A Significant Transformation of the Paramedic Profession in Our Time
Introduction
Over the last 25 years, the need for a robust, highly skilled, and autonomous emergency workforce - capable of dealing with the increasingly complex health and social needs of modern society - has seen the paramedic profession undergo a significant transformation. Influenced heavily by the findings of the Bradley report and the McClelland review, the implementation of a more formal educational training route has placed increased emphasis on underpinning clinical reasoning and patient assessment skills with evidence-based practice, whilst using Continuous Professional Development as a way of encouraging practitioners to take control of their personal and professional accountability.
One vital learning tool adopted from the wider industry and used to good effect is that of reflective practice. Broadly understood to refer to the process of looking at a significant positive or negative event with a critical eye, using recognized reflective models such as Gibbs’ Reflective Cycle, the reflective practice involves identifying and analyzing personal ideologies, experiences and knowledge, challenging and evaluating them against evidential research, and adopting and actioning any identified changes in order to improve individual practice and attitudes. Not only does the process offer an opportunity to improve self-awareness and foster a more proactive approach to providing good quality healthcare, but it enables the practitioner to identify potentially dangerous practices or lapses in knowledge which may ultimately compromise patient safety.
Indeed, the benefits of good reflective practice on individual and team development are clearly recognized by the Health Care and Professions Council who not only stipulates the need for registrants to ‘be able to reflect on and review practices’, but has joined with other healthcare regulators to actively promote its use.
However, reflection is a process which requires engagement and understanding, relying on the reflector having a genuine interest in wanting to learn from their actions and possessing the skills to implement their findings appropriately. Evidence suggests that whilst reflection skills can be developed, a number of influencing factors such as education, mentoring, and context, can lead to confusion and misunderstanding about what the overall aim is, which may ultimately inhibit true reflection. Furthermore, Kirk and Howlett suggest that, when used as an assessment tool, students may omit or censor their true feelings or findings for fear of failing, a practice that clinicians may continue to adopt even after qualification. It is therefore essential that an open, non-judgmental culture is fostered, where individuals are supported both through the process and in implementing any changes they have identified.
Using the 5-step adapted Gibbs cycle to reflect on the frustrating and conflicting experiences encountered during an unsuccessful out-of-hospital cardiac arrest within my last clinical practice placement, this essay aims to explore and evaluate what, if any, factors or influences may have impacted my expectations, approaches, and performance at the scene, and how by critically and honestly analyzing my understanding and beliefs and acknowledging my strengths and weaknesses, I can identify what learning opportunities and strategies may exist to shape my professional identity.
All names and locations used within this assignment have been omitted in line with the confidentiality requirements of the College of Human Health and Science.
Description of Events
As part of the 2nd crew attending to the scene of a cardiac arrest of undisclosed nature, we were confronted by a crew of two paramedics administering Cardiopulmonary Resuscitation (CPR) whilst also frantically trying to gain both IV access and to stabilize the airway of a young man later suspected of overdosing on a multi-drug combination. After introductions and a brief handover from one of the paramedics, I took over chest compressions, whilst my PPEd and technician crew mate tried to establish from the other crew what, if any, advanced life-support (ALS) procedures had been undertaken. Noting the absence of IV access, the urgency of the situation, and the need for intervention, they inserted 2 Intraosseous (IO) devices and administered ALS drugs within a few minutes of our arrival, preferring to leave the iGel in situ rather than attempt intubation.
Over the next 10 minutes, both crews became increasingly divergent and less communicative in their approaches with each other, and I was pulled between conflicting requests without clear guidance or direction. Becoming aware that no one was noting drug and shock administration and times, and attempting to provide organization, I began asking the clinicians for an update on their actions so far, recording their responses on a piece of card and asking them to verbalize when any additional actions of note were taken. When intubation was once again unsuccessful, the paramedics became more task-orientated, and effective communication began to diminish. Attempts at scribing became unsustainable at this stage due to the increased workload in light of their new, ad-hoc approaches.
Waiting for an appropriate juncture, I looked to the team for direction about the main priorities, but the lack of eye contact and general demeanor of the individuals suggested I should keep my questioning of them to a minimum. Despite informing them of my preparedness to assist with slightly more challenging techniques albeit with a little additional guidance, the group dynamic led me to focus on straight-forward tasks, suctioning our patient’s airway when required, and cleaning his eyes and face of vomit in order to maintain dignity.
On achieving a 4th ROSC, it was agreed the need for a Clinical Team Lead to aid in the transportation of our patient to the hospital was necessary. Arresting once more on route to the hospital and having had over 2 hours of clinical interventions prior to arrival at the hospital, it was decided by the emergency department clinicians that continued resuscitation would be futile and the decision to terminate was made after a short period of time.
Thoughts and Feelings
My initial feelings about the situation as a whole were a mixture of anger, frustration, and intense disappointment both at myself and others involved in the incident. Having previously attended several red calls with my PPEd and technician crewmate, I knew that by discussing our plan prior to arrival and maintaining good communication, we had worked well together, and thought that by making them aware of my capabilities and limitations, I would be supported in being able to contribute safely and effectively to the team effort, an approach advocated by a number of key authors and organizations.
However, the lack of clear direction and leadership, along with the obvious conflict and indecision amongst the clinicians about definitive, appropriate care, made me feel frustrated and overwhelmed almost immediately, whilst my requests to participate in more complex techniques in order to demonstrate competency resulted in undertaking too many tasks and suppressing my true emotions in order to appear calm and focussed. According to Jennings, this feeling is not uncommon, with a large proportion of students (78%) admitting to not only covering up emotions during paramedic placement in order to maintain the expectations of others but equating ‘mastery of skills’ with demonstrating an ability to do the role well.
Despite having a clear internal plan about ways to improve team cohesion and confidence in its success, I felt my relative inexperience as a 1st-year student especially within the hierarchy at the scene, and a fear of appearing controlling prevented me from fully asserting my ideas, despite the benefits it may have brought to the patient. In contrast, watching the seamless and organized resuscitation attempts within the emergency department, and their interaction with me as a student observer, was a much more inclusive and rewarding experience.
With the benefit of hindsight, I realize that the age of the patient initially took me by surprise, and his failure to respond to repeated doses of Naloxone, alongside excessive vomit aspiration made me feel helpless and annoyed that I couldn’t do more for him. Although I found discussing these emotions and my performance a fairly easy task with my PPEd, addressing my feelings around the lack of support I had experienced at the incident felt too critical at the time, especially given the newness of the relationship and the desire for him to retain a positive opinion of me.
Evaluation and Analysis
Caused by a partial or complete cessation in the electrical activity of the heart, over 30,000 out-of-hospital cardiac arrests (OHCA) occur every year in the UK, with over 2,800 in Wales alone. Whilst good quality early pre-hospital cardiopulmonary resuscitation (CPR) and defibrillation, recognized as crucial links in the ‘Chain of Survival’ proposed by the American Heart Association, have been tentatively shown to have potentially positive influences on patient outcomes, typically the rate of survival of OHCA is extremely low (less than 1 in 10), with a reduction in chances of up to 10% every minute with a lack of intervention or poor resuscitation.
Paramedics, and students alike, are often exposed to these high pressured and dynamic cardiac arrest situations where they are required to demonstrate an ability to not only provide exemplary clinical and medical interventions but to exhibit equally proficient non-technical skills such as communication and teamwork in their pursuit of the successful patient and colleague interactions. Defined by Flin et al as ‘‘the cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient performance’’, the theory behind human factors has its origins in the aviation industry where the need for reducing the potential for catastrophic errors led to extensive research into the adverse influences that factors such as fatigue, stress, situational awareness, leadership, and communication had on decision-making and teamwork within both routine and high-pressured working environments. The subsequent introduction of Crew Resource Management (CRM) practices modeled on the desired non-technical skills required to promote an effective and safe working environment proved successful in reducing adverse incidents and has now been increasingly adopted into the wider healthcare industry.
However, whilst the focus on perfecting key technical resuscitation skills such as airway management, effective chest compressions, and drug therapy is evident by large numbers of wide-scale studies and detailed research trials such as the PARAMEDIC trial and the PARAMEDIC-2 trial, there is a comparative lack of similar volumes of evidence on the specific effects and influences of human factors and non-technical skills on performance within paramedic practice, although it has become an increasingly recognized area for research over the last 10 years.
In looking at the cardiac arrest I attended, I have identified a number of occasions where human factors may have contributed to both positive and negative outcomes in our individual and team approaches.
Marsch et al identify CPR as a ‘’team endeavor’’, with research undertaken by Roberts et al and Hunziker et al suggesting that, during cardiac arrest simulations, the effectiveness of resuscitation was related to the cohesion of the team and the factors involved in its formation. I felt it was important that I discussed my concerns and role allocation with my PPEd and technician crewmate prior to arrival on the scene in order to not only minimize information disorganisation and potential confusion but also to ensure that there was a streamlined approach to early resuscitative attempts. My reasoning behind adopting this approach was that having a clear objective, and a clear plan, would allow me to focus predominantly on the specific and straightforward task of chest compressions whilst taking an opportunity to gather my thoughts and assess the wider scene for my next potential task. The World Health Organisation recognises the importance that pre-task briefings and information exchange in healthcare have on reducing patient harm, while other research shows that patient safety is increased by cohesive teams that utilize good communication and share a mutual awareness of ongoing plans and goals. I also felt that being the least experienced within the team, it was expected of me to undertake the less complex tasks as not requiring guidance to perform them, I would be providing fewer distractions for my PPEd and the other clinicians. However, whilst trying to cover all basis in my preparations, I had assumed that our crew’s strengths and weaknesses would align seamlessly with that of the other crew and had failed to consider what would happen if they didn’t.
Belbin proposes that successful teams possess a fine mix of 9 key behaviors that, when combined, can lead to efficiency and high performance. However, as this situation demonstrates, there are clear limitations in terms of being able to predict what pre-existing behaviors any additional crews or individual clinicians may possess, and so flexibility is key. Evaluating my own behaviors against the Belbin model, I believe I possess strengths within a number of the categories, but that similarly I have a wide range of weaknesses. Whilst not a definitive confirmation of skill, I have a starting point to explore further the individual facets of my personality and develop a better understanding of how these may shape my approaches in certain situations.
One of the key issues encountered at the scene was the establishment of a definitive leader and the maintenance of clear leadership throughout the incident. On several occasions, and certainly, at the start of the resuscitation attempts, it was unclear who was guiding the overall scene with many conflicting requests and priorities resulting in confusion and additional pressure. JrCalc and the Resuscitation Council UK regard effective leadership as an integral tool in achieving the best from a cardiac arrest team, recognizing the importance of a team leader in assigning tasks to members of the team that are commensurate with their experience and knowledge. However, Hunziker et al showed that ad hoc teams or distinct teams merged to form a larger team, encountered significantly more barriers to establishing effective leadership than preformed teams, with the need for incorporation and familiarisation of additional crews into an emergency situation being seen as another potential hurdle to overcome.
On arrival, it was evident that there was the loss of situational awareness by the initial paramedic crew which may have hindered their attempts at intubation and effective cannulation. Situational awareness is considered as having an awareness of the environment around you and using the information contained within it to guide present and future decisions.
