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[Ace844]

Hi Everyone,


I saw this and wasn't quite sure where to post it...but since it is related to some of the other topics here and it's abit long I figured it warranted it's own "post". It's an interesting read...and I'm curious to hear what others think... you can get the articles and more here:: http://www.jephc.com/

ABSTRACT
This paper is the first in a series that heralds a study examining paramedic accounts and constructs of judgment and decision-making (JDM) of mental health and mental illness. Providing an introduction and background to the evolving study, the paper will establish a warrant for the research and scope of the research agenda and methods of inquiry.

Keywords
clinical judgment; clinical judgement; decision-making; mental health; paramedic practice


Background to the Research
The provision of appropriate mental health services for Australians is an urgent national health priority. The National Mental Health Report 2000 cites that almost one in five (18%) Australians suffers from a mental disorder, and that 3% of the total population live with a serious psychiatric disorder at any one point in time.1 Fundamental changes to health-care policy in Australia and around the world have led to an increase in the extent to which emergency personnel come into contact with patients experiencing mental health problems.2,3 The launch of the National Mental Health Policy by the Australian Health Ministers in 1992 provided the stimulus for significant changes to psychiatric services within the Australian health-care system.4 Mainstreaming of services was a central feature of these changes, shifting the provision of traditional psychiatric care from dedicated institutions to integration and co-location with mainstream general health services and community settings. Such changes to mental health service delivery have been problematic for health-care workers across many disciplines. The decentralisation of mental heath services has resulted in increased attendance at emergency departments and to emergency medical services by patients with mental health problems, something well documented in Australia and around the world.2,4,5 Some facilities have reported a 10-fold increase of the number of patients presenting to the Emergency Department (ED) with mental health problems in 10 years.6 Health care workers from a variety of disciplines have reported perceiving themselves as lacking the skills and expertise to provide appropriate care and treatment to this client group.1,4,5,7,8 Such events and factors have meant that health-care workers, particularly community health and emergency personnel, are increasingly required to manage a variety of patients mental health problems, often complex and chronic in nature.1-4, 6 In Queensland, legislation has recently undergone major revision in line with national and international reform in the provision of mental health services. The Mental Health Act 2000 (Qld) (MHA)9 is, broadly speaking, the major legislative instrument regulating involuntary treatment and protection of people who have mental illnesses in Queensland. The MHA provides for the involuntary assessment, treatment, and protection of persons experiencing a mental illness while at the same time safeguarding their rights. While the MHA focuses on the aspects of mental illness that cannot be dealt with in other legislation, it does not specifically provide for voluntary treatment of mental illness. Voluntary treatment of mental illness is regarded in the same way as treatment for any other illness, with the protection of rights secured by other legislation. The MHA has been drafted to comply with the National Standards for Mental Health Services (1997), the United Nations Principles for the Protection of People with Mental Illness and for the Improvement of Mental Health Care (1997), and a model mental health legislation agreed to by all Australian states and territories. The MHA also reflects contemporary clinical practice, international, national, and state policy directions, and broad community expectations. An important aim of the MHA is to reduce the stigma associated with mental illness.

The MHA provides for the involuntary assessment, treatment, and protection of persons (whether adults or minors) who have mental illness while at the same time safeguarding their rights. Emergency provisions under the MHA exist for police officers, paramedics, and psychiatrists. Pursuant to section 33(1) of the MHA, a paramedic (or a police officer) may make an emergency examination order for involuntary admission where the officer ‘reasonably believes’ that: (a) a person has a mental illness; and ( because of the person’s illness there is an imminent risk of significant physical harm being sustained by the person or someone else; and © proceeding under Division 2 (Justice’s examination order) would cause dangerous delay and significantly increase the risk and harm to the person or someone else; and (d) there is no less restrictive way of ensuring the person is assessed.9 The MHA defines mental illness as ‘a condition characterised by a clinically significant disturbance of thought, mood, perception or memory’. The MHA further defines ‘belief’ as a ‘reasonable belief’, which is characterised as a ‘belief on grounds that are reasonable in the circumstances’. An emergency examination order is dependent on the belief of the paramedic that the patient meets all of the criteria set out in section 33(1) of the MHA. The emergency examination order made by a paramedic or police officer is critically informed by a determination, or a judgment of the paramedic or police officer, that satisfies the criteria for involuntary admission. In the event that an individual does not satisfy the criteria for involuntary assessment, the provisions of the MHA do not apply.


The Research Problem
Paramedics are required to undertake rigorous, thorough, and complete assessment of their patients, often in difficult or emergency situations. Paramedic assessment of mental status is essential in determining the appropriate treatment for patients presenting with a mental illness. The introduction of new Queensland mental health legislation precipitated widespread industrial concern within the Queensland Ambulance Service (QAS) regarding the ability of paramedics to comply with explicit legislative requirements, citing poor education in mental illness and assessment techniques. The QAS prepared and distributed an in-service education program on the new MHA, which was designed primarily to orientate paramedics to the administrative functions of the MHA to meet their statutory and professional obligations. Its introduction was problematic. Paramedics expressed concern voiced through the union about the quality of existing education of its members and the ability of paramedics to satisfy legislative requirements owing to limited education and training in mental illness historically. Paramedics at the time expressed concern for their preparedness to manage mental illness in practice given the prevailing policy frameworks and contexts. The introduction of this education program signalled the existence of other issues in this context, and provided an opportunity to examine the relationship between theory and practice in paramedics’ judgment and decision-making (JDM). Importantly, it has highlighted the dearth of knowledge and research, substantiated by a literature search, about paramedic knowledge, judgment, and clinical decision-making in the context of mental health, mental illness, and mental health assessments.


Six key themes are discussed that establish the warrant and justification for the research.

1. Industrial Relations and Action
The introduction of new legislation governing the practice of paramedics of the Queensland Ambulance Service (QAS) has precipitated significant industry concern about the ability of paramedics to satisfy legislative requirements citing insufficient education and training in mental illness. These concerns are mirrored in the related literature that examines mental health assessment and management practices in medicine, nursing, and the allied health professions. The related literature of studies into the nursing and medical professions illustrates that generally the recognition and care of mental illness is limited.2-5, 7, 8 This literature demonstrates the problematic nature of knowledge, recognition, and management of mental illness by health-care professionals, and that further education and training of such professionals is required. To date there has been no published study found that specifically examined paramedic mental health knowledge, judgment, and decision-making practices nationally or internationally.


2. Statutory and Legislative Obligations
The style and working provisions of the various mental health Acts worldwide have attracted intense criticism in the international literature. In particular, the major area of concern relates to the conditions in which clinical judgments that precipitate involuntary assessments are made. Holdsworth and Dodgson10 report that the Mental Health Act (2004) (UK) seriously impairs the clinical reasoning practices of individuals who act under provisions of the legislation in clinical or practical settings. Stating that the use of criteria that are based on frequentist statistical analysis excludes the ability of the clinician to use information idiosyncratic to the individual in making clinical judgments, Holdsworth and Dodgson10 argue that legislation of this nature over-values statistical frequency of clinical risk assessment and under-values idiosyncratic qualitative information, which is much more difficult to explicate, represent, or qualify. The use of objective statistical frequency assessments in determining clinical risk without concomitant weight or consideration to idiosyncratic qualitative judgments has been strongly criticised.11 The workings of Australian mental health Acts are yet to be examined in the published literature and will be examined in detail in this study.


3. Paramedic Clinical Practice and Clinical Practice Policy
In order to improve clinical practice and clinical governance, the QAS has published a clinical practice manual consisting of a series of clinical guidelines, protocols, and flowcharts, including one for the management of ‘psychiatric emergencies’. The protocol is designed to provide paramedics with a guide to managing patients who are suffering a ‘psychiatric emergency’. In simple terms, the protocol requires that all paramedics transport their patients who they suspect suffer from a ‘psychiatric emergency‘ to definitive medical care. This policy, and its workings, is at odds with provisions of the MHA, which require paramedics to take action based on ‘reasonable beliefs in such circumstances’. The workings of this discrepancy in terms of conflict in judgment by paramedics in practices are of interest to this study. Shaban and colleagues12,13 suggest that the protocol is problematically constructed, narrow in the breadth of psychotic disorders, not reflective of the spectrum of mental illnesses, heavily biased towards a small percentage of psychotic disorders, and has significant limitations in view of the context and challenges presented to paramedics in the emergency care setting. The protocol will be the subject of further analysis in the continuing study. Anecdotally, the majority of cases reported by paramedics relating specifically to psychiatric emergency are those where there exists unacceptable risk of suicide, self-harm, or harm to others. No definition for ‘psychiatric’ is provided in the wider context of mental illness. It is suggested that lack of characterisation of the category limits or biases the use of it in the field. The term ‘psychiatric’ is narrow and may only reflect states of psychosis or serious psychiatric states (e.g. suicide) rather than broader mental health conditions encountered by paramedics that are more prevalent in the community. The generic classification of mental illness and mental disorders by paramedics as ‘psychiatric’ is problematic, particularly as it relates to conventional and contemporary definitions of mental illness. No other category exists to which mental illness other than that which is ‘psychiatric’ could be applied.


4. Paramedic Education and Training Programs
Accredited paramedic and ambulance officer education and training programs are relatively new.12,13 The practice of paramedics and ambulance officers on a state, national, and international level may be characterised as a craft or guild. With the exception of a recent in-service undergraduate degree, all ambulance education programs are of a competency-based training (CBT) nature. CBT, an extension of competency-based education based on behavioural learning theory, focuses primarily on demonstrated outcomes rather than inputs. It is concerned with what someone may be expected to do, rather than on what actual learning processes occur.14 The capacity of paramedics with either CBT or Diploma based qualifications to conduct complex cognitive assessments, such as mental health assessments, has not been examined. Shaban and colleagues12,13 suggest that in, in principle, the level of existing ambulance qualifications does not adequately prepare paramedics to make clinical judgments in contexts outside those they have learned, and may be of limited relevance in complex or uncertain environments and ecologies.

In view of this, even more problematic is the notion that paramedics are performing tasks that may or may not lead them to a ‘belief’ that someone is mentally ill when in fact the characteristics or assumptions that determine it to be ‘belief’ have not been described or examined. Patel, Arocha, and Kaufman15 argue that the concept of ‘belief’ is justified and is based on knowledge explicitly formulated in symbolic forms. These symbolic forms or ‘beliefs’ of paramedics surrounding mental health, mental illness, and mental health assessments have not been examined in the published research. The widespread systemic and profound negative stereotyping of mental illness within the community is well documented nationally and internationally.16

An analysis of QAS education, training, and professional development materials used from 1991 to 2003 12,13 reported an absence of explicit education and training in mental health assessment practices, clinical judgment, and decision-making. Analysis of this information, which included training materials, curricula, syllabi, clinical practice policies, and education records, suggests that ambulance officers and paramedics are not trained in comprehensive mental health assessment practice or clinical judgment and decision-making as it relates to mental health. The QAS Clinical Practice Manual (2003)17 provides a list of cues that officers should look for when managing someone with a ‘psychiatric emergency’. However, it does not detail declarative judgment processes as to how to conduct the assessment or how judgments would, should, or could be formed.


5. National and International Trends in Mental Health Care
The National Mental Health Report 2000 recommends increased participation of a wide range of health, welfare, and disability professionals and organisations in the provision of services to people with mental disorders.1 Further, the report calls for increased knowledge and understanding of mental health and mental disorders for all health-care professionals, an awareness of additional needs with increased co-ordination of services provided to consumers and carers, and increased community interest and involvement in mental health issues. In order to contribute to and participate in the national mental health reform agenda, paramedics must be provided with comprehensive education and training opportunities with particular focus on judgment and classification, and management of mental disorders within appropriate professional practice, policy, and legislative frameworks. The role or potential role, impact, and influence of paramedics in the wider mental health agenda have not been examined in the published literature nationally or internationally in this context.


6. The Literature
The largest body of research located in support of JDM relating to mental illness is limited to the professions of medicine, nursing, and police. While much research has been undertaken to investigate mental health assessment practices in the domain of psychiatry, research into practices in the ambulance or paramedic setting is limited. Few studies were found from other health-care disciplines (such as multi-disciplinary technical services) with no studies relating to the specific research problem of this study.

Studies of paramedic JDM in cases of mental illness or psychiatric emergency referrals are rare. A search of the national and international literature sourced ten articles that examined paramedic JDM. All the articles found related to the examination of paramedic JDM as it related to cardiac arrest, trauma, triage, or decision to transport patients to definitive medical care. No articles were located that examined the JDM practices of paramedics in the domain of mental health, mental illness, or mental health assessments.

The literature and theories on judgment and decision-making are as extensive as they are controversial. The fragmented nature of studies to date within the general health disciplines addressing aspects of clinical judgment process has not yet resulted in a comprehensive understanding of the phenomena18 or a suitable universal model or theoretical framework. Studies have traditionally followed or engaged one particular JDM paradigm or philosophy exclusively. Few, if any, have sought to view or examine JDM in more than one paradigm, which is a recent and growing criticism of the current body of research.18 Much of the work to date has applied descriptive approaches, such as information processing theory, in an attempt to contribute greater understanding of how judgments are made. In doing so, these studies, in the main, have provided greater insight into the cognitive process involved, particularly with respect to assessment practices. However, the ecological validity of many of these studies has been questioned,19-21 particularly with the criticism that they have focused on the representativeness of the judgment tasks presented.18 Many JDM studies have occurred in contexts and ecologies away from the clinical setting and therefore do not induce the same cognitive effect commensurate with the context.18,19

Conversely, some studies have focused primarily or exclusively on the accuracy or quality of the judgment or judgment process. To date, these studies have focused on judgment error in particular disciplines, largely the operations and management sciences.11 A major criticism of these studies, that are normative in nature, is that they negate to value of context, ecology, and interaction in examining the JDM processes.18, 22, 23 Other authors have criticised the methods by which risk, uncertainty, and stress have been quantified, arguing that no matter how quantified, the full effect of such factors can never fully be understood outside the context of the individual.24, 25 Sources of judgment errors in other contexts and disciplines need to be examined and explored. The use of prescriptive approaches, which attempt to improve JDM and help individuals to make better judgments, has also been criticised as a single paradigm of inquiry.18,22 Used considerably in teaching or instruction contexts and intervention studies, prescriptive models have been used to help individuals make better judgments and improve the quality of both the judgment and decision-making process. However, most studies have worked only within the prescriptive paradigm, resulting in significant limitations on the value of their findings in other contexts and paradigms.26 Further, a number of studies have attempted to improve JDM in the absence of any normative or descriptive data or constructs, and have failed because of a lack of understanding of the judgment process or the quality of a good judgments.18,22

It is clear that there are differing and competing accounts of judgment and decision-making in the literature and in research. In considering this study, it is apparent that none of the theories, philosophies and accounts of JDM individually are sufficient to address the specific research problems. There exists a dearth of judgment research in paramedic practice. A thorough literature review failed to locate research that examines the mental health assessment practices of paramedics. Given the recency of paramedic practice and pre-hospital care as a recognised discipline in healthcare, this omission is not unexpected.12, 27

There is a paucity of published work on critical thinking and clinical reasoning in this setting, which could suggest that the value of these skills are not yet fully appreciated in the field of pre-hospital care.12, 27 The few studies that have been conducted have examined JDM as it related to specific cases and instances (particularly cardiac arrest and trauma) and have worked within one particular JDM paradigm or theoretical construct, such as normative or prescriptive theory. These studies, as discussed earlier, are significantly problematic and have significant limitations due to study design or philosophical context. No article could be located that addresses either generally or specifically paramedic JDM practices with respect to mental illness, mental health, and mental health assessments, despite a growing warrant for this research. The absence of published research examining paramedic practice to achieve more accurate judgments (or indeed JDM at all) in the context of mental illness and mental health has meant that the impact of significant changes to practices precipitated by the MHA and trends in mental health care have occurred unexamined. The complexity of clinical situations faced by paramedics, where for example multiple contexts exists with significant levels of uncertainty, risk, and time criticality, most of which make clinical judgment process difficult has not been examined. The identification of strategies to support a more effective judgment processes a challenge has not been attempted.18

Summary and Future Considerations
The rapid change in paramedic practice and ambulance care over the last decade has precipitated a number of challenges to the profession to ensure the sufficiency of professional practice standards, education and training programs, clinical standards, and policy for ensuring quality practice and accountability in the field. This paper has presented the background and warrant for of an ongoing study into one important area of paramedic practice: the management of the mentally ill. At issue in this ongoing study and warrant for research is the preparedness of the role of paramedic and the ambulance profession to recognise, assess, and manage mental illness in everyday practice. This research provides for a unique opportunity to examine the relationship between theory and practice in paramedics’ judgment and decision-making JDM in the context of mental illness and mental health assessment.

Acknowledgments
The author would like to acknowledge and thank Mr Jim Higgins, Commissioner QAS, and Dr Richard Bonham, Medical Director QAS for their approval and support of this research. I would also like to acknowledge and thank Associate Professor Claire Wyatt-Smith and Professor Joy Cumming for their supervision and support, and Mr Jason Emmett for his editorial review of this manuscript.

References

1. Commonwealth Department of Health and Aged Care: The National Mental Health Report 2000: Changes in Australia's Mental Health Services under the First National Mental Health Plan of the National Mental Health Strategy 1993-1998. In. Canberra; 2000.
2. Wand T, Happell B: The mental health nurse: contributing to improved outcomes for patients in the emergency department. Accident and Emergency Nursing 2001, 9:166-176.
3. Green G: Emergency psychiatric assessments: do outcomes match priorities? International Journal of Health Quality Assurance 1999, 12(7):309-313.
4. Sharrock J, Happell B: The role of the psychiatric consultation-liaison nurse in the general hospital. Australian Journal of Advanced Nursing 2000, 18(1):34-39.
5. Salkovkis P, Storer D, Atha C, Warwick HMC: Psychiatric morbidity in an accident and emergency department - Characteristics of patients at presentation and one month follow-up. British Journal of Psychiatry 1990, 10:1-8.
6. Kalucy R, Thomas L, Lia B, Slattery T, Noris D: Managing increased demand for mental health services in a public hospital emergency department: A trial of 'Hospital-in-the-Home' for mental health consumers. International Journal of Mental Health Nursing 2004, 13:275-281.
7. Anstee BH: Psychiatry in the casualty department. British Journal of Psychiatry 1972, 120(625-629).
8. Bell G, Hindley N, Rajiyah G, Rosser R: Screening for psychiatric morbidity in an accident and emergency department. Archives of Emergency Medicine 1990, 7:154-162.
9. Mental Health Act (Qld). In. Brisbane, Australia: Queensland Government; 2000: 339.
10. Holdsworth N, Dodgson G: Could a new Mental Health Act distort clinical judgment? A Bayesian justification of naturalistic reasoning about risk. Journal of Mental Health 2003, 15(5):451-462.
11. Vincent C (ed.): Clinical risk management: Enhancing patient safety. London: British Medical Journal Books; 2001.
12. Shaban RZ: Mental health assessments in paramedic practice. In: B. Barlett. F. Bryer & R. Roebuck (Eds), Educating: Weaving Research into Practice. Brisbane: School of Cognition, Language and Special Education, Griffith University
13. Shaban RZ, Wyatt-Smith CM, Cumming J: Uncertainty, error and risk in human clinical judgment: Introductory theoretical frameworks in paramedic practice. Journal of Emergency Primary Health Care 2004, 2(1-2).
14. CCH Australia: Managing training and development. Canberra: CCH Australia Limited; 2004.
15. Patel VL, Arocha JF, Kaufman DR: Expertise and tacit knowledge in medicine. In: Tacit knowledge in professional practice. Edited by Sternberg RJ, Horvath JA. London: Lawrence Erlbaum Associates; 1999.
16. Fontaine KL, Fletcher JS: Mental health nursing. Sydney: Addison Wesley; 1999.
17. Queensland Ambulance Service: Clinical Practice Manual. Brisbane: Department of Emergency Services, Queensland Government; 2004.
18. Thompson C, Dowding D: Clinical decision making and judgement in nursing. London: Churchill Livingstone; 2002.
19. Gordon M: Strategies in probabilistic concept attainment: A study of nursing diagnosis. Doctoral Dissertation. Massachusetts: Boston University; 1972.
20. Greenwood J, King M: Some surprising similarities in the clinical reasoning of 'expert' and 'novice' orthopaedic nurses: Report of a study using verbal protocols and protocol analyses. Journal of Advanced Nursing 1995, 22:907-913.
21. Tanner CA, Benner P, Chelsa C, Gordon DR: Diagnostic reasoning strategies of nurses and nursing students. Nursing Research 1987, 36(6):358-363.
22. Hamm RM, Scheid DC, Smith WR, Tape TG: Opportunities for applying psychological theory to improve medical decision making: Two case histories. In: Decision making in health care: theories, psychology and applications. Edited by Chapman GB, Sonnenberg FA. Cambridge: Cambridge University Press; 2000.
23. Cooksey RW: Judgment analysis: Theory, methods and applications. Sydney: Academic Press; 1995.
24. Hammond KR: Human judgment and social policy: Irreducible uncertainty, inevitable error, unavoidable justice. London: Oxford University Press; 1996.
25. Hammond KR: Judgments under stress. New York: Oxford University Press; 2000.
26. Chapman GB, Elstein AS: Cognitive processes and biases in medical decision making. In: Decision making in health care: theories, psychology and applications. Edited by Chapman GB, Sonnenberg FA. Cambridge: Cambridge University Press; 2000.
27. Lord B: Book review: 'Clinical reasoning in the health professions'. Journal of Prehospital Emergency Primary Health Care 2003, 1(3-4).

This article was peer reviewed for the Journal of Emergency Primary Health Care Vol.2 (3-4) 2004

Author Disclosure
The author has no financial, personal or honorary affiliations with any commercial organization directly involved or discussed in this study.

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2005; Volume 3 : Issue 1-2
Article Number: 990114

Theories of clinical judgment and decision-making: A review of the theoretical literature
Ramon Shaban


ABSTRACT
This paper provides a survey of the terrain of theories of human judgment and decision-making (JDM). It provides an introduction, overview, and some insight into the understanding of some conceptual theories, frameworks, and the literature of JDM. This paper is in no way an exhaustive meta-analysis of the literature on JDM, nor is it intended to be. It does not seek to categorise and compare existing theories of judgment and decision-making or critically evaluate each in terms of others, nor does it seek to reclassify existing categories. Indeed much of the debate in the literature is about that very issue—how researchers and theorists view, characterise, categorise and apply existing theory of JDM in existing philosophies, ‘schools-of-thought’, and professional domains. The problematic, controversial, and, in the view of some researchers, inappropriate attempts to do so are well-documented.1-4 This paper will provide an overview of the competing accounts that various theories and philosophies place on judgment and decision-making.

INTRODUCTION
There is a well-developed and growing body on judgment and decision-making (JDM). Considerable debate exists about the constructs and definitions of judgment and decision-making. Much work has been done in an attempt to define the constructs of human clinical judgment.3, 5-10 Several authors have sought to describe JDM using a number of different expressions and constructs essentially to describe the same phenomena.1 There is no one universal or ‘true’ definition of JDM, with descriptions of JDM varying considerably across disciplines, professions and philosophies. Other representations of the constructs of judgment and decision-making include clinical decision-making,1, 11-13 clinical judgement,1, 5, 6, 14, 15 clinical inference,16clinical reasoning,17,18 and diagnostic reasoning.19, 20

In a professional clinical context, judgment is viewed as a “professional choice rather than tasks: real life practice rather than imagined activities of those who see professional status as a good in its own right rather than a means to a desirable, namely the higher quality care and treatment of patients”1, p.7. Dowie21 defines judgment as ‘the assessment of the alternative’, the ‘choosing between alternatives’, and argues that judgments are always in some way an assessment of the future. In proposing this, Dowie argues that if a decision is to be considered sensible then surely some knowledge of what the future might look like after the decision is made is required. Individuals predict the future when making decisions all the time; otherwise choices would be made with no thought as to the likely consequences of the decision. When making choices, individuals draw on a variety of sources of information: experience, the ‘first principles’ of stored knowledge or facts, the expertise of others, and occasionally the experiences of tens, hundreds, even thousands, of others in the form of research evidence.1 Decisions are not always made with ‘complete’ or ‘true’ objectivity, and indeed many wage an argument that complete and objective judgment providing the ‘truth’ is always, on some level, biased. Sadler22 and others argue that no consideration of the nature of qualitative judgments proceeds far before the matters of subjectivity and objectivity are raised. Others insist that the notion of uncertainty is an underestimated component of JDM processes, particularly in stressful circumstances and contexts.10, 23 Hammond 10 suggests there exists a level of irreducible uncertainty in all JDM, particularly in the context of social policy, and argues that all judgments and decisions are flawed and fallible on some level. Thompson and Dowding1 claim that individuals’ experiences are commonly distorted with hindsight, and people can be selective in providing the information they think is needed where first principles often have to be recast as new knowledge replaces old.


‘CLASSICAL’ DECISION-MAKING PARADIGM
In a broad context, theories of human judgment and decision-making may be viewed from a number of different positions and philosophies. Decision-making, as a scientific inquiry, was first established in the early 1950s by Edwards24 and Hammond.25 This work was continued and through the work of Tversky, Kahneman and others, it has flourished. One of the original paradigms of JDM, referred to as ‘classical decision-making’ (CDM), views the decision maker as acting in a world of complete certainty.3 The classical decision maker faces a clearly defined problem, knows all possible action alternatives and their consequences, and chooses the optimum alternative. Often used in management, CDM theory has been applied in multiple contexts in the health professions, although Chapman3 and others note that CDM may not fit well in chaotic worlds, uncontrolled environments, or critical situations. CDM models are often used in controlled settings and environments in purely theoretical and non-applied constructs. Most predominantly found in laboratory settings, CDM models and theories seek to prescribe the correct way to make a decision in an ideal situation, environment or world.


‘NATURALISTIC’ DECISION-MAKING PARADIGM
During the mid-1980s, growing criticism of CDM led to a reframing of thinking on JDM theory. A new philosophical paradigm referred to as ‘naturalistic (or behavioural) decision- making’ (NDM) was developed.26 NDM recognises that human beings operate with cognitive limitations in bounded rationality. Orasanu and Connolly27 describe characteristics of decision-making in naturalistic environments as those presenting with ill-structured problems in uncertain, dynamic environments with shifting, ill-defined, and competing goals. In these ecologies, time constraint is a significant factor, requiring assessment, interpretation and assimilation of multiple data from multiple sources, often in high stakes settings. Organisational norms, goals, and expectations are often balanced against the decision maker’s personal choice. The naturalistic decision maker faces a problem that is not clearly defined, has limited knowledge of possible action alternatives and their consequences, and chooses a satisfactory alternative.26 It assumes that the decision maker acts only in terms of what they perceive about a given situation. This model of decision-making is more appropriate in the contexts of chaotic environments with uncertain conditions and limited information. Individuals rely primarily on their experience in making naturalistic decisions.28

DESCRIPTIVE THEORIES
Descriptive theories, naturalistic and behavioural in nature, originate from the philosophies and professions of psychology and behavioural science.2 Specifically, descriptive theories are interested in understanding how individuals actually do make judgments and decisions. Descriptive theories place no restriction on whether the individual is rational and logical or irrational and illogical, and seek to understand how individuals make judgments and decisions in the real world, focusing on the actual conditions, contexts, ecologies, and environments in which they are made.1 Irrationality in this context refers to instances where individuals have not given any thought to the process of judgment or decision-making, and, even if they have, are unable to implement the desired process.2 These theories seek to understand the learning and cognitive capabilities of ‘ordinary people’ and aim to determine if their behaviour is consistent ‘rational’.2 Context, interactions, and ecology are central to the interpretation and study of descriptive JDM theory.

Arguably the most influential and frequently used descriptive theory or model used in nursing and the midwifery is that of ‘information processing theory’ (IPT). 29 Information processing theory, also referred to as ’hypothetico-deductive approach’, suggests that human judgment and the reality of reasoning are ‘bounded’ and limited to the capacity of the human memory. 29 IPT suggests that individuals, in making decisions, go through a number of stages that are guided predominately by the acquisition of cues from the environment.1 Many authors have proposed variations of essentially the same phenomena with this theory.20, 30-32 Descriptive models and theories of JDM place significant emphasis on investigating, heuristics, uncertainty, biases, and error in JDM. Heuristics are simplifying strategies or ’rules of thumb’ used to make decisions, and make it easier to deal with uncertainty and limited information. Thompson and Dowding1 describe a number of categories of heuristics. ‘Availability heuristics’ base decisions on recent events that relate to the situation at hand. ‘Representativeness heuristics’ base a decision on similarities between the situation at hand and stereotypes of similar occurrences.26 ‘Anchoring and adjustment heuristics’ base a decision on incremental adjustments to an initial value determined by historical precedent or some reference point. Although useful when dealing with uncertainty, heuristics often lead to systematic errors that affect the quality and/or ethics of decisions.1

Descriptive theories as methods of inquiry have been applied to multiple professions for nearly half a decade. Large bodies of descriptive theory research have been conducted, particularly in the nursing profession.1, 33 A distinct feature of descriptive theories is that they are not concerned with the quality of the judgment or the outcome of the decision in any qualitative way. How the individuals arrive at a judgment or decision, regardless of how good or bad it may be, is paramount. Evaluation of judgments and decisions within this philosophy is based on the empirical validity or extent to which the model observed corresponds to the observed choices in the judgment or decision.

NORMATIVE THEORIES
Normative theories of JDM, classical and positivist in nature, were born from the statistical, mathematical, and economic philosophies.2 In this domain, researchers (often referred to as decision theorists) seek to propose rational procedures for decision-making that are logical and may be theorised. The focus of normative theory is to discover how rational people make decisions with the aim of determining how decisions should be made in an ideal or optimal world, where decisions are based on logical and known conclusions supported by clear or probable evidence. Normative theories, often based on statistics and probabilities within the positivist domain, propose to evaluate how good judgments should be made and how good outcomes should be achieved.1 Normative theories give little or no consideration to how judgments are made by ‘ordinary people’ in reality and everyday practice, and place little or no emphasis on the context or ecology of the judgment.2 They are concerned only with optimal conditions and environments, and assume that decision makers are ‘superrational’, 34 with little or no emphasis on how JDM occurs in the ‘real’ world.

‘Expected utility theory’ (EU) and ‘subjective expected utility theory’ (SEU) are the normative approaches of choice, often referred to as the gold standard for optimal decision-making. Subjective expected utility theory is a normative approach that takes into account the decision-makers values or beliefs in a ‘rational’ context and calculates the probability of various outcomes occurring before identifying the optimum decision for that individual.3 ‘Multi-attribute utility theory’ is the normative theory of decision-making with multiple goals. A common normative approach to JDM is ‘Bayes Theorem for Judgments’. A central tenant of normative theories is the assessment and explication of risk. In order to determine how judgments and decisions should be made, comprehensive risk analysis must be undertaken and all possible risks are explicated and weighted.1 Decision analysis is the direct implementation of these theories to specific decisions. Decision analysis and the use of decision trees based on the predicability of event probability and statistics occurrence is commonly used to assist in JDM in medicine.1 Clinical decision analysis uses techniques to make the decision-making process explicit by breaking it down into processes and components so the effect of different observations, actions, probabilities, and utilities can be analysed.21 Decision trees work by breaking down problems into smaller decisions and choices and adding numerical values such as the probability of the events to each part of the decision. Once each choice has been assigned a probability, based on the assumption that this is possible, the option with the highest utility for the decision maker can be calculated.1 Often referred to as ‘expected utility theory’, the model attempts to quantify the probability of the most likely and most desirable event in an attempt to assist the individual or group in making that judgment or decision by making it known. Decision analysis has been applied in multiple settings:1 assisting women to make decisions to continue with a pregnancy with risk of Down’s Syndrome in childbirth, 1, 35 and deciding on the types of intervention that should be used for psychiatric patients with violent tendencies.36 Chapman and Sonnenberg 3 criticise the use of decision analysis in instances where probabilities are based on cultural or societal norms from areas and locations outside of the use area.

Judgment and decision-making in the context of uncertainty, stress, and social policy has been the focus of much of the work of Hammond 10, 23 and many others. Large bodies of statistical and probabilistic theory, such as Bayes Theorem, seek to manage or redress this uncertainty and stress in judgment making. Reason 37 and Vincent 38 have examined errors and slips in JDM, proposing that human error is based on one or more of, or a combination of, skills-based failure, rule-based failure, and failure at knowledge-based level. They and others have examined the use of rule-applications processes in an attempt to limit bias and error in JDM.39, 40 Risks assessments, tools, scales, and measurements have been in use in medicine for years and are prolific in the medical, psychological and scientific literature.1 Such instruments seek to quantify risk and, in doing so, aim to make all risks known.

A major criticism of normative theoretical approaches is that they fail to capture the reality of most decision situations in heath-care, particularly in nursing, that are characterised by incomplete knowledge of all available alternatives, a lack of reliable probabilistic data of the consequences of these alternatives, and few readily acceptable techniques for reliably gauging patient utility.41 Normative theories rely on the quantification of risk in complete and known ways, which many have argued is not possible.1, 3 Hastie and Dawes42 suggest that good decisions are those in which the process follows the laws of logic and probability theory. Others have argued that it is not possible to identify, assign relative probabilistic weight to, and account for all aspects of risk, particularly in medicine and health care.10, 23, 25 Attempts to do so provide an analysis that is only valid for one point in time with significant, unrepresented, and unaccounted bias.

PRESCRIPTIVE THEORIES
In 1982, Bell, Raiffa, and Tversky 2 challenged the dichotomy of normative and descriptive theories. A growing group of individuals had expressed discontent and opposition to the notion of a dichotomy in the theorising and understanding of JDM. Rather than forcing JDM into diametrically opposed philosophies, this group proposed the need for theories to improve the quality of decisions and judgments in practice. In challenging the existing dichotomy, Bell et al.2 suggested that in fact the central purpose for examining JDM is to help individuals make better decisions. A number of researchers were concerned with devising methods that incorporate the insights gained from normative theories in ways that recognised the cognitive limitation of individuals. Others were concerned with explaining rational models in a manner that would appeal to ordinary people. Bell et al 2 established a third philosophical stance, known as ‘prescriptive theory’, thereby creating a trichotomy. This third philosophy is often used in operational research and the management sciences in an attempt to help people to make good decisions and train them to make better decisions.

Prescriptive theories set out to ‘improve’ the judgments and decisions of individuals by investigating how people make decisions.1, 2 The focus of prescriptive theories is to ‘help’ or ‘improve’ individual’s judgments. In evaluating the application of prescriptive models and theories that attempt to aid in the JDM process, the central question asked is pragmatic—did it make the judgment any better? Prescriptive theories have been applied in multiple settings and contexts. Decision analysis and decision trees (normative techniques described earlier) are used commonly in prescriptive modelling in medicine to improve clinician JDM.1 A recently introduced but now common prescriptive model for assisting JDM in clinical settings is the use of clinical guidelines and clinical policies. Clinical guidelines are prescriptive tools used to assist practitioner and patient decisions about appropriate health-care for specific circumstances.1 They are largely guidelines that outline operational information, procedures, and guidelines with options, and are often referred to as ‘protocols’. Primarily aimed at improving the quality of care or standardising care, guidelines are mechanisms for reducing variations in clinical practice and discouraging practices that are not based on sufficient evidence.1 While they have been found to provide improvements in the quality of care,43 the effects of their application are significantly variable and the extent to which they are routinely applied is not clear.44

Woolf et al.45 argue that clinical guidelines clearly benefit users and patients, although their use is reported to be overtly problematic,46 particularly given that they can contribute to an illusion of a single answer for a complex problem.1, 47 Guidelines themselves are supposed to, but may not, contain the best available research evidence, and may lead to judgments that may not have otherwise been made because of the absence of a more suitable options. Thompson and Dowding1 argue that decisions do not occur in a vacuum, and that individuals operate in complex environments having to assess and weigh multiple data on multiple levels at multiple times. Schon 48 argues that clinical guidelines should never (and should never claim to) aim to cover all aspects and possibilities of the JDM process.

Computer-assisted decision-making has also recently been applied to assist with JDM, particularly in the operational areas of industry, science, aviation, and medical and emergency call centres.1 Computer-assisted decision-making software such as Medical Priority Dispatch System (MPDS) has been implemented in a number of emergency services nationally and internationally, including in Australia. Farrand et al49 examined the introduction of a computerised dispatch system into an EMS call centre traditionally staffed with nurses. The study found that while attempting to formalise nurse decision processes using artificial intelligence the complexities of the decision processes were revealed. An assessment of the accuracy of the decision process, using an expert panel review of 1,006 calls, found almost perfect sensitivity with telephone triage and decision whether to send an EMS resource or not. In this instance, the study demonstrated that nurses JDM processes in this setting were sophisticated .1 Other studies have reported similar findings. 50, 51


SOCIAL JUDGMENT THEORY
An alternative way of looking at judgment is by comparing the ‘quality of the judgment’ and the ‘judgment process’. Accuracy, as a measure of the quality of JDM, is popular across a broad spectrum of disciplines and philosophies. One theoretical framework that provides a mechanism to measure the accuracy of judgment is ‘social judgment theory’ (SJT). The central assumption of SJT is that an individual’s judgment relates to the reality of their social environment and that the environment can be represented by a series of lenses.7

A central SJT theoretical approach for the study human judgment, proposing scope and theoretical framework constructs for judgment analysis is the ‘Lens Model’. Social judgment approaches use the relationship between the information and the outcomes of interest as the basis for establishing the criterion. The ‘Lens Model’ is an alternative approach for the study of human judgment, proposing scope and theoretical framework constructs for judgment analysis. According to Hammond 2, p.167 “an organism is depicted as a lens; that is, it ‘collects’ the information from the many cues that emanate from an object and refocuses them within the cognitive system of the organism in the form of a judgment about the object”. Cooksey1 presents a number of variations in ‘Lens Model’ analytic assessment systems, each placing different emphasis on the different aspects, types, and contexts of judgment. The characteristics and application of the ‘Lens Model’ is described in considerable detail elsewhere by Shaban, Wyatt-Smith & Cumming.52


INTUITION
A popular alterative method for explaining how health-care workers such as nurses and midwives make judgments and decisions has been the notion of intuition.1 Intuition has been defined in the literature in many ways,1 such as ‘understanding without a rationale’6 or an ‘immediate knowing of something without the conscious use of reason’, 53 ‘knowledge of a fact or truth, as a whole, with immediate possession of knowledge and an independence from linear reasoning process’.54 Although there is no agreement in the literature as to a universal definition of intuition, there is a common assumption about its contextual meaning. A common theme throughout all the definitions of intuition is the notion that the judgment and reasoning process just happens, cannot be explained, and is not rational. 1 Benner 5, 6, 14 first examined the notion of ‘nurse intuition’, establishing that expert nurses display intuitive judgment that is not found in novices. In Benner’s interpretation, the ability to make judgments intuitively characteristically distinguishes experts from novices and, in doing so, expert nurses are no longer reliant on analytic principles to connect their understanding of a situation to an appropriate decision and action.1

One strength of the intuition is that is acknowledges the ability of individuals to know or readily and quickly recognise the possible outcomes of a given situation—a key element of decision-making in situations of risk and uncertainty.1 However, this theory has attracted intense criticism over the last decade, particularly in that experts who rely heavily on intuition demonstrate knowledge constructs that are ‘context nature specific’, and therefore the nature and applicability of their knowledge is largely limited to narrow, specific contexts.55 For example, Dowding7 argues that a major criticism of ‘nurse intuition’ is that the expertise and ‘intuition’ is grounded around a specific context and is of a specific nature, and that nurses cannot take their ‘intuition’, knowledge, or skills and apply them out of that context. Further the notion of intuition has been criticised when contextualised against ‘truth’ or ‘knowing of the truth’, in that it disregards the positivist paradigms in which much of medicine and health-care is grounded. Thompson & Dowding 1 argue that expertise is almost entirely connected to a more extensive knowledge base, because experience itself is knowledge.


EXPERT-NOVICE THEORY
Expertise, as a theory for JDM, was first promulgated in the late-1960s largely due to attempts to develop artificial intelligence systems.56 The definition of ‘expertise’ is as problematic and controversial as that of judgment. Chi et al., 56 in characterising this expert-novice phenomenon, suggest that experts excel mainly in their own domain/s in which they perceive possess large meaningful patterns of knowledge. Experts are fast; they are faster than novices at performing skills of their domain and they quickly solve problems with little error, demonstrating that experts have superior short-tem and long-term memory. Experts see and represent a problem in their domain at a deeper level than novices; novices tend to represent a problem at a superficial level. Experts spend a great deal of time analysing a problem qualitatively and have strong self-monitoring skills.

The expert–novice theory has been widely applied to multiple professions and contexts.14, 56, 57 Experts achieve better clinical results, where reasoning is based on accurate and technical competence, although Higgs and Jones 58 argue that other outcome dimensions, particularly from that of the patient’s perspective, may be lacking in peer-judged contexts. Alexander and Judy 59 argue that individuals who monitor and regulate their cognitive processing during task performance demonstrate expertise. This concept, known as metacognition, is essential to high quality human performance. Experts demonstrate the ability to manage their intellectual resources and possess a wealth of domain-specific knowledge, including propositional knowledge, craft knowledge, and personal knowledge.59 Expert theories and its immediate extension, expert-novice theory, are theories used widely across multiple disciplines and contexts, particularly in health, education, and the humanities.1


COGNITIVE CONTINUUM
A number of researchers and theorists suggest that clinical reasoning practices are based on a combination of IPT stages and intuition. This theory, referred to as ‘cognitive continuum’, suggests that reasoning is neither purely intuitive nor purely analytical, and that it is located somewhere in between.1 Cognitive continuum is described as a prescriptive model, as it aims to help people improve their judgments.1 In order to ascertain what cognitive mode is in use, three factors must be known: the structure of the task, the number of information cues, and the time available to make the judgment or decision. Intuition, in this interpretation, is viewed as the most appropriate form of cognition in instances where a task is poorly structured, multiple information cues available, and there is little time for judgment or decision-making to occur. Conversely, if the task is largely structured, with few information cues available, and much time available for JDM, then an analytical approach is appropriate. Thompson and Dowding1 suggest that most medical JDM falls between the two extremes, and therefore suggests that the most appropriate form of cognition for practitioners to use is that of system-aided judgments.


SIGNIFICANCE AND LIMITATIONS OF THE THEORETICAL LITERATURE ON JUDGMENT AND DECISION-MAKING
The literature and theories on judgment and decision-making are as extensive as they are controversial. The fragmented nature of studies to date within the general health disciplines addressing aspects of clinical judgment process has not yet resulted in a comprehensive understanding of the phenomena1 or a suitable universal model or theoretical framework .

Studies have traditionally followed or engaged one particular JDM paradigm or philosophy exclusively. Few, if any, have sought to view or examine JDM in more than one paradigm, which is a recent and growing criticism of the current body of research.1 Much of the work to date has applied descriptive approaches, such as information processing theories to judgment processes, in an attempt to contribute greater understanding of how judgments are made. In doing so, these studies, in the main, have provided greater insight into the cognitive process involved, particularly with respect to assessment practices. However, the ecological validity of many of these studies has been questioned,32, 60, 61 particularly with the criticism that they have focused on the representativeness of the judgment tasks presented.1 Many JDM studies have occurred in contexts and ecologies away from the clinicalsetting and therefore do not induce the same cognitive strain and commensurate effect on accuracy.1, 60 Conversely, some studies have focused primarily or exclusively on the accuracy or quality of the judgment or judgment process. To date, these studies have focused on judgment error in particular disciplines, largely the operations and management sciences.38 A major criticism of these studies, that are normative in nature, is that they negate to value of context, ecology and interaction in examining the JDM processes.1, 62, 63 Other authors have criticised the methods by which risk, uncertainty, and stress have been quantified, arguing that no matter how quantified, the full effect of such factors can never fully be understood outside the context of the individual. 10, 23 Sources of judgment errors in other contexts and disciplines need to be examined and explored.

The use of prescriptive approaches, which attempt to improve JDM and help individuals to make better judgments, has also been criticised as a single paradigm of inquiry.1, 62 Used considerably in teaching or instruction contexts and intervention studies, prescriptive models has been used to help individuals make better judgments and improve the quality the JDM process. The use of only prescriptive theoretical approaches significantly limits that ability to interpret findings in other contexts and paradigms, such as descriptive theory [64]. Further, a number of studies have attempted to improve JDM in the absence of any normative or descriptive data or constructs and have failed because of a lack of understanding of the judgment process or the quality of a good judgments.1, 62

CONCLUSION
The study of JDM has been a focus of psychologists, scientists, and others for more than half a century.1 Considerable research exists in the literature proposing a variety of theories of JDM. Theories of JDM have long and extensive philosophical foundations, often emanating from specific professions or disciplines. The literature and theories of JDM are as extensive and comprehensive as they are controversial. There is no single way to organise the research and literature on JDM. It is clear that there are differing and competing accounts of JDM in the literature and in research. There exists a dearth of the judgment research in paramedic practice.52 Much of the research conducted to date carries with it considerable controversy and conflict even when considered within its own paradigm or context. Many of the studies demonstrate poor ecological validity and a significant potential for overgeneralisation. Thompson and Dowding1 suggest it is time to consider new approaches to existing knowledge and research on JDM that will make lasting contributions. Additional research, new approaches and rethinking about existing judgment and decision-making and they ways in which they may be applied to professional work is required.


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Other papers in this series:
Paper One - Mental health and mental illness in paramedic practice: A warrant for research and inquiry into accounts of paramedic clinical judgment and decision-making
http://www.jephc.com...?content_id=170

Acknowledgments
The author would like to acknowledge and thank Associate Professor Claire Wyatt-Smith and Professor Joy Cumming for their supervision and support, and Mr Jason Emmett for his editorial review of this manuscript.

This Article was peer reviewed for the Journal of Emergency Primary Health Care Vol.3, Issue 1-2, 2005

Author Disclosure
The author has no financial, personal or honorary affiliations with any commercial organization directly involved or discussed in this study.

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2005; Volume 3 : Issue 3
Article Number: 990123

Accounting for assessments of mental illness in paramedic practice: A new theoretical framework.
Ramon Shaban


This is the third paper in a series that heralds a study that examines paramedic accounts and constructs of judgment and decision-making (JDM) of mental health and mental illness. This paper will overview an innovative theoretical framework for conducting a discourse-historical case study of paramedic judgment and decision-making of mental health and mental illness using ethnographic and ethnomethodological research methods. The review of the existing research and literature suggests an insufficiency of current theoretical and methodological frameworks to address the research problem and questions of this study. Little examination of judgment in mental illness and health has occurred, which is discussed in an earlier paper.1 Those studies, and the theoretical frameworks used, are insufficient in addressing key aspects of inquiry in judgment and decision-making, particularly in the paramedic ecology. The theoretical framework described here seeks to begin addressing this insufficiency in a new and innovative way.

Background
Medicine is not an exact science, if ever such an entity existed. Accidents in medicine cost lives, generate public and political controversy, and erode public confidence and trust in health care workers and institutions. Individuals and organisations today, more than ever before, are being called to account for their judgments and decisions as society demands greater transparency in the decisions policy-makers take on its behalf. Health care workers are taking on new roles—promoting health, giving diagnostic advice and prognostic information to patients, performing complicated and invasive medical procedures, assessing health risks and screening for early signs of treatable disease—in many cases with decreasing direct supervision. Accountability for decision-making is the cornerstone of a largely self-regulated profession, and the relationship between knowledge and decision-making is coming under increasing scrutiny as health professions attempt to increase their professional status.

Although the craft of ‘ambulance care’ is not new, its evolution into a recognised health profession is arguably in its infancy. The hallmarks of true professionalism encompasses, among other things, a body of knowledge ground in systemic research from which evidence is drawn to guide best-practice. The relationship between knowledge and decision-making has been a crucial element of many health professions’ attempts to increase their professional status—which many, such as medicine and dentistry, have achieved—spearheaded largely by the birth of evidence-based medicine. However, health ‘professions’ such as nursing and ambulance are yet to develop this relationship between knowledge, judgment, and decision-making, particularly in the paramedic ecology that is, the total contexts in which paramedics are engaged in decision-making.3 Paramedics are taking on new roles, performing more procedures and are being called to account for their clinical judgments, decisions, and actions more than ever before. FitzGerald4 argues that one of the characteristics of a profession is the possession of a body of knowledge that is the peculiar domain of the group, where growing this body of knowledge is principally dependent on the conduct of appropriate scientific research to inform such clinical JDM. The need to explore clinical judgment and ground clinical practice in results of sustained systematic research is central to this pursuit’.3

Earlier papers5 identified the need to investigate one area of paramedic practice that has to date been largely unexamined–the ways in which paramedics make clinical judgments of mental illness in the emergency care setting. In those works, the warrant for research into judgment and decision-making practices of paramedics in the context of mental health and mental illness was established. An initial problem faced by the continuing study from which this paper is generated was the lack of any applied or suitable theoretical framework for the examination of paramedic clinical JDM practices in the emergency care setting. A search of the literature, including MEDLINE, CINAHL, ERIC, Cochrane, and PsychINFO, located few studies that examine theoretical model through which paramedic knowledge and clinical judgment constructs are elicited. In particular, no rigorous theoretical model for the mental health assessment of patients in ambulance care could be located and no published research supporting any such investigation could be located. The review of the existing research and literature demonstrates an insufficiency in current theoretical and methodological frameworks in addressing the research problem and questions of this study. Not only is there an insufficiency of the existing literature and research, there is a paucity of any application or demonstration of this work to the specific domain of inquiry of this study. Little examination of judgment in mental illness and health has occurred.

An analysis of the wider literature on the theories of judgment and decision-making suggests the terrain is as competing as it is extensive and controversial.3 The fragmented nature of theories and studies to date within the general health disciplines addressing aspects of clinical judgment process has not yet resulted in a comprehensive understanding of the phenomena7 or a suitable universal model or theoretical framework. This paper will herald a new theoretical framework to enable investigation into the accounts and representations of paramedic judgment and decision-making.


Existing Frameworks and Theoretical Constructs
Broadly, the continuing study seeks to examine paramedic constructs and accounts of judgment and decision-making of mental illness in the emergency care setting. This framework proposes the use of a number of methodologies to answer the research question within significant depth and authenticity.


Ethnography and Discourse-Historical Case Study
Fundamentally, the theoretical framework and methodology of this study is grounded in ethnography. Ethnography is a form of social inquiry that seeks to describe and examine the practices and beliefs of individuals, cultures, and communities.6 Central to this paradigm is the necessity of a form of enquiry and writing that produces descriptions and accounts about ways of living and life. It is the study of people in naturally occurring settings or ‘fields’ by means that capture their social meanings and ordinary activities in order to collect data in a systematic manner but without meaning being imposed on them externally.7 Ethnography is conducted in instances where there is a need for an empirical approach, a need to remain open to the elements that cannot be codified at the time of the study, and a concern for grounding the phenomena observed in the field.8 The key facet of ethnography that is critical to this study and the encompassing theoretical framework is that ethnography provides for ‘thick descriptions’ with an emphasis on context. In this study, the individuals, culture and community of interest are paramedics. The context of inquiry is the emergency care setting. The nature of inquiry relates to mental health assessments. A thick and dense description of the ecology, context, and setting is essential to the understandings and interpretation required of this study.

Ethnographic research often is susceptible to problems of replication because it is conducted in the naturalistic setting.6 Freebody6 argues, however, that the susceptibility of ethnographic research, such as problems with replication, may be averted methodologically, and that the enhancement of reliability and validity is achieved in the same manner for ethnographic research as it is for any other. This is achieved by ensuring the clarity and accuracy of the representations on the context of the research, the statement of the problem to be investigated, the ways the researcher gained access to the data, the assumptions of the participants, and understandings on the site about the researcher’s role as a researcher.6 The use of ‘triangulation’ enhances the internal reliability. In this instance, the use of observation, interviews, site documents, and other supporting sources of data will be used to instil confidence in the interpretations and conclusions. 9

This theoretical framework positions inquiry in a discourse-historical case study approach within the ethnographic paradigm. The use of ethnography and discourse analytic studies to examine professional work, particularly judgment and decision-making, are well documented.10-12 A discourse-historical descriptive case study approach will be used to investigate specific instances of experience, and attempt to gain theoretical and professional insight from a full documentation of those instances.6 Cases of real incidents that paramedics have attended will be selected. The use of real case data is essential to provide representations of authentic accounts of judgment. Official records of these cases, the Ambulance Report Forms, will be obtained for analysis. Analysis of such records, and the ‘talk’ about the cases elicited through interviewing, will occur. The use of ethnography and discourse analytic techniques together is useful because it allows the examination of what clinicians actually do, what they say they do, and how they write or represent their day-to-day activities.10 The complexity of judgment, decisions and actions are acknowledged in the investigation.

Although case study has enjoyed considerable prominence as a research methodology for many years, it is often criticised as a methodology because of lack of reliability. Case study methodology does not intend to produce results or understandings of settings that are applicable to the entire population in a setting. Unlike in experimental research, where manipulation of variables is central to the methodology, case study research uses observation of naturally occurring phenomena as it method of inquiry. The purpose and advantage of this methodology is the ability to probe deeply and to analyse intensively to gain insight and understanding of phenomena that are new, not-understood, or unexamined. Paramedic judgment and decision-making of mental illness in the emergency care setting is unexamined and, arguably, not-understood. There is a lack of evidence in the literature that this phenomena has been examined or is understood in the setting described.5,13 Much of the criticism of experimental research, particularly in judgment and decision-making, suggest that understanding and knowledge of phenomena from naturalistic research is fundamental to fundamental to understandings of the same phenomena from experimental research.11


Theories of Judgment and Decision-Making
Ethnography and discourse analytic studies of professional work alone are insufficient in charting or gauging insight into the complexity of JDM. The framing and relevance of contemporary JDM theory must be considered, even if to exclude existing knowledge and theory. The use of ethnographic discourse-historical case study with ethnomethodological techniques must be situated within or be referenced against knowledge of JDM theories and philosophies.

The literature and theories on judgment and decision-making are as extensive as they are controversial. The fragmented nature of studies to date within the general health disciplines addressing aspects of clinical judgment process has not yet resulted in a comprehensive understanding of the phenomena11 or a suitable universal model or theoretical framework. Studies have traditionally followed or engaged one particular JDM paradigm or philosophy exclusively. Few, if any, have sought to view or examine JDM in more than one paradigm, which is a recent and growing criticism of the current body of research.11 Much of the work to date has applied descriptive approaches, such as information processing theories to judgment processes, in an attempt to contribute greater understanding of how judgments are made. In doing so, these studies have in the main provided greater insight into the cognitive process involved, particularly with respect to assessment practices. However, the ecological validity of many of these studies has been questioned,14-16 particularly with the criticism that they have focused on the representativeness of the judgment tasks presented.11 Many JDM studies have occurred in contexts and ecologies away from the clinical setting and therefore do notinduce the same cognitive effect commensurate with the context.11,14

Conversely, some studies have focused primarily or exclusively on the accuracy or quality of the judgment or judgment process. To date, these studies have focused on judgment error in particular disciplines, largely the operations and management sciences.17 A major criticism of these studies, that are normative in nature, is that they negate to value of context, ecology, and interaction in examining the JDM processes.11,18,19 Other authors have criticised the methods by which risk, uncertainty, and stress have been quantified, arguing that no matter how quantified, the full effect of such factors can never fully be understood outside the context of the individual.20,21 Sources of judgment errors in other contexts and disciplines need to be examined and explored. The use of prescriptive approaches, which attempt to improve JDM and help individuals to make better judgments, has also been criticised as a single paradigm of inquiry.11,18 Used considerably in teaching or instruction contexts and intervention studies, prescriptive models have been used to help individuals make better judgments and improve the quality of JDM process. However, most studies have worked only within the prescriptive paradigm, resulting in significant limitations on the value of their findings in other contexts and paradigms.22 Further, a number of studies have attempted to improve JDM in the absence of any normative or descriptive data or constructs, and have failed because of a lack of understanding of the judgment process or the quality of a good judgments.11,18 It is clear that there are differing and competing accounts of JDM in the literature and in research. In considering this study, it is apparent that none of the existing theories of JDM individually is sufficient to address the specific research problem in its entire context. Thompson and Dowding11 suggest it is time to consider new approaches to existing knowledge and research on JDM that will make lasting contributions. Additional research examining the applicability of the variety of theories of JDM in paramedic practice is required, and new approaches are required.


Ethnomethodology and Accounts
Further central elements to this theoretical framework are the notions of accounts, and a methodology for exploring them, ethnomethodology. The world is subjectively structured, possessing particular meanings for its inhabitants, where the task of the educational investigator is very often to explain the means by which an orderly social world is established and maintained in terms of its shared meanings.23 The concept of ethnomethodology, first mooted by Harold Garfinkel in 1967, provides a means to analyse and explore the ways in which people make sense of and reproduce ordinary, everyday social practice.10 The particular strength of this philosophy is that it seeks to moves away from judging whether a particular practice is right or wrong, and looks instead at how the practice gets to be practice, how it gets done, and what practical action makes it work p. 51.10 This provides for a very significant dimension to inquiry into actions that ethnography would otherwise not be able to provide. Maynard24 notes that:

‘…ethnographers have traditionally asked - ‘How do participants see things? – With the presumption that reality lies outside the words spoken in a particular time and place. The questions – how do participants do things?’ – suggests that the micro social order can be appreciated more fully by studying how speech and other interactions and behaviours constitute reality within actual mundane situations [p. 144]

The use of accounts and ethnomethodology to examine aspects of JDM is not new, and is well documented.10 By looking at the actions of individuals, and more importantly their representations of their actions through talk, investigators gain insight as to how actions themselves produce orders, culture, and other taken-for-granted aspects of the ecology.10 The emphasis of language or the ‘talk’ in ethnomethodology is central to success of the methodology, through which special emphasis is placed on the accounts people produce of and for their actions. All actions, wether intended or not, are built upon some construct or belief through which activity is justified by the individuals. Patel, Arocha, and Kaufman25 argue that the concept of ‘belief’ is justified and based on knowledge explicitly formulated in symbolic forms. Individuals, and their representations of their symbolic forms, are accounted in their actions. In accounting for events, individuals publish kinds of justification for their action taken. In ethnomethodology, what people say cannot be taken as an unproblematic representation of what really happened p52.10 In formulating complex judgments, or beliefs, individuals enact complex decisions, judgment-in-action, about what they say or do on the basis of sets of behavioural norms which illustrate a drawing upon of tacit knowledge about which moral orders exist and are encountered.


A new theoretical framework
The review of the existing research and literature on judgment and decision-making specific to the paramedic context suggests an insufficiency of current theoretical and methodological frameworks to address the research problem and questions of this study. Studies of paramedic JDM in cases of mental illness or psychiatric emergency referrals are rare. All the articles found related to the examination of paramedic JDM as it related to cardiac arrest, trauma, triage, or decision to transport patients to definitive medical care. These articles are discussed elsewhere.1,2 A thorough literature review failed to locate research that examines the assessment or judgment practices of paramedics in the specific domain of mental health, mental illness, or mental health assessments. Not only is there an insufficiency of the existing literature and research, there is a paucity of any application or demonstration of this work to the specific domain of inquiry of this study–paramedic practice in the mental illness. Given the relatively recent genesis of pre-hospital care as a health-care discipline, this omission is not surprising.26

In proposing a new theoretical framework suitable for use in the paramedic setting, the study will engage with both classical and naturalistic models and paradigms in addressing the research problem. A key criticism of existing research is that individual paradigms examine JDM in ‘parts’ or ‘bits’ and, in doing so, inevitably results in the loss of the full context and interaction, falling short of providing a rich account of the ecology of judgment. This study places JDM at the centre of the framing of the literature and, in doing so, attempts to draw strengths from multiple paradigms and philosophies. The original works of Bell and colleagues,27 and others11,12,20,21,28 inform the foundation for the theoretical framework for this study. In order to gain a thorough and rich account on JDM in paramedic practice a variety of contexts must be considered. Descriptive models, with a focus of how ‘ordinary’ individuals actually make decisions, must be a central factor in theoretical inquiry. Normative models, with a focus on how decisions should optimally be made, should equally be a consideration in JDM modelling. Finally, prescriptive theories, which are ways of helping and improving judgments, must also be considered. The study will merge the three paradigms of existing JDM theory within the ethnographic context in an attempt to gain a comprehensive perspective of paramedic JDM and ‘thick description’ of the ecology and context of paramedic JDM. A representation of this model is provided in Figure 1.

This theoretical framework seeks to enable an exploration of how paramedics make and account for their judgments about mental illness, exploring what informs and influences their judgments, accounts, and constructs. This study will attempt to illustrate how paramedics account for their JDM of mental health, illness, and mental health assessments. Central to this study is capturing the contextual and ecological factors that may influence paramedic JDM. In particular, the study seeks to investigate how judgments are arrived at while seeking to make known the factors that influence the judgments of paramedics in the context of mental health assessments.


Figure 1: Theoretical framework for inquiry into paramedic JDM








Through investigation of paramedic practice, the study seeks to make known tacit and otherwise unavailable constructs and accounts of knowledge, judgment, and decision-making processes that underpin the performance of mental health assessment of patients in the emergency pre-hospital care setting. The study proposes to investigate the JDM experiences of paramedics in a comprehensive and innovative way, acknowledging and including perspectives from both classical and natural paradigms that are essential to the comprehensive understanding of JDM. Using these paradigms, the study will seek to understand and document descriptive (how paramedics in ordinary contexts and situations do make judgments and decisions) and normative (how paramedics should make judgments and decisions) accounts of paramedic JDM with respect to mental health and mental illness. In order to explore prescriptive accounts of JDM (how to make better judgments and decisions), it is essential to have an understanding and insight into how paramedics actually do make their judgments and decisions (in real contexts and ecologies), and how they should be making their judgments and decisions in view of prevailing official accounts, standards, policies, and guidelines. The suitability of the combination of these methodologies, analytic techniques, and paradigms will be investigated in the ongoing study.

None of the individual methodologies or paradigms identified in this theoretical framework is themselves new to the JDM arena. What is new is the application of this combination of methodologies and paradigms in the paramedic JDM context. This framework, and the study within which it will be used, offers a new way of examining JDM of individuals. Ethnomethodological techniques are essential to this theoretical framework, as they assist in the inquiry as to the viability of normative theories of judgment (that is those that imply that JDM can be optimised and all risk are able to be quantified and accounted for) given the ecology. Is it reasonable for paramedics, in the context of this study, to make decisions where the results and outcomes are optimised and all risks and uncertainties can be made known in environments that are characterised by high levels of stress, uncertainty, and risk? Is it possible for paramedics to make quality judgments of an individual’s mental health in the emergency care setting and, if so, what do these judgment processes look like, how are they made and, more importantly, what are the outcomes from them. Is it possible to then apply prescriptive theories to paramedic JDM processes to help and improving their judgment, or are the environment, context, and ecology of the judgment process too labile and uncertain. Can uncertainty be made certain? Hammond20,21 and many others29,30 would strongly suggest otherwise.

Conclusion
There is a paucity of published work on critical thinking and clinical reasoning in this setting, which could suggest that the value of these skills are not yet fully appreciated in the field of pre-hospital care.3,26 The few studies that have been conducted have sought to examine JDM as it relates to specific instances or cases, particularly cardiac arrest or trauma, and have worked within one particular JDM paradigm or theoretical construct, such as normative and prescriptive theory. These studies, as discussed earlier, are significantly problematic and have significant limitations due to study design or philosophical context. No article could be located that addresses either generally or specifically paramedic JDM practices with respect to mental illness, mental health, and mental health assessments, despite a growing warrant for this research. The absence of published research examining paramedic practice to achieve more accurate judgments (or indeed JDM at all) in the context of mental illness and mental health has meant that the impact of significant changes to mental health service delivery, and the recognition and care of the mentally ill have occurred unexamined.

The complexity of clinical situations faced by paramedics, where, for example, multiple contexts exists with significant levels of uncertainty, risk, and time criticality, most of which make clinical judgment process difficult has not been examined. The identification of strategies to support a more effective judgment processes a challenge has not been attempted.11 The review of the existing research and literature demonstrates an insufficiency of current theoretical and methodological frameworks to address the research problem and questions of this study. Not only is there an insufficiency of the existing literature and research, there is a paucity of any application or demonstration of this work to the specific domain of inquiry of this study. Little examination of judgment in mental illness and health has occurred. This framework does not seek to classify or compare these theories artificially or in terms of each other. Indeed much of the debate in the literature is about that very issue–how researchers and theorists categorise various theories of JDM, and their classification or categorisation into philosophies, schools-of-thought, and professional domains. The problematic, controversial, and, in the view of some researchers, inappropriate attempts to do so are well-documented.11,12,27,31 Rather, the framework moots the drawing on existing literature as a foundation to propose a suitable conceptual theoretical framework to address a new research problem. This framework attempts to draw on the relative strengths and advantages of a variety of theories of JDM, in an attempt to offer a new approach to unexplored terrain as suggested by Thompson and Dowding.11 By drawing on the strengths of existing theories and applying additional analytic technique, the framework attempts to offer a unique perspective of paramedic judgment and decision-making.


References

Shaban RZ. Theories of clinical judgment and decision-making: A review of the theoretical literature. Journal of Emergency Primary Health Care 2005;3(1-2). Available from: http://www.jephc.com...?content_id=192.
Shaban RZ, Wyatt-Smith CM, Cumming J. Uncertainty, error and risk in human clinical judgment: Introductory theoretical frameworks in paramedic practice. Journal of Emergency Primary Health Care 2004;2(1-2). Available from: http://www.jephc.com...?content_id=144
Shaban RZ. Paramedic accounts of judgment and decision-making of mental health and mental illness. Proceedings from 'Educating: Weaving Research Into Practice - 2nd Annual International Conference on Cognition, Language and Special Education Research, Gold Coast, Australia. 3-5 December 2005; 3(3)96-106.
FitzGerald GJ. Guest Editorial - Research in the pre-hospital care. Journal of Prehospital Emergency Primary Health Care 2003;1(3-4). Available from: http://www.jephc.com...m?content_id=77
Shaban RZ. Mental health and mental illness in paramedic practice: A warrant for research and inquiry into accounts of paramedic clinical judgment and decision-making. Journal of Emergency Primary Health Care 2004;2(3-4). Available from: http://www.jephc.com...?content_id=170.
Freebody P. Qualitative research in education: interaction and practice. 1st ed. London: SAGE Publications; 2004.
Brewer JD. Ethnography. Buckingham, UK: Open University Press; 2000.
Baszanger I, Dodier N. Ethnography: Relating the part to the whole. In: Silverman D, editor. Qualitative research: theory, method and practice. London: SAGE Publishers; 2003.
Mertens D. Research methods in education and psychology: Integrating diversity with quantitative and qualitative approaches. Thousand Oaks, California, USA: SAGE Publications; 1998.
White S, Stancombe J. Clinical judgment in the health and welfare professions: Extending the evidence base. Philadelphia, USA: Open University Press; 2003.
Thompson C, Dowding D. Clinical decision making and judgement in nursing. London: Churchill Livingstone; 2002.
Chapman GB, Sonnenberg FA, editors. Decision making in health care: theories, psychology and applications. Cambridge: Cambridge University Press; 2000.
Shaban RZ. Paramedic accounts of judgment and decision-making of mental health and mental illness. In: Bartlett B, Bryer F, Roebuck R, editors. Educating: Weaving research into practice; 2004; Brisbane: School of Cognition, Language and Special Education, Griffith University; 2004. p. 93-106.
Gordon M. Strategies in probabilistic concept attainment: A study of nursing diagnosis. [Doctoral Dissertation]. Massachusetts: Boston University; 1972.
Greenwood J, King M. Some surprising similarities in the clinical reasoning of 'expert' and 'novice' orthopaedic nurses: Report of a study using verbal protocols and protocol analyses. Journal of Advanced Nursing 1995;22:907-913.
Tanner CA, Benner P, Chelsa C, Gordon DR. Diagnostic reasoning strategies of nurses and nursing students. Nursing Research 1987;36(6):358-363.
Vincent C, editor. Clinical risk management: Enhancing patient safety. London: British Medical Journal Books; 2001.
Hamm RM, Scheid DC, Smith WR, Tape TG. Opportunities for applying psychological theory to improve medical decision making: Two case histories. In: Chapman GB, Sonnenberg FA, editors. Decision making in health care: theories, psychology and applications. Cambridge: Cambridge University Press; 2000.
Cooksey RW. Judgment analysis: Theory, methods and applications. Sydney: Academic Press; 1995.
Hammond KR. Human judgment and social policy: Irreducible uncertainty, inevitable error, unavoidable justice. London: Oxford University Press; 1996.
Hammond KR. Judgments under stress. New York: Oxford University Press; 2000.
Chapman GB, Elstein AS. Cognitive processes and biases in medical decision making. In: Chapman GB, Sonnenberg FA, editors. Decision making in health care: theories, psychology and applications. Cambridge: Cambridge University Press; 2000.
Cohen L, Manion L. Research methods in education. London: Routledge; 1999.
Maynard D. On the ethnography and analysis of discourse in institutional settings. Perspectives on Social Problems 1989;1:127-146.
Patel VL, Arocha JF, Kaufman DR. Expertise and tacit knowledge in medicine. In: Sternberg RJ, Horvath JA, editors. Tacit knowledge in professional practice. London: Lawrence Erlbaum Associates; 1999.
Lord B. Book review: 'Clinical reasoning in the health professions'. Journal of Prehospital Emergency Primary Health Care 2003;1(3-4). Available from: http://www.jephc.com...?content_id=124
Bell DE, Raiffa H, Tversky A, editors. Decision making: descriptive, normative and prescriptive interactions. Cambridge: Cambridge University Press; 1988.
Hammond KR. An approach to the study of clinical inference in nursing: Part II. Nursing Research 1964;13(4):315-319.
Thompson C, Dowding D. Responding to uncertainty in nursing practice. International Journal of Nursing Studies 2001;38:609-615.
Tversky A, Kahneman D. Judgments under uncertainty: heuristics and biases. Science 1974;211(438-458).
Clemen RT. Naturalistic decision making and decision making analysis. Journal of Behavioural Decision Making 2001;14:353-384.

Other papers in this series:
Paper One - Mental health and mental illness in paramedic practice: A warrant for research and inquiry into accounts of paramedic clinical judgment and decision-making.
http://www.jephc.com...?content_id=170

Paper Two - Theories of clinical judgment and decision-making: A review of the theoretical literature.
http://www.jephc.com...?content_id=192

Acknowledgments

The author would like to acknowledge and thank Associate Professor Claire Wyatt-Smith and Professor Joy Cumming for their supervision and support, and Mr Jason Emmett for his editorial review of this manuscript.

This Article was peer reviewed for the Journal of Emergency Primary Health Care Vol.3, Issue 3, 2005

Author Disclosure
The author has no financial, personal or honorary affiliations with any commercial organization directly involved or discussed in this study.

Comments on this Article

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2005; Volume 3 : Issue 4
Article Number: 990159

Paramedic clinical judgment of mental illness: Representations of official accounts
Ramon Shaban

This paper is the fourth in a series that heralds a study that examines paramedic accounts and constructs of judgment and decision-making (JDM) of mental health and mental illness. This paper will provide the results of one stage of this study in which a discourse-historical case study of paramedic JDM of mental health and mental illness using ethnographic and ethnomethodological research methods was conducted. Preliminary themes describing the ways in which paramedics officially account for their judgments of mental illness will be presented.

Introduction
In earlier papers,1,2 the warrant for research, literature review and theoretical framework for research into judgment and decision-making practices of paramedics in the context of mental health and mental illness were established. The aim of the overarching study was to examine paramedic JDM constructs and practices with respect to assessment of mental illness in the pre-hospital emergency care setting. Through investigation of paramedic practice, the study seeks to make known tacit and otherwise unavailable constructs and accounts of knowledge, judgment, and decision-making processes that underpin the performance of mental health assessment of patients in the emergency pre-hospital care setting. The study proposed to investigate the JDM experiences of paramedics in a comprehensive and innovative way, acknowledging and including perspectives from both classical and natural paradigms that are essential to the comprehensive understanding of JDM, discussed in earlier papers.3-5 Using these paradigms, the attempts to understand and document descriptive (how paramedics in ordinary contexts and situations do make judgments and decisions) and normative (how paramedics should make judgments and decisions) accounts of paramedic JDM with respect to mental health and mental illness. In doing so, the study then further aimed to explore prescriptive accounts of JDM (or how to make better judgments and decisions). It was considered essential to have an understanding and insight into how paramedics actually do make their judgments and decisions (in real contexts and ecologies), and how they should be making their judgments and decisions (in view of prevailing official accounts, standards, policies, and guidelines) before considering ways to improve their judgments or make them better. In doing so, the study attempts to understand what informed or influenced their judgments in this setting and context.

In this paper, we examined one element of the overall study – how paramedics are expected to officially account for their JDM with respect to mental illness in the emergency care setting. This component of the continuing study sought to explore how official accounts of paramedic JDM are represented and accounted for.


Research Design, Methodology, and Data Collection
The theoretical framework suggested by Shaban5 was used to guide the research design, data collection, and analysis of this component of the continuing study. The study used discourse-historical case study as the primary methodology, applying ethnographic and discourse analytic techniques in data analysis.

The first data set incorporated the gathering and analysis of ‘official, expected, or intended’ accounts and standards of paramedic JDM of mental illness. This included the collection of a comprehensive array of material such as policies, procedures, clinical guidelines, pedagogical materials, standards, policies, and legislation. An extensive data set was obtained, culminating in the collection of a variety of documents including legislation, memoranda, letters, correspondence, clinical standards and guidelines, policy, procedures manuals, and pedagogical material over a historical period spanning 15 years. The corpus included a large volume of historical documentation such as current and superseded pedagogical material, policies, and procedures, including working drafts and consultation documents.

This material was then catalogued and examined. A first-pass ethnographic analysis of the two documents was conducted, including Membership Categorisation Analysis (MCA), Linguistic Analysis (LA), and Document and Policy Analysis (DPA) as described by Freebody6 and Silverman.7,8 Analysis of these documents illustrated an anomaly in official accounts as described by the original warrant for the research by Shaban.1 From this analysis, a series of questions were formulated for use in semi-structured interviews with key stakeholders of the research problem that on analysis will provide insight into the ‘official responses’ to prescriptive accounts and constructs. Of paramount interest at this stage in data collection was how paramedics might be expected account for their judgments considering the prevailing official standards and guidelines, and how the prevailing policies, or normative accounts (how judgments should be made and accounted for) mandate or are mandated by practice.

A historical-discourse perspective was used, to allow for a thick and dense description of the evolution of this phenomenon. Two key documents—the QAS Clinical Practice Manual and the Mental Health Act 2000 (Qld)—were used at interview to provide a focus for discussion as to what influence the policy has in mandating practice, or if indeed practice mandated an interpretation of the policy not represented in the official accounts. A total of six semi-structured interviews were conducted, with a variety of key stakeholders, including a practicing advanced care paramedic, an two senior education officials (one manager and one educator), an ambulance operational manager, a union delegate, and an ambulance medical officer. Interviews were recorded on digital recorders, transcribed, and returned to interviewees for verification. Interview transcripts was analysed using a variety of discourse, ethnographic, and ethnomethodological methods outlined by Silverman,8 Freebody,6 and Baker[9]. These included Membership Categorisation Analysis (MCA), Discourse Linguistic Analysis (LA), and Conversation Analysis (CA). The complementarity of the research approaches and analytic methods will be examined in the continuing study. Ethics approval was obtained from the Commissioner and Medical Director, Queensland Ambulance Service, and Griffith University Human Research Ethics Committee.


Preliminary Thematic Considerations
A number of important preliminary themes have emerged from first-pass analysis of the data.


Categories of the mentally ill
The ways in which the mentally ill are categorised within the official accounts of the data correlate strongly with the existing related literature in allied health professions such as nursing10,11 medicine12 and the police.13-15

Interviewer: ‘In the paramedic setting, how might psychiatric patients be viewed?’

Participant: ‘…I would have to say in my view most psychiatric patients I think would have been identified loosely under a dreadful term as ‘mad people’ and the police would have been called, I’d suggest…’ (Excerpt from interview with participant 2 - senior ambulance manager)

The official accounts suggest that categories of mentally ill are most frequently identified as presenting with violent, suicidal, drug-induced, overdose, or overtly psychotic behaviour, and appear to dominate the official account of the experience base in the pre-hospital paramedic setting. The clinical category to which mental illness is assigned in clinical policies and procedures is that of ‘psychiatric emergency’. What is unclear at this stage is how mental illness, wether or not it is classified as an emergency, is recognised, managed or represented in the field. Stereotyping of mental illness is pandemic and found across other health professions.10 How paramedics themselves specifically categorise, recognise, represent, and manage mentally illness, or those they consider to be mentally ill, will be further investigated in this study.


Role of the paramedic
Preliminary data analysis suggests that the official account of the working role of the paramedic has changed rapidly over the last decade, which is consonant with movement with the pre-hospital and paramedic discipline nationally and internationally. For example, the standard of education has moved dramatically from non-standardised, non-accredited, in-house vocational training to accredited vocational training and tertiary programs such as graduate diplomas and research higher degrees in just over 15 years.

Interviewer: ‘Historically, what has been the role of the paramedic in the delivery of care?’

Participant: ‘…Ostensibly the various committees at that time had very, very little in the way of training. Even baseline first aid training, from my understanding, was extremely primitive…

Interviewer: ‘And in 1991?’

Participant: ‘There was a notion that they would try and increase the academic level—the Service would increase the academic level of the service and introduce the associated diploma… It took a few years after 199, for the single service notion. The introduction of the Associate Diploma, the bridging program, there was huge change at the front end of the business and the creation of a Commissioner position, at the creation of the single service had an extraordinary effect, I think, on the professionalism of the ambulance service and the concept in the mind of the ambulance officers of the job that they were actually going to do. As I said, from 1991 to the present day, there has been such a paradigm shift in terms of ambulance officers being seen as pre-hospital professionals treating as well as transporting patients, and you know, use the analogy that prior to 1991, an ambulance officer would arrive, hand some paper work to a nursing staff at a causality department and the paper work would often be thrown away. Now days we walk in with the elaborate ambulance report form and there is an expectation that the patient would have been assessed in a particular way, that a provisional diagnosis would have been made to guide the treatment, comprehensive handover given, and that record is filed with the patient’s documentation and seen as a valuable adjunct if the person goes to orthopaedic surgery. You know, that sort of stuff. So just huge, huge changes…’ (Excerpt from interview with participant 2 - senior ambulance manager)

This rapid change in the role of the paramedic has precipitated the introduction of additional skills, procedures, and training aimed to improve the pre-hospital management of a variety of medical conditions.

Interviewer: Do you see the role of the paramedics to include managing neuroses, depression, and anxiety-based conditions rather than just psychiatric emergencies, and if so, do we need another card [protocol]?

Participant: ‘…we get in the ambulance service as you know, we get a lot of calls to patients who are depressed, who are suffering from phobias, or neurosis of all sorts and they call the ambulance often as they have no other form of care, or they are feeling lonely, unwell or safe and if they want to get to a place of safety they don’t have any mechanism to getting there, none of those patients are what you would term a psychiatric emergency at that point, unless they are going to self-harm, that may not be the case, they might be just feeling unsafe and want to go into care and we get called to those patients all the time, and I think… I think, sadly, those patients are still, not well understood, they are not treated appropriately by some ambulance services…’

Interviewer: Are there any specific reasons for that do you think?

Participant: ‘…I think the ambulance officers have insufficient training to understand how these people are presenting. There is a bit of a culture in ambulance which pushes us towards this urgency, lights and sirens, psychiatric emergency—that’s an ambulance job, if it’s a person just not feeling unwell then why couldn’t they wait until tomorrow and go down to their local doctor. Well because to them it is a very acute situation and they need help and they’re as needy as the child with the cut finger on the jam tin…’ (Excerpt from interview with participant 1 - senior ambulance education official)

Traditionally, such skills and procedures have commonly anchored around conditions such as cardiac arrest, asthma, trauma, and endocrine emergencies such as hypoglycaemia. A common denominator of these conditions is that they are anchored in ‘physical’ where paramedic are able to recognise conditions using hypothetico-deduction processes.16 What is unclear at this preliminary stage is how official accounts of additional skills, education, and training have prepared the paramedic to meet with other non-explicit cases (such as those that do not necessarily require immediate time critical intervention) such as the broad sweep of mental illness. Further exploration is needed and will be conducted in the remainder of the study.



Need for additional training, preparation, and clinical practice clarification
A common theme across the official accounts is the reported need for greater education and training in mental illness and clinical judgment and decision-making, which is congruent with official accounts of mental illness in the majority of the health professions10,12,14 and across the community.17

Interviewer: ‘Would it be fair to say that perhaps most of the experiences of ambulance officers are with psychotic patients or those with serious mental illness rather than say the neuroses or other less explicit conditions?’

Participant: ‘My understanding at just looking at our AIMS data, is that mental illness and its manifestations which is so confused with other issues, like drugs, is becoming so prevalent and it is a real conundrum for our ambulance officers to be able to differentiate the cause of this disturbed and abnormal behaviour..’

Interviewer: ‘If I asked you to summarise, do you think paramedics are well equipped to manage mental illness in pre-hospital context’.

Participant: ‘Ambulance officers are not exposed to seriously mental ill patients all that frequently. We see a lot of sub-acute presentations of patients and we have little training in the area and basically we go out and treat the patients systematically, as we do with many things. So in answer to your question no I don’t think we are well equipped…’ (Excerpt from interview with participant 1 - senior ambulance education official)

Participants were asked to consider wether or not they were adequately prepared to manage mental illness in the emergency care setting.

Interviewer: ‘If you were to summarise how well do you think paramedic are to assess and manage mental illness in their practice?’

Participant: ‘Very poorly equipped, and I have to say there is a disinterest. I have to say there is a disinterest. Because there is a fear of mental stigma, because I don’t need to bother, they can either call the police, treat them as dangerous, and they don’t particularly want to know.’ (Excerpt from interview with participant 5 - Ambulance counsellor)

Interviewer: ‘In your experience how do you see that paramedic manage or handle mental illness? Are they well equipped to deal with it?’

Participant: ‘As with most things in the job, some are, some aren’t, and it gets down to individual things probably the interest the individuals has, the background experience in the service, and the educational models. So it is really an individual things on a whole I would probably say we are probably under equipped in so far as what we are doing under the Mental Health Act is putting us into a legal realm as such, as we are grabbing people under the Act, we may not do well if things actually went court.’ (Excerpt of interview with participant 6 – union delegate)



Legislative, Policy and Clinical Practice Conflict
There appears, on preliminary document analysis, conflict in the official accounts across legislation, policy, and practice. The two legislative instruments governing paramedic practice with respect to the mentally ill (particularly involuntary assessments), the Ambulance Service Act 1991 (Qld) (herein ASA) and the Mental Health Act 2000 (Qld) (herein MHA), appear to mandate practice and different ways, making their implementation problematic.

Interview: ‘How would you characterise the preparedness of emergency service personnel to deal with their legislative requirements?’

Participant: ‘…I think both police and ambulance are in a very difficult position when the legalisation asks them to make value judgment calls when they are ill equipped to be able to comment on, and so that has always been an issue for me.’ (Excerpt of interview with participant 3 - senior ambulance manager)

The ASA mandates that paramedics may take any reasonable measure to protect individuals, whereas the MHA mandate the formulation of a ‘belief’ of mental illness to enable action and decisions. The third dimension of the official account, the Clinical Practice Manual, mandates that all patients who are categorised as a ‘psychiatric emergency’ be transported to definitive medical care.

Interviewer: ‘So are ambulance officers more likely to use the Ambulance Service Act and not have to make that belief, and protect the patient, rather than use Mental Health Act and have to make a belief judgment and then invoke an order?’

Participant: ‘If you can take a person to hospital under your powers under the Ambulance Service Act and the person is compliant, and is happy to stay in hospital and be assessed, why fill out an Emergency Examination Order?. Whereas, under the Mental Health Act, it is far more prescriptive in terms that you have to met all these criteria and you have to believe that the person is a mental illness and don’t have any of the exclusions. You know, it puts an extraordinary number of almost impedients in the way of the paramedic, in saying take this person to hospital...’ (Excerpt of interview with participant 2 - senior ambulance manager)

This nexus appears to be conflicting in the official accounts. The workings of the official accounts in practice, and the nature of any conflict, are unclear at this stage. Further investigation of this phenomenon will ensue.

Interviewer: ‘In your opinion, what are some of issue for future paramedic practice in the context of managing mental illness?’

Participant: ‘I think for ambulance in the future, we need to able to have a high diagnostic sieve level for our officers, the ability to be able to differentiate causes of disturbed and abnormal behaviour, which is the manifestation that we see that obviously triggers as to why someone calls the ambulance. I think in the past if someone’s behaviour was behaviour in a bizarre or abnormal way, it was the same process—they were simply dragged off to hospital. If they couldn’t be dragged off to hospital the police were called and they were taken into police custody. So there wasn’t too many options in terms of how they were managed…’ (Excerpt of interview with participant 2 - senior ambulance education official)

At interview, the issue of interpretation of the term ‘belief’ as intended by the Mental Health Act 2000 in contrast to the ‘judgment’ mandated by official clinical practice guidelines was explored.

Interviewer: ‘What is your sense interpretation of the term ‘belief’ in the Mental Health Act and its workings? How might be viewed or interpreted by paramedics, their ‘belief; someone is mentally ill? Does that imply judgement, does it imply level of assessment or that somebody just has a hunch of it?’

Participant 5: ‘OK, people don’t make an informed diagnosis for judgment. In other words I don’t believe that people are doing anything other than operating on an extinct or a hunch. Yeah ok a hunch. In the absence of overt information this bloke might have suicidal assessment instrument.’ (Excerpt of interview with participant 5 - ambulance counsellor)

These and other themes will be examined and explored in detail in the continuing study.



Significance and Future Considerations
It appears from this data that tensions between and across official accounts appear to dominate how policy and practice is mandated, and that a variety of factors other that those related directly to education influence paramedic judgment and decision-making. This study suggests that the changing role of the paramedic in assessing and managing mental illness in a rapidly changing pre-hospital care environment has not been comprehensively examined. This appears to have contributed to role confusion in the face of competing and conflicting official accounts, with insufficiencies in the preparation for practice. The participants explicated a need for additional skills and training, specifically a tool to better guide their practice—also known as prescriptive accounts of judgment and decision-making. The sufficiency of programs then for ensuring quality care and accountability in the field is heavily dependent on the systematic examination of practice in the pursuit evidence-based practice. The data suggests that paramedics themselves have identified a gap in their knowledge and skills. Improvement in clinical practice and patient care outcomes is more than just about providing training—it is about the systematic characterising and evidencing existing practice that make known the very issues that guide and mandate such practice in the field. It is also about recognising the evolving role of paramedics in the field and characterising contextual variables and interactions that impact on the paramedic’s preparedness and ability to provide quality patient care. Although not intended to be generalisable across populations, the purposeful, systemic, and structured selection of participants; application of a comprehensive and integrated data collection methods; structured data analysis; and rich, thick descriptions of the ecologies under study should provide for some insight into the complexity of paramedic JDM, ultimately aiming to improve the quality of care provided to individuals suffering from a mental illness by improving pre-hospital recognition and management of these conditions, and the preparedness of paramedics to do so.

Preliminary thematic considerations reported here provide an introductory look at the characteristics of paramedic JDM of mental illness. The continuing study will pursue greater exploration and examination of these themes and their relevance to paramedic JDM in an attempt to provide a rich and thick description of the nature and ecology of paramedic JDM of mental health and illness. It is anticipated that additional components of the continuing study will provide greater insight and understanding into these and other challenges of paramedic judgment, decision-making and practice in the pre-hospital context.

References

Shaban RZ: Mental health assessments in paramedic practice: A warrant for research and inquiry into accounts of paramedic clinical judgment and decision-making. Journal of Emergency Primary Health Care 2004, 2(3-4).
Shaban RZ: Mental health assessments in paramedic practice: case analysis of the constructs of knowledge and judgment. In: Doing the public good: Positioning education research: 28 November - 2 December, 2004 2004; Melbourne, Australia: The Australian Association for Research in Education; 2004: 234.
Shaban RZ: Theories of judgment and decision-making: A review of the theoretical literature. Journal of Emergency Primary Health Care 2005, 3(TBA).
Shaban RZ: Clinical judgment and assessment tools for mental health and mental status examination: A review of the literature. Pre-hospital Emergency Care 2005, TBA(TBA):TBA.
Shaban RZ: Accounting for assessments of mental illness in paramedic practice: A new theoretical framework. Journal of Emergency Primary Health Care 2005, TBA(TBA).
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Other papers in this series:

Paper One - Mental health and mental illness in paramedic practice: A warrant for research and inquiry into accounts of paramedic clinical judgment and decision-making. http://www.jephc.com...?content_id=170

Paper Two - Theories of clinical judgment and decision-making: A review of the theoretical literature. http://www.jephc.com...?content_id=192

Paper Three - Accounting for assessments of mental illness in paramedic practice: A new theoretical framework. http://www.jephc.com...?content_id=263

Acknowledgments

The author would like to acknowledge and thank Associate Professor Claire Wyatt-Smith and Professor Joy Cumming for their supervision and support, and Mr Jason Emmett for his editorial review of this manuscript.

This Article was peer reviewed for the Journal of Emergency Primary Health Care Vol.3, Issue 4, 2006 Comments on this Article

Hope this helps,
ACE844

[retired_medic61]

Aw heck, thats a lot of reading...I better call my shrink!!!

[Ramon Shaban]

Hey everyone

If anyone wants more info on this research, I'd be happy to chat with you.

Ramon