged as an important area in the participant accounts. The following elements appeared to form part of this overall activity:
Situation management
This stage was pervasive in the accounts provided by participants. This included organising and taking charge of sometimes quite complex and chaotic situations, managing others, asking for assistance and dealing with conflicting agendas (e.g. of police, other health professionals and bystanders) while exerting relational agency (Edwards, 2005: 168–169). Such work at the boundaries of practice can be uncomfortable where individual passions are high (Kerosuo, 2003: 169–187; Nardi, 2005: 37–51; Edwards, 2010: 41–45).
Paramedics often need to ‘see the situation in alternative ways’ (Dreyfus and Dreyfus, 2005: 789), recognising their responsibility and ‘relational agency’ capacity as part of a multi-agency team (Edwards, 2005: 172). Typically, the paramedics interviewed described the need to take charge/organise situations. In this context, the problem space requires effective ‘multi-agency practice’ with the players involved working ‘across traditional service and team boundaries’ (Daniels et al, 2007: 522). In addition, the players need to demonstrate capacity to interpret the needs of the ‘object of activity’ (i.e. the patient) in their action (Daniels et al, 2007: 522). Additionally, participants in the study described having to manage situations despite conflicting agendas (e.g. of other professionals). Indeed, working effectively in a multi-agency context requires the paramedic to take on board the ‘perspectives of others’ if the object of the problem space (i.e. the patient) is to receive the best care (Burn and Edwards, 2007: 397). Indeed, managing complex situations requires the paramedic to exert, as noted earlier, what Edwards describes as ‘relational agency’ (Edwards, 2010: 61–62). Further, in what is often an ill-defined context where professional passion and values are at the fore (see Nardi, 2005: 37), the expert paramedic needs to adopt an outward facing resourceful stance seeking to respond to and decode the situational problem they face (Edwards, 2005: 50).
Working in a team and working alone
The need to work as part of a team in seeking to make sense of the problem space was very evident in the accounts offered by participants. The paramedics described having to work with other ambulance staff as well as multi-agency working with other professionals as part of a wider team (Boreham, 2002). Often the complexity of incidents described resonates with notions of ‘interacting activity systems’ (Engeström, 2001: 136); for example, when working with multiple patients (i.e. child and parents). Indeed, the ‘transformative potential’ of the problem spaces encountered by paramedics when responding to emergency calls often results in the need for ‘reorganised’ activity (Gutiérrez et al, 1999: 287). Such activity may have progressed from the use of mediating tools to reorganising the problem space and improvising the technique used (Gutiérrez et al, 1999: 287) while waiting for back-up to arrive. The action resonates with Schatzki (1996: 99) as an example of transfigured domain specific integrative practice and, through the apparent confidence and innovative approach, is knowledge that Eraut and Hirsh (2007: 7) describe as ‘additional capability.
Conclusion
This commentary suggests a potential framework for contemporary paramedic student learning and assessment in practice. The evidence from previous work identified here seeks to follow an approach that focuses upon holistic paramedic capability that can be supported by identified competencies to underpin activity. Such an approach may provide a pragmatic solution to learning and assessment for paramedic practice educators and students.