Predictors and impacts on paramedic clinical decision making, attitudes and behaviours Alexander Cardenas A thesis in fulfilment of the requirements for the degree of Doctor of Philosophy School of Public Health and Community Medicine Faculty of Medicine March 2017 THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname or Family name: Cardenas First name: Alexander Other name/s: Daniel Abbreviation for degree as given in the University calendar: PhD School: School of Public Health and Faculty: Medicine Community Medicine Title: Predictors and impacts on paramedic clinical decision making, attitudes and behaviours. Abstract Paramedicine has transitioned rapidly from a trade to a modern, autonomous largely unsupervised health profession. The speed and extent of this development has resulted in its clinical governance, procedures and accreditation being largely untested, leading to a situation with immediate potential implications for patient care. This mixed methods study began with an examination of the evolution of paramedicine within the context of current best practice training and management of sudden cardiac arrest (SCA). It then utilised the findings to inform the design and testing of two new online platforms to assess and improve paramedic decision making in SCA. The first platform developed was the Online Cardiac Arrest Simulator (OCAS), which included both instructional videos and a simulated SCA. The second platform, the Online Clinical Decision Platform (OCDP), was then designed based on the results and recommendations of OCAS. All educational materials and platforms were designed by the PhD candidate and included point of view filming, realistic location shoots, high- fidelity simulation and clinically accurate scenarios; and were accessible by multiple media devices. The decisions made by participants were then analysed to examine if a paramedic’s age, gender, educational attainment, geographical posting or tenure had an impact on their clinical decisions. More than 1,200 paramedics across an ambulance service in Australia participated in this project. OCDP revealed significant variance in the management of SCA by paramedics of difference backgrounds and qualifications. Age was found to be a key predictor for paramedic compliance with best practice guidelines, with increased age associated with poorer compliance. Gender and geographical posting were also found correlate with certain paramedic attitudes, preferences and behaviours towards SCA education and management. The findings of these trials illustrate the opportunity to improve paramedic decision making through new clinical decision tools and clinical governance initiatives. The findings also demonstrate the potential of online simulation to assess and improve paramedic clinical decision making. This demonstrated effectiveness as well as paramedic support for these methods, supports their future use in educational programs to train and assess paramedics on SCA treatment protocols and procedures. Page ii of 417 Dedication This thesis is dedicated to my wife Dr Cassandra Brown. Only though her endless love, support and patience, has this been possible. Page iii of 417 Acknowledgements The thesis is completed with the support of NSW Ambulance in partnership with the University of NSW. NSW ambulance has supported the study through procurement of equipment, access to facilities, provision of study leave, and approval for over 1,200 staff to participate at various stages of this study. The commitment of NSW Ambulance to its staff, the development of knowledge in the field of paramedicine, and the use of evidence based decision making, is commendable and greatly appreciated by the researcher. The researcher also thanks the Council of Ambulance Authorities who in 2016 awarded the study second place for Excellence in Research and Education across Australia and New Zealand. Finally, the researcher would like to thank his Co-Supervisors Professor Joanne Travaglia and Professor Riana MacIntyre for their guidance, mentorship and support, throughout the candidature. Their passion and commitment to both paramedicine and the delivery of exceptional patient care continues to be an inspiration. The thesis has been professionally edited by Elite Editing, with editorial intervention restricted to Standards D and E of the Australian Standards for Editing Practice. Page iv of 417 Statement of Original Authorship Page v of 417 Copyright Statement Page vi of 417 Authenticity Statement Page vii of 417 Table of Contents Dedication ............................................................................................................... iii Acknowledgements ................................................................................................. iv Statement of Original Authorship ............................................................................. v Copyright Statement ................................................................................................ vi Authenticity Statement .......................................................................................... vii Table of Contents .................................................................................................. viii List of Figures ......................................................................................................... xv List of Tables .......................................................................................................... xix List of Abbreviations ............................................................................................... xx Glossary ............................................................................................................... xxii Chapter 1: Introduction .......................................................................................... 23 1.1 Context .................................................................................................................. 23 1.1.1 Evolution of Paramedicine ............................................................................. 23 1.1.2 Paramedicine as a Unique Profession Requiring Research ........................... 24 1.1.3 Variance in Paramedic Governance Standards and Potential Implications for Patient Care .............................................................................................. 25 1.1.4 Unknown Nature of Effectiveness of Paramedic Clinical Decision Making ... 26 1.1.5 Impact of Paramedic Clinical Decision Making on the Management of Sudden Cardiac Arrest as a Case Study ......................................................... 27 1.2 Problem Statement ............................................................................................... 27 1.3 Aim and Significance of the Study ......................................................................... 28 1.3.1 Aim ................................................................................................................. 28 1.3.2 Significance of the Study ................................................................................ 29 1.4 Overview of the Study ........................................................................................... 31 1.5 Research Questions and Aims ............................................................................... 32 1.5.1 Research Questions ........................................................................................ 32 1.5.2 Research Study Aims ...................................................................................... 33 1.6 Conclusion ............................................................................................................. 34 1.7 References ............................................................................................................. 35 Chapter 2: Situating the Study ................................................................................ 41 2.1 Introduction .......................................................................................................... 42 2.2 The Emergence of Paramedicine .......................................................................... 42 2.2.1 Ambulance Drives and Stretcher Bearers ...................................................... 43 2.2.2 Transition from Ambulance Driver to Ambulance Officer ............................. 43 2.2.3 Transition from Ambulance Officer to Paramedic ......................................... 44 2.2.4 Have Modern Paramedics Achieved Professional Status? ............................ 46 2.3 Role of a Paramedic .............................................................................................. 47 2.3.1 Paramedic Duties across Settings .................................................................. 47 2.3.2 Paramedic Acute Care Practice ...................................................................... 49 2.3.3 Paramedical Subacute Care ........................................................................... 50 Page viii of 417 2.3.4 Ambulance Special Operations and Retrieval Services .................................. 51 2.3.5 The Unique Culture and Organisational Context of Paramedicine................ 51 2.4 Paramedic Education ............................................................................................ 53 2.4.1 Paramedic Education in the United States of America .................................. 53 2.4.2 Paramedic Education in Australian Statutory Ambulance Services ............... 54 2.4.3 Paramedic Education in