Clinical decision-making can be thought of as a process of applying medical knowledge and skills to a clinical situation. In the prehospital environment, this process is a vital part of paramedic clinical life that often takes place in settings that are chaotic and unpredictable (Shaban, 2005). Lord (2003) purported that unlike controlled clinical settings (emergency departments and inpatient units), where clinicians have access to expert opinion, medical records and advanced diagnostic tests, the assessment and management of patients in the prehospital setting is usually characterized by independent and time critical factors and where access to similar support systems and medical technology is unavailable. In this context, the role of a paramedic is a complex one, centred on performing a range of assessments aimed at gathering, evaluating and synthesizing information that relates to a patient's presentation before deciding on appropriate treatment and transport decisions (Saunders, 2005; Caroline, 2008). Throughout this decision-making process, paramedics must continuously evaluate and decide the degree to which they are making the correct clinical decisions in relation to a particular patient.
Responding to mental health emergencies
The response to mental health emergencies in the community often presents unique and complex challenges for paramedics. This is often a result of the ambiguous nature of presentations, the lack of background information and back-up assistance (Shaban, 2006; Roberts, 2009; Townsend and Luck, 2009). Yellowlees (1998) claimed that unlike hospital-based settings, where the focus is often on examining the psychopathology of the patient, in community settings, the emphasis is often on clarifying what the patient's major concerns are before attending to any physiological variables. In crisis situations, this is not always possible or appropriate, as the goal is often centred on identifying and responding to immediate risk issues that may be present.
When paramedics provide prehospital mental health care, a number of areas must be explored. These key areas relate to the medical, psychiatric, environmental and legal aspects of a patient's presentation. To achieve this, paramedics perform a number of specific assessments; including a primary survey of the patient's basic physiological status, a brief mental health assessment, suicide risk assessment and scene safety assessment (Saunders, 2005). The combined outcomes of these assessments enable paramedics to determine the most appropriate management, treatment and transport options. The process is often guided by organizational protocols and clinical guidelines that mandates a particular clinical pathway to be taken (Shaban, 2006).
In relation to the transportation of mentally ill or mentally disordered patients, anecdotal reports suggest that the majority are brought voluntarily to the emergency department by paramedics, that is, patients willingly agree to be transported to hospital. In some circumstances however, it is necessary to transport patients to hospital against their will; particularly patients whose behaviours and actions are posing a significant or immediate level of risk to their own safety or that of others and who lack the capacity to make an informed decision about their immediate welfare (Townsend and Luck, 2009).
‘Paramedics must continuously evaluate and decide the degree to which they are making the correct clinical decisions in relation to a particular patient’
In these circumstances, police and authorized paramedics in some Australian states and territories may make the decision to temporarily remove a patient's civil liberty and detain them under the involuntary provisions of mental health legislation. This is likely to occur in response to a range of clinical presentations including but not limited to, patients with deterioration in their mental state; those expressing self-harm or suicidal ideation or intent; patients in acute distress, or those under the influence of alcohol or other drugs.
The removal of a patient's civil liberty has serious consequences and as such those exercising this function must be satisfied that their decisions are appropriate and justifiable in each circumstance (Townsend and Luck, 2009). The challenge for paramedics when providing prehospital mental health care is to ensure they possess the necessary clinical skills and competencies to not only deliver safe and effective emergency mental health care but also that they are skilled at making clinically appropriate and justifiable decisions, which protects and promotes the legal and human rights of each patient.
This means ensuring the clinical decisions made by paramedics adhere to the fundamental principles articulated in mental health legislation, which mandates that mental health care and treatment should be delivered in the least restrictive means possible (Wand, 2004; Townsend and Luck, 2009). This means that patients should only be detained as an involuntary patient when other less restrictive methods have failed.
Paramedic clinical decision-making in relation to mental health care
Broadly, a number of approaches to account for clinical decision-making in relation to paramedic practice have been proposed in the literature. These include the hypothetico-deductive approach (Corcoran, 1986; Tanner et al, 1987; Bandman and Bandman, 1988; Carnevali and Thomas, 1993), algorithmic approach (Bendall and Morrison, 2009), pattern recognition approach (Boyle et al, 2008; Kalas, 2010), worst case scenario approach 2011) (Bendall and Morrison, 2009) and the event driven approach (Sandhu and Carpenter, 2006). While these approaches provide insight into the role of paramedics in the delivery of prehospital care, including emergency mental health care, the literature suggests that the success or usefulness of any individual approach is likely to vary between individual paramedics (Saunders, 2005; Caroline, 2008).
Kovacs and Croskerry (1999) have also pointed out that clinicians (paramedics) probably use a range of clinical decision-making approaches whether individually or collectively, depending largely on the unique characteristics of individual clinical situations and the unique settings in which paramedics find themselves.
A number of earlier non-peer reviewed sources (United States Transportation, 1998; Saunders, 2005; Caroline, 2008) have also provided a useful introductory basis for informing our understanding of the knowledge and skills required by paramedics to make effective patient care decisions in the prehospital setting. From these key texts, it is proposed that clinical decision-making by paramedics follow a sequential pathway.
The first phase refers to concept formation whereby relevant information regarding a patient's presentation is gathered and forms the basis of the paramedic's initial assessment. During the second phase (data interpretation), information is evaluated and synthesized in order to form an impression of the clinical presentation and to aid in formulating a working diagnosis. This process is dependent on the ability of paramedics to recognize a range conditions, signs and symptoms and has been found to be heavily influenced by prior knowledge and clinical experience (Wyatt, 2003).
Once a conceptual understanding of the situation has been formed, paramedics are able to develop an appropriate care plan (deciding on appropriate treatments and interventions) and implementing that plan (initiating treatments and interventions).
Wyatt (2003)
The association between clinical decision-making and the concept of tacit knowledge (intuition) has long been debated (Hammond et al, 1980; Corcoran, 1986; Benner and Tanner, 1987; Wyatt, 2003; Sands, 2009; Alexander, 2010). Nonetheless, Wyatt (2003) has been credited with furthering this research area by examining this relationship within the context of paramedic practice.
Wyatt used an ethnographic case study to investigate the means by which experienced paramedics draw on their tacit knowledge when responding to unfamiliar clinical situations and to explore and chart the transition that paramedics undergo as they move from being novice paramedics to expert paramedics. Wyatt purported that because the constructs of paramedic judgment and decision-making are found to be heavily grounded in the social and contextual nuances of the clinical setting (prehospital environment), ethnographic techniques provide an ideal means of collecting dense ‘descriptions that are sensitive to the socio-cultural patterns of interactions within the social order being investigated’ (Wyatt, 2003).
For example, Wyatt used participant observations as a means of observing paramedics perform clinical duties in their natural clinical environment. This was in keeping with traditional ethnographic case study techniques, and also emulated those used in other studies that have examined the role of tacit knowledge in clinical settings (Daley, 2001). To enable a deeper exploration of the specific behaviours and judgments paramedics had made during these observations, Wyatt invited paramedics to also take part in semi-structured interview. To maximize the opportunity to source rich descriptions from paramedics, a purposeful sampling strategy was used to ensure only highly skilled paramedics were recruited to take part in the study.
Findings from Wyatt's study revealed that for novice paramedics, clinical judgments were heavily influenced by established organizational protocols and guidelines. As paramedics became more experienced and familiar with clinical duties, they were found to rely much less on established protocols and guidelines and developed an increasing degree of independence and confidence when managing clinical presentations. These findings suggested that over time prior clinical experience has the potential to significantly improve the ability of paramedics to engage in skilled and independent clinical decision-making.
Shaban (2004, 2005, 2006)
In relation to the delivery of prehospital mental health care, Shaban's studies (2004, 2005, 2006) and theoretical contributions have revealed some of the factors that account for how paramedics are expected to and actually do make clinical decisions, and have highlighted that paramedics often work under increasing stress and uncertainty when providing mental health care. His contributions have also emulated those of traditional decision-making theorists (Hammond, 1980; Rew and Barrow, 1987; Benner and Tanner, 1987; Gerrity, 1987; Wyatt, 2003) which have found that intuition and prior experience were typically the only effective strategies paramedics draw on when managing mentally ill or mentally disordered patients.
In an exploratory study, Shaban used ethnographic and discourse analytic techniques in the context of a discourse-historical case study design to analyze different sources of data that related to ambulance mental health care. These included organizational documents such as ambulance specific protocols, clinical guidelines and policies, as well as qualitative data obtained from semi-structured interviews. An analysis of the data identified a range of official accounts and constructs paramedics used to describe the manner in which they accounted for their judgments and clinical decisions when providing mental health care. These included ‘categories of the mentally ill’, ‘role of the paramedics’, ‘needs for additional training’ and ‘legislative, policy and clinical practice conflict’. The analysis also found that paramedics perceived a disparity between their knowledge and training in relation to mental health care and their overall preparedness (in terms of skills and competencies) to provide high-quality prehospital mental health care. Interestingly, this study also found that the clinical decisions paramedics made when responding to mental health emergencies were heavily influenced by a patient's physical status, rather than on their mental state.
Organizational protocols and clinical guidelines around the management of mental health patients were also found to influence the decisions paramedics made and the clinical pathways they followed (Shaban, 2006; Roberts and Henderson 2009; Townsend and Luck, 2009).
Roberts and Henderson (2009)
In a similar descriptive study, in South Australia, Roberts and Henderson (2009) used a mixed method design to explore the perceptions of paramedics with respect to their role, work practices and preparedness when providing prehospital mental health care. In this study, a quantitative measure was used to identify the percentage of mental health cases paramedics were called to attend. Overall, the measure revealed that the annual percentage of mental health cases had remained relatively stable across a six-year period.
A self-report survey was then administered to explore the perceptions of paramedics in relation to a range of themes which relate to mental health care. For example, their work practices, the involvement of other services (such as police and mental health crisis teams), organizational culture and management support, and how their mental health training and clinical skills were applied in the clinical field.
The survey results revealed a disparity when comparing the perception of paramedics in relation to mental health caseload with the actual mental health caseload data derived from the clinical data set. For example, 50% of participants believed that mental health cases represented 10–20% of their caseload whereas the clinical data set identified mental health cases as representing only 3% of all cases. The survey results also identified a significant difference in the perceived time on scene and the actual time of scene for mental health cases. For example, in the survey participants perceived that they spend on average 20–40 minutes on-scene whereas the clinical data set indicates that time on scene for mental health cases was only 1–10 minutes.
Focus groups were then used to explore a range of themes relating to ambulance mental health care. These ranged from education and training, increased prevalence of acute psychiatric presentations in the community and the availability of resources, and organizational systems to support the delivery of prehospital mental health care.
Lack of suitable education and training featured predominately throughout the focus group discussions, with participants reporting a greater need for better theoretical knowledge of mental health presentations as well as access to suitable assessment tools that are applicable across the spectrum of mental health conditions. Similar to Shaban's study, participants in this study felt that their role when providing mental health care was focused primarily on the transportation of patients to hospital rather than on providing direct clinical care, and that the physical status of patients was viewed as being of greater importance than the emotional wellbeing of patients.
Towsend and Luck (2009)
In a theoretical paper by Townsend and Luck (2009), concerns were raised about the apparent confusion and misunderstanding in relation to the legal impediments that surround decision-making by paramedics when providing mental health care. The paper claimed that the expanding roles and responsibilities of paramedics, and the associated legal and ethical challenges they faced when providing prehospital care, appeared to add further confusion around the issue of duty of care and where their professional responsibility actually rested. Paramedics who took part in Shaban's (2006) study also touched on this issue, claiming that the fear of persecution from patients who are not transported to hospital was found to prejudice their clinical decision-making.
Cheney et al (2008)
In another study conducted in the US, Cheney et al (2008) used an unblinded prospective observational study to examine safety issues relating to the introduction of a triage protocol for use by paramedics when responding to mental health patients. The triage protocol was designed to enable paramedics to screen mental health patients for other medical conditions before transporting them directly to a mental health facility. The intention of the triage protocol was to reduce the number of mental health patients who would otherwise be transported directly to the emergency department.
The study found that introducing such a triage protocol was an effective screening tool for paramedics to use and provided a standardized framework to facilitate effective clinical decision-making. The study, however, was not able to identify the extent to which the triage protocol could be successfully used on patients who arrived at the emergency department by other means. In addition, the overall effectiveness of the triage protocol was determined by the subjective evaluations made by psychiatric physicians once patients arrived at the mental health facility, that is, whether the psychiatric physicians felt that patients should have been transported directly to the emergency department or the mental health facility.
Discussion
The studies described in this article provide an insightful view into the delivery of ambulance mental health care across Australia, the UK and US and have illustrated that a variety of research methods have been used to examine the clinical decision-making behaviours and actions of paramedics in the context of prehospital mental health care. Future research is now needed to investigate how paramedics navigate the interplay between organizational protocols and clinical guidelines, their clinical knowledge and skills and their legislative responsibilities under mental health legislation.
Hermeneutic phenomenological methods: a theoretical framework
When compared to other health professions, research into the science of paramedic practice is still in its infancy. Consequently, research in this area has had to borrow and adapt research methodologies found in other health disciplines (Shaban, 2004).
While the popularity of quantitative research methods is well-documented across the health milieu, recently researchers have begun turning to interpretive qualitative methods to answer health-related questions that are not directly amenable to statistical manipulation, such as the experience of illness (i.e. ‘how does it feel to have this illness’) or the delivery of health care (i.e. ‘why do you make the clinical decisions that you do’). Green and Britten (1998) purport that qualitative approaches afford researchers with an opportunity to bridge the gap between scientific evidence and clinical practice, without implying a rejection of more traditional research evidence.
Hammell et al (2000) extended this view, suggesting that qualitative research can add significant value to the continuing development and advancement of professional theories and conceptual understanding of clinical practice.
In the context of paramedic practice, Shaban (2005) claimed that a problem facing many researchers seeking to advance research in this field, has been the obvious lack of an appropriate theoretical framework on which to position these inquiries. While ethnography has already been shown to be a suitable theoretical framework for examining clinical decision-making in paramedic practice (Shaban, 2005), hermeneutic phenomenology will be proposed as a suitable alternative theoretical framework for advancing research in this field.
Rather than seeking to discover and understand the beliefs and cultural aspects of paramedics in the clinical environment, as is the focus of ethnographical-orientated research, a hermeneutic phenomenological research will focus our gaze on the lived experience of paramedics as they engage in clinical decision-making, and importantly, the interpretations which are made of their lived experiences within the context of their clinical practice.
Theoretical origins
Interpretative qualitative methods include descriptive and hermeneutic phenomenology, discourse analysis, grounded theory and ethnography. Interpretive qualitative methods are based on the epistemology of idealism which holds that what an individual knows about objects in the world can only exist in the mind of that individual.
Hermeneutic phenomenological methodology is based on the philosophical traditions of both hermeneutics and phenomenology. The word ‘hermeneutics’ is thought of as a process of forming an understanding of a whole text by understanding the individual parts of that text and the relationship that each part has with the whole text (Cohen et al, 2000). In addition, the word phenomenology is used to describe a philosophical approach to the study of human experience—therefore, hermeneutic phenomenology is an approach to the study of how individuals interpret their lives and how they make meaning from their experiences. It is at this juncture that the concept of double hermeneutic becomes apparent, a process whereby a researcher attempts to make sense of participants who is attempting to make sense of ‘something’. Smith et al (2009) illustrated this point, referring to the participant's meaning-making as first-order, while the researcher's sense-making is regarded as second order.
The principles of phenomenology can be traced back to Husserl (1964) who emphasized the importance of the lifeworld or ‘lived experience’ and our fundamental perception of reality as it is presented to human consciousness (Ajjawi, 2007). Husserl claimed that we could only know what we experience in our reality, and that only phenomenology will enable us to understand such lived experience.
As part of the rise of existential philosophy, Husserl sought to make phenomenology a commensurable science of its time, refuting the then established and popular belief that traditional empirical sciences were the only means for examining and understanding the world. According to Husserl, there are three key elements which reflect the central interest of hermeneutic phenomenology in the individual and which are used to differentiate it from other qualitative methodologies. These include bracketing, intentionality and subjectivity.
According to Husserl, researchers using hermeneutic phenomenology to investigate a particular phenomenon must consciously bracket out their preconceived ideas and thoughts about that phenomenon in order to fully understand what is being investigated. This idea was later challenged by other emerging phenomenological philosophers (Sartre, 1948; Heidegger, 1962; Merleau-Ponty, 1962; Gadamer, 1976) who challenged this idea, arguing that it is not possible to remove one's own preconceived ideas or knowledge of a particular phenomenon but instead as researchers, we must bring our prior knowledge and experience of the particular phenomenon to the research arena in order to fully understand how others experience that phenomenon.
Thus, in hermeneutic phenomenology, there is no true interpretation of a phenomenon but a range of possible interpretations which provides the possibility for a deeper and richer layer of understanding (Van Manen, 1990).
The term intentionality is another important aspect of hermeneutic phenomenology. This refers to an individual's continuous awareness (consciousness) of something in the world of lived experiences. Further, it reflects the idea that the lifeworld is not an objective environment or even a subjective consciousness but rather, it is what an individual perceives and experiences it to be (Finlay, 2008). The study of a person's unique experience of a phenomenon, using hermeneutic phenomenological research methods, reveals this consciousness (Crotty, 1998).
The third aspect, subjectivity, refers to the researchers' ability to engage with and understand the participant's perception of their reality and their subjective interpretation of their experience of the lifeworld.
The structure of phenomena is much less important than how phenomenon is interpreted. When undertaking hermeneutic phenomenological research, Van Manen (2007) postulated that the aim is not to discover what we should do or even how we should do something but rather it seeks to reveal to us the relationship between ‘being and acting, between who we are and how we act’ (2007). It is at this juncture, that Gadamer's (1976) own philosophical influence in relation to contemporary hermeneutic phenomenology becomes apparent. Gadamer argues that because hermeneutics is focused on examining the language that people use to describe meaning, the objective of hermeneutic phenomenological research is to examine, understand and make sense of this language, and the individual user of that language. From Gadamer's perspective, ‘our experience of the world is bound to language’ (1976). If we are to understand and examine this experience we must understand the language people use to describe this experience.
What makes hermeneutic phenomenological research distinctly different from other interpretive qualitative approaches is its emphasis on examining a single phenomenon (or experience) rather than other aspects of that phenomenon, such as the social processes (grounded research) or cultural nuances (ethnographic research). As Cohen and Omery (1994) reminded us, while these factors may be important and form part of an individual's experience, they are not overtly the focus on our interest.
Hermeneutic phenomenological methods are also useful for examining and understanding commons themes or trends that go across a cohort of individuals who examine the same phenomenon, and also provides an opportunity to discover any issues that are alluded to by those who may not articulate in their discussions of a particular issue.
The importance of generalizability and validity of findings derived from phenomenological research is critical if a particular investigation is to be considered scientifically rigorous. In the context of hermeneutic phenomenological research, a number of strategies can be used at various stages of an investigation and these are congruent with fundamental principles of phenomenology.
Strategies include constructing an audit tool that provides a detailed description of how the research was undertaken; a process of ‘participant validation’, whereby the researcher seeks additional clarification and consensus from participants about the identification of emerging themes; as well as a peer review process whereby an experienced colleague is invited to review the data or findings at various stages of the analytic process in order to validate or question the analytic linkage being made between the data, categories and emerging themes (Hammell et al, 2000).
‘When compared to other health professions, research ino the science of paramedic practice is still in its infancy’
Hermeneutic phenomenological research methods in action
In research terms, hermeneutic phenomenological methods are most useful when researchers wish to understand a particular experience as it is understood by those who are having it. Dahlberg et al (2001) purported that ‘being in the world thus means that we cannot avoid meaning. This fact is the starting point for phenomenological research’ (2001).
A review of the current literature failed to identify any studies which used hermeneutic phenomenology to examine paramedic practice. Nonetheless, hermeneutic phenomenology has a long history of being used in the broader context of health research to investigate the lived experiences from the perspective of both patients and clinicians (Crotty, 1998). In relation to the examination of clinical decisionmaking, researchers have employed hermeneutic phenomenological research methods to explore and discover this phenomenon across a broad range of clinical settings and health disciplines.
In relation to the complex phenomenon of clinical reasoning, Loftus (2006) asserted that the hermeneutic framework provides an ideal approach from which to examine this phenomenon, adding that ‘a hermeneutic approach to clinical reasoning opens up its enormous complexity, allowing us to appreciate the many disparate ways in which people have tried to understand what is involved in this particular aspect of professional activity. (Loftus, 2006).
For example, Drury et al (2005) used hermeneutic phenomenology to compare and contrast the experiences of nurses working in rural and metropolitan locations. The study revealed that unlike nurses working in metropolitan areas, those working in rural and remote locations often carried out clinical duties in isolation, were found to employ more advanced nursing practices and tended to assume a multi-faceted approach to clinical care.
Loftus and Higgs (2005) employed hermeneutic phenomenological methods to examine the way in which physiotherapists working in clinical teams use language when they engage in clinical decision-making. The study found that the behaviours and interactions of and between physiotherapists (both written or verbal) were very much dependent upon the characteristics of language (narrative, hermeneutics and rhetoric) which are in turn formed from words, metaphors and categories for each participant. From this perspective, Loftus contended that clinical decisionmaking as experienced by physiotherapists was viewed as a social phenomenon.
In another study, Baker (2001) sought to examine clinical decision-making in relation to a patients experience of pain and how the perceptions among nurses in relation to a patient's experience of pain changed over time. From this study, Baker was able to identify that the clinical environment, the role other clinicians and prior experience greatly impacted on and influenced clinical decision-making behaviours and actions among nurses. For example, the study found that as nurses gain clinical experience, they were found to rely on more experiential knowledge and less on theoretical principles and clinical guidelines.
The above mentioned examples illustrate how hermeneutic phenomenological methods can be used to examine clinical decision-making across of range of settings and clinical disciplines. What these examples have in common is the view of participants as being actively involved in the lifeworld (clinical practice) and therefore research that is primarily focused on understanding how participants make sense of this experience.
Future research proposed
While the literature has proposed a range of clinical decision-making approaches which are relevant to paramedic practice, a gap exists in our understanding and knowledge of the decision-making processes, actions or behaviours paramedics engage in when fulfilling their responsibilities under mental health legislation.
Central to this is the question of what impact mental health legislative responsibilities has had on clinical practice and to what extend does it influence, prejudice or even dictate certain clinical decision-making outcomes that paramedics arrive at.
By applying the theoretical principles of hermeneutic phenomenology and adapting research methods which are positioned with this framework, future research is now needed to investigate the lived experience of paramedics as they engage in clinical decision-making with respect to mental health legislation. In doing so, future research will help to advance our understanding of paramedic clinical practice and whether traditional clinical decision-making theories can be applied to this phenomenon in the prehospital environment.