Paramedics’ clinical reasoning and decision-making in using clinical protocols and guidelines

Author: Sonja Maria

Maria, Sonja, 2021 Paramedics’ clinical reasoning and decision-making in using clinical protocols and guidelines, Flinders University, College of Medicine and Public Health

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Paramedicine in Australia began with first aid troops and railway corps providing first aid from the turn of the nineteenth century, and the profession advanced rapidly in the late 1900s. Across this period, we have seen a shift from basic first aid training and driving people to hospital, to minimum requirements of tertiary education and training in advanced life-saving techniques. With this change in basic training, paramedicine protocols have advanced and become more sophisticated. This study is the first of its kind to investigate protocols within the profession of paramedicine, and to examine their fundamental value as decision-making tools.

Paramedics within Australia have utilised protocols since the 1970s. Before that time, they often used protocols developed for first aid training. After the training level of intensive care paramedic was introduced in the mid-1970s, societal expectations of pre-hospital care changed. Many ambulance services have moved to the use of guidelines as opposed to protocols, sparking a debate on their relative benefits. Guidelines are considered to offer paramedics more freedom for independent thought, and less focus on set instructions, whereas protocols are stricter and more algorithmic.

Constructivist grounded theory was used as the methodology for this study, with interview data gathered within a cyclic framework until theoretical saturation occurred. Interviews were conducted with paramedics, historians and creators of the protocol documents from several states within Australia. Data were also gathered from the New South Wales Ambulance protocols, and the protocols for resuscitation, mental health and epilepsy were analysed in detail.

The analysis of the protocols and the interviews identified that educational background, vocational or university, has a significant influence upon how paramedics consider their ownership of their education and consequently their ability to transition to higher levels of independence in using protocols and clinical decision-making. Additionally, the paramedics’ scope of practice and length of service were also associated with particular trends in using protocols. Paramedics use protocols not only for patient care, but as teaching and training tools, especially those following a vocational model of education. Later in their career most paramedics discard their protocol book and use it as a reference only when they feel they need a refresher. This can be problematic with regards to maintaining best practice and mitigating risk.

During the interviews and the analysis of the protocols, it became evident that protocols are valued by organisations as tools to monitor paramedic performance and to meet organisational and governmental key performance indicators. Fundamental to creating ‘good’ protocols that are functional, guide best practice, and are translatable to the ‘on-road’ environment, is understanding who the audience is and considering the expectations/requirements of both the paramedic and the organisation.

The findings of this dissertation led to the development of substantive theory on building trust and managing risk: using protocols and guidelines to guide clinical decision-making. The Model of Purposes for Paramedic Clinical Practice Guidelines was also constructed as a framework to assist in the development of paramedic guidelines which can be tailored to each organisation. Together, this theory and model provide a significant contribution to knowledge by providing the first detailed analysis of how (if and why) paramedics use (or don’t use) protocols to makes decisions about patient care. Understanding these processes is critical to improved practice, patient outcomes, and advancement of the profession of paramedicine.

Keywords: paramedic decision-making, paramedic clinical decision-making, protocols, guidelines

Subject: Health Service Management thesis

Thesis type: Doctor of Philosophy
Completed: 2021
School: College of Medicine and Public Health
Supervisor: Sharon Lawn