Clinical Reasoning among Registered Nurses in Emergency Medical Services: A Case Study

Abstract

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.

Balancing structure and flexibility in the ambulance service: the pursuit of professional judgement in caring and learning

“…These educational strategies were applied to adapt the environmental complexities and tasks to the students' learning needs to create a balance between demands and needs. The preceptors' conceptualization of different activities and phases in AS care assignments are in line with previous researchers' descriptions [39,55,183]. The preceptors used these phases and activities as mental support structures to facilitate the students' fundamental development of situational awareness level 1 (perception) to be able to direct attention to the most important informational cues and be flexible to adapt to situationally unique sources of information (Study II, III), thus reducing the risks of cognitive overload and cognitive bias [184].…”

“…Caring in the AS also entails being confronted with ethical dilemmas concerning patient autonomy when caring for patients with impaired decisionmaking abilities related to e.g., levels of consciousness, language confusion, cognitive abilities, or conflicting perspectives on patient needs between the professionals, the patient, and their relatives [54]. This is obviously both troublesome and challenging since the professionals' clinical decision-making during care is based on the patients' narrative in order to identify and meet the subjective needs of the patients [55]. The decision-making process when being responsible for deciding whether to convey or not to convey a patient is experienced as complex and difficult, bringing with it a large responsibility and demands on the professionals' knowledge and skills [30].…”

“…The expanded scope of AS practice towards more advanced medical assessments and multicomplex interpersonal encounters in highly dynamic situations has resulted in calls for a reshaping of the views on the professionals' educational needs in several countries, including Sweden [16,17,40,41]. Calls have been made for developments with a clearer focus on non-technical interpersonal skills often supported by higher education academic schooling [9,16,40,41,55,60]. Most westernized countries, such as Australia, the United Kingdom, and the United States, base their AS on the paramedic-system with post-secondary vocational training and/or academic schooling for AS professionals.…”

“…The preceptors used talking aloud during caregiving and created mental schemata for recurring sources of information to support the students to collect the correct cues and avoid cognitive biases in clinical decision-making. A lack of situational awareness is associated with aspects such as confirmation bias, tunnel vision syndrome, fatigue, and stress [173,176,181], risking cognitive bias in clinical reasoning and decision-making due to the fluid environment of AS work [33,39,55,182].…”

“…Supporting the students to not fasten in these structured perspectives was identified as of significant great importance for promoting an understanding of all the dimensions of caring and decision-making in the professional role (Studies III, IV). This was seen even though the situated medical, technical, and practical dimensions of the professional work were challenging (Studies I, II, III, IV) and were reported as being highly important for upholding basic security, confidence, and safety in the professional work to safeguard patient safety and avoid adverse events [33,55,176].…”