ABSTRACT BRAITHWAITE, SUSAN SMITH. Ethics in Paramedic Practice: A Qualitative Case Study of Paramedic Perceptions of Ethical Decision-Making in Practice. (Under the direction of Dr. Susan J. Barcinas). The purpose of this qualitative study is to understand how practicing paramedics perceive ethics in patient care, specifically the process of navigating ethical decision-making in emergent situations. The Iserson Model for ethical decision making in emergency medicine was used as the conceptual framework. This exploratory case study utilized semi- structured interviews of thirteen North Carolina certified and educated paramedics, nine men and four women, as the primary method of data collection. Open-coding and theoretical framework coding were the two methods used. Paramedics ethical values, accountability, professional identity, and decision stress were the themes determined during the initial coding process. Reliance on previous experience in decision-making, consult, emergent ethical decision-making and the Iserson Model, “Rapid Approach to Ethical Problems” were themes determined during the theoretical framework coding process. Findings suggest that participants do not routinely use a process driven application as they make emergent decisions. They do, however, frequently consider feelings of empathy (a step in the Iserson Model) as they navigate such decisions. Findings further suggest the participants both learn ethical decision-making from peers and mentors in a community of practice through experiential learning, and then critically reflect on ethical dilemmas within the same community. This study illuminates the understanding of ethics in the unique profession of practicing paramedics and contributes to the literature in adult education for the health care professions. © Copyright 2014 by Susan Smith Braithwaite All Rights Reserved Ethics in Paramedic Practice: A Qualitative Case Study of Paramedic Perceptions of Ethical Decision-Making in Practice by Susan Smith Braithwaite A dissertation submitted to the Graduate Faculty of North Carolina State University in partial fulfillment of the requirements for the degree of Doctor of Education Adult and Community College Education Raleigh, North Carolina 2014 APPROVED BY: _______________________________ ______________________________ Dr. Susan J. Barcinas Dr. Kevin Brady Committee Chair ________________________________ ________________________________ Dr. Brad Mehlenbacher Dr. Chad Hoggan DEDICATION I am dedicating this research to my mother, Margaret Ann Smith. She believed in me while I was trying to get a G.E.D., convinced me that education was the path to a life of security and opportunity, and then inspired and supported me as I kept moving until I had reached the top, my Ed. D. Mom is a great teacher that taught me so much about life and learning. ii BIOGRAPHY Born in Pennsylvania and having lived in Florida, Susan Smith Braithwaite moved to North Carolina in 1999. In 2000 she transitioned from full-time paramedic and part-time EMS instructor to a full-time program director at a community college. She has since remained in adult education, and is now a professor at Western Carolina University. This represented a long time career goal and a return to teach at her alma mater, a graduate of the Emergency Medical Care program in 1988. Susan began graduate study in 2003 when North Carolina State University offered a cohort program at Johnston Community College. With the encouragement of her mother, Susan began her graduate journey in a course entitled the Adult Learner, taught by Dr. Colleen Weissner. Dr. Weissner passed away while Susan was still on her graduate journey, but remains an inspiration of what it is to be an adult learner and to teach the adult learner. iii ACKNOWLEDGMENTS To the many friends and family that have supported the pursuit of a dream inspired by Dr. Weissner. Brittany and Lindsay, my beautiful daughters, who gave me the motivation to keep moving no matter how hard the journey. As a single mother, I felt they deserved the best life I could give them, and believed a graduate education was the way to give it. I missed many hours with my family to pursue this dream. My mother, Margaret Smith, spent hours reading my papers. Thank you for helping me believe in myself. I wanted to make you proud. This diploma is for you. Along the way I added some very special people. Pam Earp and Twyla Wells have been with me since the first day of class and through every challenge along the way. I am so indebted and proud of you both. We did it. To Robert Braithwaite, who joined the journey as I was working on my dissertation and became more than a supportive friend, but grew into the love of my life. To the Noltes’, for giving me a warm home away from home to keep the dream alive while I drove and wrote. To Amanda, a very dear lifelong friend. To the thirteen brave men and women that fought through tears and difficult memories to share their story, all for the hope of making EMS an even stronger profession. To my committee, Dr. Barcinas, Dr. Hogan, Dr. Mehlenbacher, and Dr. Brady, I can’t express the feeling of accomplishment to sit in a room with such talent and wisdom and have the opportunity to defend my work. Thank you for that honor. A special thank you to Dr. Susan Barcinas, Committee chair. You inherited a tired, scared doctoral student after Dr. Weissner passed and mentored me into a confident graduate. You were a friend and hero through my greatest achievement. iv TABLE OF CONTENTS LIST OF TABLES…………………………………………………………….……………. x LIST OF FIGURES…………………………………………………………..…………… xx CHAPTER 1: INTRODUCTION .......................................................................................... 1 PURPOSE OF THE STUDY/RESEARCH QUESTION ..................................................................... 2 CONCEPTUAL FRAMEWORK ................................................................................................... 3 SIGNIFICANCE OF THE STUDY ................................................................................................ 5 DEFINITION OF TERMS ........................................................................................................... 7 RESEARCH METHOD .............................................................................................................. 9 SUMMARY ............................................................................................................................ 10 CHAPTER 2: THE LITERATURE REVIEW .................................................................. 12 INTRODUCTION .................................................................................................................... 12 HISTORICAL PERSPECTIVE ................................................................................................... 13 EMERGENCY MEDICAL SERVICES OVERVIEW ...................................................................... 17 EMERGENCY MEDICAL SERVICES LITERATURE ................................................................... 22 Themes in EMS literature. .............................................................................................. 23 Professional ethics. ..................................................................................................... 24 Stress and job retention. .............................................................................................. 25 Decision-making. ........................................................................................................ 26 Resuscitation decisions. .............................................................................................. 28 ETHICS INTRODUCTION AND DEFINITIONS ........................................................................... 30 FOUNDATIONS OF ETHICS IN LITERATURE ........................................................................... 33 Modern period philosophy: Immanuel Kant. .................................................................. 34 Contemporary period philosophy: Lawrence Kohlberg. ................................................ 35 CURRENT TRENDS IN ETHICS LITERATURE .......................................................................... 37 Feminist perspectives. ..................................................................................................... 39 Bioethics. ........................................................................................................................ 42 Iserson model. ................................................................................................................. 45 Attributes..................................................................................................................... 45 EXPERIENTIAL LEARNING THEORIES IN LITERATURE .......................................................... 48 Constructivism: the orientation. ...................................................................................... 50 Fenwick’s perspectives: the framework. ......................................................................... 51 Experiential learning: the theoretical assumption. .......................................................... 53 John Dewey. ................................................................................................................ 54 David Kolb. ................................................................................................................. 56 Situated learning: the perspective. .................................................................................