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Clinical reasoning among emergency medical service clinicians: An iterative and fragmented process involving the collaborative effort(s) of many
University of Borås, Faculty of Caring Science, Work Life and Social Welfare.ORCID iD: 0000-0002-1789-8158
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Aim: The overall aim of the thesis was to generate knowledge and understanding of clinical reasoning in the context of EMS from the perspective of EMS clinicians.

Method: Three different methodologies were employed to describe various aspects of clinical reasoning. In Study I, an integrative literature review was conducted to summarise the existing literature related to clinical reasoning in EMS. After conducting systematic searches and screening, 38 articles were identified and analysed through an inductive thematic analysis. Studies II and III were conducted as case studies within an EMS organisation to capture clinical reasoning as it takes place in the naturalistic environment. In total, 34 patient encounters were observed, and group and individual interviews were conducted with EMS clinicians and organisational representatives at various hierarchical levels within the EMS organization. The data were analysed through pattern matching and triangulation in a computerised software program for qualitative analysis. Study IV was conducted as a goal-directed task analysis which focused on what EMS clinicians need in terms of achieving situation awareness. An online survey was created and answered by 30 EMS subject matter experts, consisting of active EMS clinicians, academic teachers in specialist ambulance nursing programmes, and researchers in the field of EMS. The data were analysed using qualitative content analysis and descriptive statistics.

Main results: Clinical reasoning in EMS is a continuously ongoing, iterative, and fragmented process. Information is gathered, analysed, and utilised at any given point during the mission. This information is then reasoned against various goals or instructions provided by the EMS organisation or what is perceived as the most suitable action by the EMS clinician. In the reasoning process, the clinicians take the patients’ and their relatives’ points of interest into account, striving to fulfil these. The clinical reasoning process continues after and between the missions well, and clinicians constantly evaluate their decisions and care provision for future improvement. Even if medical and caring interventions are the focus of clinical reasoning, this process involves the consideration of other aspects as well, such as logistics and safety for everyone present. Nevertheless, there seems to be a vague mandate for decision making among EMS clinicians in relation to other collaborative partners. Furthermore, organisational support for clinical reasoning and development is lacking, often due to economic limitations.

Conclusion: This thesis contributes to the caring science field with an increased understanding of the complexity of clinical reasoning in EMS. EMS clinicians today need to rely on themselves or their partners to have sufficient knowledge or experience to handle the situation encountered and provide safe patient care. As the reasoning process involves more than the physical patient encounter, additional support is needed to inform clinicians in decisions related to logistics and safety. As the reasoning process involves more than the physical patient encounter, additional support is needed to inform clinicians in decisions related to logistics and safety. EMS clinicians today need to rely on themselves or their partner to have sufficient knowledge or experience to handle situations encountered and provide patient safe care. 

Place, publisher, year, edition, pages
Borås: Högskolan i Borås, 2023.
Series
Skrifter från Högskolan i Borås, ISSN 0280-381X ; 142
Keywords [en]
Emergency medical services, Clinical reasoning, Ambulance, Pre-hospital, Health and well-being
National Category
Nursing
Research subject
The Human Perspective in Care
Identifiers
URN: urn:nbn:se:hb:diva-29844ISBN: 978-91-89833-11-1 (print)ISBN: 978-91-89833-12-8 (electronic)OAI: oai:DiVA.org:hb-29844DiVA, id: diva2:1760107
Public defence
2023-11-10, C203, Allégatan 1, Borås, 09:00 (Swedish)
Opponent
Available from: 2023-10-20 Created: 2023-05-29 Last updated: 2023-12-12Bibliographically approved
List of papers
1. Clinical reasoning in the emergency medical services: an integrative review
Open this publication in new window or tab >>Clinical reasoning in the emergency medical services: an integrative review
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2019 (English)In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241Article in journal (Refereed) Published
Abstract [en]

Abstract: Clinical reasoning is the process of gathering and understanding information conducted by clinicians in the emergency medical services (EMS) so as to make informed decisions. Research on clinical reasoning spans several disciplines, but a comprehensive view of the process is lacking. To our knowledge, no review of clinical reasoning in the EMS has been conducted.

Aim: The aim was to investigate the nature, deployment, and factors influencing EMS clinicians’ clinical reasoning by means of a review.

Method: Data was collected through searches in electronic databases, networking among research teams ,colleagues and friends, “grey literature,” and through ancestry searches. A total of 38 articles were deemed eligible for inclusion and were analyzed using descriptive thematic analysis. The analysis resulted in an overarching finding -namely, the importance for EMS clinicians to adjust for perceived control in unpredictable situations. Within this finding, 3 themes emerged in terms of EMS clinicians’ clinical reasoning: (1) maintaining a holistic view of the patient; (2) keeping an open mind; and (3) improving through criticism. Seven subthemes subsequently emerged from these three themes.

Results: This review showed that EMS clinicians’ clinical reasoning begins with the information that they are given about a patient. Based on this information, clinicians calculate the best route to the patient and which equipment to use, and they also assess potential risks. They need to be constantly aware of what is happening on the scene and with the patient and strive to control the situation. This striving also enables EMS clinicians to work safely and effectively in relation to the patient, their relatives, other clinicians, associated organizations, and the wider community. A lack of contextually appropriate guidelines results in the need for creativity and forces EMS clinicians to use “workarounds” to solve issues beyond the scope of the guidelines available. In addition, they often lack organizational support and fear repercussions such as litigation, unemployment, or blame by their EMS or healthcare organization or by patients and relatives.

Conclusion: Clinical reasoning is influenced by several factors. Further research is needed to determine which influencing factors can be addressed through interventions to minimize their impact on patient outcomes.

Keywords
Clinical reasoning, Decision-making, Emergency Medical Services, Ambulance, Clinicians
National Category
Health Sciences
Research subject
The Human Perspective in Care
Identifiers
urn:nbn:se:hb:diva-21633 (URN)10.1186/s13049-019-0646-y (DOI)000483062300002 ()2-s2.0-85071034795 (Scopus ID)
Available from: 2019-08-20 Created: 2019-08-20 Last updated: 2024-01-17Bibliographically approved
2. Clinical Reasoning among Registered Nurses in Emergency Medical Services: A Case Study
Open this publication in new window or tab >>Clinical Reasoning among Registered Nurses in Emergency Medical Services: A Case Study
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2022 (English)In: Journal of Cognitive Engineering and Decision Making, ISSN 1555-3434, E-ISSN 2169-5032Article in journal (Refereed) Published
Abstract [en]

In emergency medical services (EMS), the clinical reasoning (CR) of registered nurses (RNs) working in ambulance care plays an important role in providing care and treatment that is timely, accurate, appropriate and safe. However, limited existing knowledge about how CR is formed and influenced by the EMS mission hinders the development of service provision and decision support tools for RNs that would further enhance patient safety. To explore the nature of CR and influencing factors in this context, an inductive case study examined 34 observed patient–RN encounters in an EMS setting focusing on ambulance care. The results reveal a fragmented CR approach involving several parallel decision-making processes grounded in and led by patients’ narratives. The findings indicate that RNs are not always aware of their own CR and associated influences until they actively reflect on the process, and additional research is needed to clarify this complex phenomenon.

Keywords
Clinical reasoning, decision-making, problem-solving, naturalistic studies, field study, healthcare delivery, emergency medical services
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
The Human Perspective in Care
Identifiers
urn:nbn:se:hb:diva-27921 (URN)10.1177/15553434221097788 (DOI)000800553600001 ()2-s2.0-85131073033 (Scopus ID)
Projects
Bedömning och beslutsfattande i ambulanssjukvård
Available from: 2022-05-25 Created: 2022-05-25 Last updated: 2023-10-03Bibliographically approved
3. Organizational factors influencing clinical reasoning in a Swedish emergency medical service organization: An explorative qualitative case study
Open this publication in new window or tab >>Organizational factors influencing clinical reasoning in a Swedish emergency medical service organization: An explorative qualitative case study
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2023 (English)In: Paramedicine, ISSN 2753-6386Article in journal (Refereed) Published
Abstract [en]

Introduction

Clinical reasoning (CR) among healthcare professionals working in emergency medical services (EMS) who focus on ambulance care is a vital part of ensuring timely and safe patient care. The EMS environment continually fluctuates, so clinicians constantly need to adapt to new situations. Organizational support is described as important for CR, but overall, research on organizational influences for CR in an EMS context is lacking. An increased understanding of these influencing factors can assist in the development of EMS by strengthening CR among clinicians. Therefore, the purpose of this study was to investigate the organizational factors influencing EMS clinicians’ CR.

Methods

Using a qualitative single case study design, an EMS organization in southwestern Sweden was explored. Data were collected from participant observations of patient encounters, individual and group interviews with clinicians and organizational representatives, and organizational document audits. Data were analyzed using qualitative content analysis and triangulation of data sources.

Results

The results revealed several organizational influencing factors. Collaboration and information sharing internally and externally were emphasized as essential components influencing CR. Additionally, the structure for the clinicians’ ‘room for action’ appeared confused and created uncertainties for CR related to decision mandates.

Conclusion

The conclusion is that organizational factors do play an important role in clinicians’ CR. Moreover, the EMS community needs to develop suitable forums for discussing and developing these influencing factors across organizational hierarchies. Finally, clarification is needed on clinicians’ ‘room for action’ within their own organization but also with possible collaborators.

 

Place, publisher, year, edition, pages
Sage Publications, 2023
Keywords
health and well-being, qualitative analysis and interpretation, clinical reasoning, decision making, emergency medicalservices, work and healthcare environment
National Category
Nursing
Research subject
The Human Perspective in Care
Identifiers
urn:nbn:se:hb:diva-30241 (URN)10.1177/27536386231189011 (DOI)2-s2.0-85175415486 (Scopus ID)
Available from: 2023-08-11 Created: 2023-08-11 Last updated: 2024-02-01Bibliographically approved
4. Situation awareness in Sweden’s emergency medical services: a goal-directed task analysis
Open this publication in new window or tab >>Situation awareness in Sweden’s emergency medical services: a goal-directed task analysis
2023 (English)In: Discover Health Systems, ISSN 2731-7501, Vol. 2, article id 44Article in journal (Refereed) Published
Abstract [en]

Situation awareness is knowing what is going on in the situation. Clinicians working in the emergency medical services (EMS) encounter numerous situations in various conditions, and to be able to provide efficient and patient safe care they need to understand what is going on and possible projections of the current situation. The design of this study encompassed a Goal-Directed Task analysis where situation awareness information requirements were mapped in relation to goals related to various aspects of the EMS mission. A group of 30 EMS subject matter experts were recruited and answered a web-based survey in three rounds related to what they though themselves or a colleague might need to achieve situation awareness related to the specific goals of various situations. The answers were analysed using content analysis and descriptive statistics. Answers reached consensus at a predetermined level of 75%. Those who reached consensus were entered into the final goal-directed task analysis protocol. The findings presented that EMS clinicians must rely on their own, or their colleagues prior experience or knowledge to achieve situation awareness. This suggests that individual expertise plays a crucial role in developing situation awareness. There also seems to be limited support for situation awareness from organizational guidelines. Furthermore, achieving situation awareness also involves collaborative efforts from the individuals involved in the situation. These findings could add to the foundation for further investigation in this area which could contribute to the development of strategies and tools to enhance situation awareness among EMS clinicians, ultimately improving patient care and safety.

National Category
Nursing
Research subject
The Human Perspective in Care; The Human Perspective in Care
Identifiers
urn:nbn:se:hb:diva-30937 (URN)10.1007/s44250-023-00061-7 (DOI)
Available from: 2023-11-28 Created: 2023-11-28 Last updated: 2024-01-18Bibliographically approved

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