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Reformulations of practice: beyond experience in paramedic airway management

  • Justin Mausz (a1) (a2) (a3), Seanan Donovan (a3), Meghan McConnell (a4), Corey Lapalme (a3), Andrea Webb (a3), Elizabeth Feres (a5) and Walter Tavares (a1) (a6) (a7) (a8) (a9)...

Abstract

Objective

“Deliberate practice” and “feedback” are necessary for the development of expertise. We explored clinical performance in settings where these features are inconsistent or limited, hypothesizing that even in algorithmic domains of practice, clinical performance reformulates in ways that may threaten patient safety, and that experience fails to predict performance.

Methods

Paramedics participated in two recorded simulation sessions involving airway management, which were analyzed three ways: first, we identified variations in “decision paths” by coding the actions of the participants according to an airway management algorithm. Second, we identified cognitive schemas driving behavior using qualitative descriptive analysis. Third, clinical performances were evaluated using a global rating scale, checklist, and time to achieve ventilation; the relationship between experience and these metrics was assessed using Pearson’s correlation.

Results

Thirty participants completed a total of 59 simulations. Mean experience was 7.2 (SD=5.8) years. We observed highly variable practice patterns and identified idiosyncratic decision paths and schemas governing practice. We revealed problematic performance deficiencies related to situation awareness, decision making, and procedural skills. There was no association between experience and clinical performance (Scenario 1: r=0.13, p=0.47; Scenario 2: r=−0.10, p=0.58), or the number of errors (Scenario 1: r=.10, p=0.57; Scenario 2: r=0.25, p=0.17) or the time to achieve ventilation (Scenario 1: r=0.53, p=0.78; Scenario 2: r=0.27, p=0.15).

Conclusion

Clinical performance was highly variable when approaching an algorithmic problem, and procedural and cognitive errors were not attenuated by provider experience. These findings suggest reformulations of practice emerge in settings where feedback and deliberate practice are limited.

Objectif

La pratique intentionnelle et la rétroaction sont nécessaires à l’acquisition de connaissances spécialisées. L’étude visait à examiner le rendement clinique dans des milieux où la présence de ces deux éléments souffre de cohérence ou est minime; selon l’hypothèse retenue, le rendement clinique, même dans des domaines algorithmiques de pratique, se manifeste par des comportements qui peuvent mettent en danger la sécurité des patients, et l’expérience n’est pas garante du rendement futur.

Méthode

Des ambulanciers paramédicaux ont participé à deux séances de simulation enregistrées, portant sur le rétablissement de la perméabilité des voies respiratoires; ces séances ont été analysées sous trois angles : premièrement, les différences de « chemin de décision » ont été relevées par le codage des actions des participants en fonction d’un algorithme de rétablissement de la perméabilité des voies respiratoires; deuxièmement, les schémas cognitifs à l’origine des comportements ont été jugés à l’aide d’une analyse descriptive qualitative; troisièmement, le rendement clinique a été évalué à l’aide d’une échelle globale de notation, d’une liste de vérification et de la mesure du temps nécessaire pour rétablir la ventilation; la relation entre l’expérience et ces mesures a été évaluée à l’aide d’une corrélation de Pearson.

Résultats

Trente participants ont réalisé, au total, 59 simulations, et l’expérience moyenne était de 7,2 (écart type=5,8) ans. Les auteurs ont observé des habitudes de pratique très variables, et ont relevé des « chemins de décision » et des schèmes de pratique idiosyncrasiques. Des faiblesses importantes de rendement, liées à la perception de la situation, aux prises de décisions et aux compétences techniques ont été notées. Il n’y avait pas de relation entre l’expérience et le rendement clinique (scénario 1: r=0,13, p=0,47; scénario 2: r=−0,10, p=0,58) ou le nombre d’erreurs (scénario 1: r=0,10, p=0,57; scénario 2: r=0,25, p=0,17) ou le temps nécessaire pour rétablir la ventilation (scénario 1: r=0,53, p=0,78; scénario 2: r=0,27, p=0,15).

Conclusions

Des différences importantes de rendement clinique ont été notées au regard de problèmes algorithmiques, et l’expérience des fournisseurs de soins ne compensait pas les erreurs cognitives ou techniques. Les résultats donnent à penser que des changements de pratique se produisent dans des milieux où il y a peu de rétroaction et de pratique intentionnelle.

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Copyright

Corresponding author

Correspondence to: Justin Mausz, Centennial College, School of Community and Health Studies, P.O. Box 731, Station A, Toronto, ON L4W 1G6, Canada; Email: jmausz@centennialcollege.ca

References

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