Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

From diagnosis to discernment : fostering the development of clinical judgment of paramedic learners… Bowles, Ronald Robin 2013

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
24-ubc_2013_fall_bowles_ronald.pdf [ 4.53MB ]
Metadata
JSON: 24-1.0073895.json
JSON-LD: 24-1.0073895-ld.json
RDF/XML (Pretty): 24-1.0073895-rdf.xml
RDF/JSON: 24-1.0073895-rdf.json
Turtle: 24-1.0073895-turtle.txt
N-Triples: 24-1.0073895-rdf-ntriples.txt
Original Record: 24-1.0073895-source.json
Full Text
24-1.0073895-fulltext.txt
Citation
24-1.0073895.ris

Full Text

FROM DIAGNOSIS TO DISCERNMENT: FOSTERING THE DEVELOPMENT OF CLINICAL JUDGMENT OF PARAMEDIC LEARNERS IN IMMERSIVE HIGH FIDELITY SIMULATIONS by RONALD ROBIN BOWLES B.Ed., University of Alberta, 2001 M.E.T., University of British Columbia, 2004  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in The Faculty of Graduate Studies (CURRICULUM STUDIES)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  June, 2013  © Ronald Robin Bowles, 2013  ABSTRACT Paramedic educators are challenged to produce greater numbers of graduates who are better prepared to function in an evolving health care system. The growth of high fidelity simulation (HFS) holds promise for reducing reliance on the practicum environment, long a crucial step between the classroom and field practice. Yet, despite significant investment in simulation infrastructure, HFS is still seen as an adjunct to, but not a replacement for, practicum placement. The practical problem addressed in this study, then, was the presumption that HF simulation can reduce reliance on practicum placement. The research question explored how HFS influences the development of clinical competence and clinical judgment. This multiplecase study employed a multi-vocal approach, gathering data from 75 classroom and HF simulations. An iterative, inductive process of analysis provided a phenomenological exploration of participants’ experiences and interactions and a critical analysis of their judgments and decision making. The findings in this study suggest that existing paramedic simulations and the practicum represent radically different learning environments, each with its own sets of roles, expectations, patterns of practice, and methods of evaluation that call on different epistemological and ontological conceptions of what constitutes competent practice, what knowledge matters most, and how learning occurs. The varied learning activities in this study fostered different ways of knowing as learners moved from the consistency of contextindependent skill performance to the socially constructed adaptation of procedures and protocols in dynamic simulations, and, finally, to the socially negotiated understandings arising from coemergent activity in a field setting. Effective simulations require situational blends of fidelity to create environments realistic enough to meet their pedagogic goals. Simulations intended to foster clinical competence and clinical judgment must provide occasions for discernment; they  ii  must create a milieu involving complex interpersonal interactions and genuine opportunities for clinical decision making. Thus, paramedic simulations must be as concerned with role, environmental, interpersonal, and social/cultural fidelity as with physiological and procedural fidelity. In this sense, populating HFS more richly with actors and authentic interdisciplinary responders may often be as important as the use of HF mannequins and standardized patients.  iii  PREFACE This thesis has ethics approval from the University of British Columbia, Office of Research Services, Behavioural Research Ethics Board, certificate: H08-02855.  iv  TABLE OF CONTENTS ABSTRACT .................................................................................................................................... ii PREFACE ...................................................................................................................................... iv TABLE OF CONTENTS ................................................................................................................ v LIST OF TABLES ........................................................................................................................ vii LIST OF FIGURES ..................................................................................................................... viii ABBREVIATIONS ........................................................................................................................ x GLOSSARY .................................................................................................................................. xi ACKNOWLEDGEMENTS ......................................................................................................... xiii CHAPTER 1: BACKGROUND AND ORIENTATION TO THE STUDY .................................. 1 Context of the Study ....................................................................................................................... 2 Questions and Goal of the Study .................................................................................................... 7 Approach ......................................................................................................................................... 7 Situating Myself as the Researcher ................................................................................................. 8 Outline of the Dissertation .............................................................................................................. 9 CHAPTER 2: REVIEW OF THE LITERATURE ....................................................................... 11 Complex Phenomena .................................................................................................................... 11 Conceptualizing Competence and Clinical Judgment .................................................................. 15 Phenomenological Views of Developing Expertise ..................................................................... 27 Current Paramedic Education Programs ....................................................................................... 35 Experiential Learning.................................................................................................................... 40 Conceptualizing Simulation-Based Learning ............................................................................... 51 Problematic Terms ........................................................................................................................ 65 Chapter Summary ......................................................................................................................... 67 CHAPTER 3: METHODS ............................................................................................................ 68 Design ........................................................................................................................................... 69 Ethical Considerations .................................................................................................................. 79 Sample........................................................................................................................................... 81 Data ............................................................................................................................................... 84 Analysis and Interpretation ........................................................................................................... 93 Bias of the Researcher ................................................................................................................ 106 Limitations and Delimitations..................................................................................................... 107 Validation Strategies ................................................................................................................... 109 Chapter Summary ....................................................................................................................... 113  v  CHAPTER 4: THREE FORMS OF PARAMEDIC SIMULATION ......................................... 114 Case: Core Skills Drill ................................................................................................................ 115 Case: Classic Case Simulation .................................................................................................... 119 Case: High Fidelity Simulations ................................................................................................. 125 Discussion: Blends of Form and Function .................................................................................. 132 The Move to Interpretation ......................................................................................................... 134 Chapter Summary ....................................................................................................................... 137 CHAPTER 5: TEACHING AND LEARNING IN SIMULATION ENVIRONMENTS .......... 139 How Do Participants Teach and Learn in Simulation? ............................................................... 139 How Do Participants Interact and Function in Simulation Environments? ................................ 182 How Do Participants Engage With Simulation Environments? ................................................. 210 How Do Participants Make Decisions in Simulation Environments? ........................................ 242 What Is Right and True in Simulation? ...................................................................................... 250 Chapter Summary ....................................................................................................................... 263 CHAPTER 6: INTERPRETATION AND IMPLICATIONS .................................................... 264 Re-Examining the Research Goal: Learning as Emergence ....................................................... 264 Returning to the Point of Entry: Clinical Competence and the Process of Discernment ........... 275 The Dilemma of Under-Theorized Practices: The Pedagogies of Simulation and Different Ways of Knowing ................................................................................................................................. 286 Taken for Granted Assumptions: Fidelity as a Complex Phenomenon ...................................... 294 Unchallenged Assumptions: Curriculum as a Potential Space of Guided Exploration .............. 298 The Practical Problem: Fostering Emergence of Learning in HF Simulation-Based Learning Environments .............................................................................................................................. 303 Fostering the Development of Clinical Competence and Clinical Judgment ............................. 312 Significance of the Study ............................................................................................................ 323 Conclusion .................................................................................................................................. 324 BIBLIOGRAPHY ....................................................................................................................... 328 APPENDIX A: INFORMATION LETTERS, CONSENT FORMS, AND MEDIA RELEASES ..................................................................................................................................................... 342 APPENDIX B: DATA TABLES ................................................................................................ 349  vi  LIST OF TABLES Table 1. Dreyfus’ (2001) model of skill acquisition. .................................................................... 31 Table 2. JICB Practice Ladder ...................................................................................................... 53 Table 3. Phases of analysis and interpretation .............................................................................. 94 Table 4. Emergent themes and conceptual categories ................................................................ 138 Table 5. Preceptor activity codes ................................................................................................ 145 Table 6. Preceptor roles .............................................................................................................. 146 Table 7. Feedback activity codes ................................................................................................ 161 Table 8. Feedback activity distribution ....................................................................................... 162 Table 9. Feedback items coded to Practice Ladder evaluation focus categories ........................ 164 Table 10. Distribution of feedback by target .............................................................................. 169 Table 11. Distribution of feedback by layers and/or focus ......................................................... 173 Table 12. Distribution of feedback in relationship to Dreyfus (2001) categories ...................... 176 Table 13. Distribution of feedback in post simulation and post program interviews in relationship to Dreyfus (2001) categories ....................................................................................................... 178 Table 14. Coding categories for instances when participants “pop out” or cognitively disengage from simulation ........................................................................................................................... 216 Table 15. Common elements of a paramedic hospital report ..................................................... 234 Table 16. Report summaries ....................................................................................................... 236 Table 17. Distribution of apparent source of authority for feedback given in Classic Case and HF simulations .................................................................................................................................. 257 Table 18. JIBC Practice Ladder analysis .................................................................................... 288 Table 19. Blends of fidelity associated with types of activities in the JIBC Practice Ladder .... 314 Table B1. Characteristics of three simulation environments ...................................................... 349 Table B2. Statements of finding sorted by research question and subquestion .......................... 354 Table B3. Coding categories for relating feedback to the Dreyfus’ (2001) model of skill acquisition ................................................................................................................................... 365 Table B4. Coding categories for interaction of participant and simulation environment ........... 366 Table B5. Coding categories for functions of the participants in the simulations ...................... 367 Table B6. Coding categories for autonomy of partners’ actions ................................................ 368 Table B7. Coding categories for procedural fidelity .................................................................. 369 Table B8. Coding categories for cognitive focus........................................................................ 369 Table B9. Coding categories for apparent source of authority for feedback .............................. 370  vii  LIST OF FIGURES Figure 1. Different ways of knowing. .......................................................................................... 15 Figure 2. Functions, processes, and resources of clinical reasoning. ........................................... 22 Figure 3. Nested relationships of clinical judgment considered in this study. ............................. 35 Figure 4. Layers of fidelity considered in this study. ................................................................... 60 Figure 5. Simulations as individual cases..................................................................................... 70 Figure 6. Location of simulations within curriculum. .................................................................. 73 Figure 7. Classroom setting for a Core Skills drill. .................................................................... 116 Figure 8. Classic Case simulation staged in a public location on campus. ................................ 120 Figure 9. Instructor preparing scenario involving police officers and bystanders. .................... 126 Figure 10. Instructor spreading fake blood at scene of “pedestrian struck” accident. ............... 127 Figure 11. Paramedic crew approaching HF simulation scene involving multiple participants. 128 Figure 12. Feedback points in PCP curriculum. ......................................................................... 158 Figure 13. Sample interaction map. ............................................................................................ 184 NOTE: Left axis represents the codes describing who/what the participant was interacting with. The horizontal access represents time during the simulation. Coloured segments represent individual video clips of an interaction. Colour coding is only to distinguish between clips –the colour itself has no significance. In this simulation, the first 2 minutes show that the participant was interacting with the partner and preceptor, while using equipment en route to the patient. The boxed area represents the segment of the simulation where participants were with the patient. ......................................................................................................................................... 184 Figure 14. Interaction patterns comparing interactions with the partner (driver) between Core Skills, Classic Case, and HFS simulations. Boxed areas highlight interactions with the patient, partner, and preceptor. ................................................................................................................ 192 Figure 15. Sample partner function interaction map in Classic Case call. Note the number of segments coded to watching/waiting. ......................................................................................... 196 Figure 16. Partner disengaged and watching simulation. ........................................................... 196 Figure 17. Partner function interaction map for HF simulation: kel_HFS_06. Note that, in contrast to Figure 15, the partner in this call is active throughout the simulation. ..................... 197 Figure 18. Contrasting procedural fidelity in CS220, CC253, and two HF simulations. ........... 206 Figure 19. Comparison of cognitive focus of attendants in sample Core Skills, Classic Case, and HF simulations. ........................................................................................................................... 212 Figure 20. Cognitive focus of selected high fidelity simulations ............................................... 213 Figure 21. Cognitive focus and procedural fidelity in vcr_HFS_08. ......................................... 214 Figure 22. Interaction map for attendant of kel_HFS_03........................................................... 219 Figure 23. Interaction map of attendant for vcr_HFS_18 showing broad engagement with personnel and physical features of the simulation environment. ................................................ 219 Figure 24. Information sources for vcr_HFS_18. Highlighting indicates instances where student did not obtain information available in from other participants or elements of the simulation environment. ............................................................................................................................... 221 Figure 25. Sample interaction map showing predominance of interactions with preceptors and partners. ....................................................................................................................................... 223  viii  Figure 26. Competence as building blocks. The skill of taking a blood pressure is conceived as stable and unchanged as the practitioner incorporates it into take a set of vital signs, and as those procedures are integrated into performing ambulance calls, completing multiple calls per shift, and through ongoing “blocks” of shifts throughout the practitioner’s career. ............................ 271 Figure 27. Adaptation of a skill over time as a rhyzomatic relationship. “Taking a blood pressure” as an experience that is incorporated into a growing body of similar, yet distinct experiences. ................................................................................................................................. 274 Figure 28. Emergence of clinical judgment from multiple encounters over time. ..................... 284 Figure 29. Comparing pedagogical commensurability of Skill stations and Practicum calls. ... 315  ix  ABBREVIATIONS Terms related to levels of training Abbreviation Definition EMS Emergency Medical Services or Emergency Medical Systems: Modern Canadian ambulance services are part of comprehensive emergency medical systems that include civilian awareness, priority dispatch, prearrival care (dispatchers providing over-the-phone instructions to bystanders at the patient’s side), layered levels of response ranging from first responders to critical care paramedics, and deeper integration of prehospital care with the overall health system (Bledsoe et al., 2005; Caroline, 2010; PAC, 2001) EMR Emergency Medical Responder: Entry-level paramedic practitioner in Canada. EMRs provide basic life support assessment and treatment, including symptomatic relief procedures. Canadian EMR education programs are typically 3 weeks in length. PCP Primary Care Paramedic: Intermediate-level paramedic practitioner in Canada. PCPs provide basic life support assessment and treatment, drug administration via PO, SL, SC, IV, IM, and inhaled routes, employ supraglottic airway devices, and automatic external defibrillation. Canadian PCP education programs are typically one- to two-years (four semester) in length. ACP Advanced Care Paramedic: ACP paramedics provide advance life support assessment and treatment, including the use of invasive procedures, including intubation, manual defibrillation, cardioversion, surgical airway, chest decompression, and pharmacological interventions for conditions affecting airway, breathing, and circulation. Canadian ACP education programs build on PCP certification and are typically one- to two-years (two to four semesters) in length.  Terms related to paramedic education or field practice Abbreviation Definition 35A or Main Cot Standard type of stretcher used by the paramedic programs at the time of this study. Code X Paramedic code used to refer to a case where the patient is not carried or transported to hospital. A call may be a Code X when there was no need for an ambulance at the incident (e.g., a motor vehicle accident with no injuries) or when the patient refuses transport. HFS High Fidelity Simulation: Created learning environments which emphasize a selected set of factors that allow the participants to engage with a dynamic, social environment in authentic physical locations. The HF simulations in this study emphasize physiological, procedural, interpersonal, role, intraprofessional, environmental, and social and cultural aspects of the situations they recreate. NS Normal Saline. Intravenous solution. O2 Oxygen OPA Oropharyngeal airway; curved plastic tube that is placed in an unconscious patient’s mouth to ensure a clear air passage. RBS Rapid Body Survey. Quick but thorough assessment of a patient, performed in the Primary Survey with the intention of identifying and stabilizing all life- and limb-threatening injuries or conditions (e.g., Major bleeding). ROS Robertson Orthopedic Clamshell. Plastic or metal lifting device that splits into two halves. The segments are placed on either side of a patient, then reconnected.  x  GLOSSARY Terms related to clinical judgment Term Definition Competence A dynamic internal construct of what a learner knows and can do; potential patterns of response to novel and/or dynamic environments. Technical Defined in this study as the consistent, independent (un-coached), timely, accurate, and competence appropriate performance of skills, knowledge, and decision making as outlined by an external authority and assessed through observable behaviours (calls upon a definition from the Canadian Medical Association Conjoint Accreditation Services, 2007a). Clinical competence The ability of the practitioner to adapt and integrate procedures and strategies within the dynamic, social environment of field practice. Clinical judgment An emergent process characterized by the learner/practitioner’s increasing awareness of and ability to incorporate an increasingly complex set of contextual factors and relationships into their decisions and (inter)actions. Professional practice Also called Field Practice or simply Practice. The holistic and integrative performance of an experienced practitioner in a specific domain or discipline. Practice within one's To function at a high level—to know, think, make decisions, function, and perform within a discipline profession or discipline. Terms related to simulation Term Definition Authentic Referring to situations, practices, and conditions found in every-day practice. The term is used in this study to describe the every-day aspects of some function or activity as generally understood by practitioners in that context. For example, an authentic location for a pedestrian struck call would be a road intersection. Fidelity A set of dynamic, overlapping, nested relationships between selected elements in a learning environment and the field setting it is representing. In this sense, the fidelity of any learning experience, such as a simulation, is conceived of as its fit with its intended pedagogical purpose. The fidelity of a simulation, then, is the intersection of a set of factors that match different blends of realism to the educational and pedagogical requirements of the desired learning outcome. Human patient Or: High Fidelity Mannequins: Interactive mannequins with computers that allow accurate simulators portrayal of physiological signs (such as ecg and heart rate) that can be dynamically changed during a simulation by manual control or preprogrammed responses to participant actions (such as administering a specific medication or performing a procedure such as defibrillation). Mastery In this study, the term is used in the sense of learning a skill or procedure through guided practice, repetition, and internalization. Mastery, from a cognitivist perspective, is demonstrated through achievement of technical competence: consistent, independent (uncoached), timely, accurate, and appropriate performance of a procedure compared to a clearly articulated set of observable behaviours. Practice learning Created experiences, centred on activity, with the goal of fostering the development of activities competence, proficiency, or expertise within a specific domain or community of practice Simulation (learning A three-phase learning activity (set up, scenario, debrief), designed around a pedagogical activity) goal, in which participants interact with other participants, the environment, and an instructor/preceptor in the context of performing a "call." Some or all aspects of the situation may be represented through simulation. Simulation (the The purposeful creation of a learning environment that dynamically represents a system of educational act of) selected elements and relationships allowing learners, participants, and physical elements to interact and function with the goal of developing understanding or changing practice/performance within a desired context.  xi  Terms related to paramedic practice Term Definition Algorithm A set of predefined steps describing the performance of a procedure. In EMS, principles of management or protocols for managing specific injuries or conditions are often presented as algorithms. The steps of the procedure are listed in a vertical "tree," with the first step at the top of the page. Procedures may have "branches" or alternate paths in which specific findings (e.g., the presence or absence of breathing) trigger different sets of subsequent steps (continuing to assess for circulation or intervening to begin artificial respiration). Call Management Call management refers to overall management of an ambulance call, including patient assessment and treatment, interpersonal communications, dealing with environmental factors, teamwork, leadership, etc. Patient Assessment A structured procedure for gathering data in a prioritized manner, develop a provisional (Patient Assessment diagnosis, and make treatment decisions. The paramedic Patient Assessment Model Model) typically consists of several components: the Primary Survey (prioritized assessment to find and control immediately life-threatening conditions), the Secondary Survey (focused on diagnosis), Treatment, Transport, and Documentation. Primary Survey Primary Survey: initial phase of the patient assessment model. The paramedic performs a prioritized check to find and intervene to control immediately life- and/or limb-threatening situations. Principles of Guidelines for the treatment of common injuries or conditions. Principles of management Management may include the use of protocols (which allow paramedics to perform delegated medical acts). Protocols Paramedic practitioners perform delegated medical acts through the use of written protocols. A typical protocol includes the indications (conditions under which a protocol may be initiated), contraindications (conditions under which it should not be initiated), steps in performing the protocol (often in the form of an algorithm), and guidelines that discuss concerns, common issues, or complications in using the protocol. First responders Paramedics often work with “first responders” such as police and fire fighters. In addition to their primary function, first responders may have basic emergency medical training and provide basic care until a paramedic crew is on scene. The paramedics will often direct first responders to perform ongoing tasks during a call, such as CPR, helping to control bleeding, or assisting with patient lifts and transfers. Standardized patients Actors who are prepared with extensive histories and coached on how to “present” as patients with specific conditions, such as a patient with an extensive cardiac history who portrays a patient having a heart attack or myocardial infarction. To manage a type of Used as an integrative term implying the assessment, diagnosis, and treatment of an injury call or condition.  xii  ACKNOWLEDGEMENTS I’m grateful to my supervisor, Don Krug, for encouraging me to enter the program and guiding me through it. Along with Don, my committee members Dan Pratt and Bernie Garrett provided ongoing encouragement, incredible insight, and critical comment. Their feedback and high standards made this a far better document and a great experience. Over 100 people participated in staging the high fidelity simulations at the New Westminster and Kelowna campuses of the JIBC. This dissertation simply couldn’t have been accomplished without the willingness of nine dozen colleagues, friends, family members, students, instructors, and preceptors to give up a day of their lives and let me watch them work together. A wider circle of staff and faculty helped put together the logistics and mechanics required to stage these days. The JIBC’s librarians remained helpful, knowledgeable, and remarkably cheerful in the support they continued to provide. And I’m particularly grateful to two presidents, three deans, a program director, and two program coordinators for their ongoing interest, advice, resources, and support of this work. Buried in this mass acknowledgement are several key individuals, Eddy Workhoven, Greg Anderson, Steven Mills, and Bill Maser, who served as variously as partners (“on car”), patrons, exemplars, and audiences (both sympathetic and critical). I’d also like to acknowledge the Social Sciences and Humanities Research Council for financial support, and the JIBC for both financial and logistical support of this study. I owe thanks as well my colleagues in Canadian EMS education who inspired me, challenged me, and listened to far too much of what I had to say about our shared passions for patient care and learning. My particular thanks goes to Tim Essington for blazing a path and Walter Tavares for joining me along it.  xiii  Many people read portions of this dissertation and provided feedback, suggestions, and corrections. Karen Crosby of Editarians provided invaluable assistance in cleaning up my abuses of the English language and my modifications of APA formatting. And I’m most grateful to my family: my wife, Karen; my daughter, Joanne; and my son, Craig who helped me through this time and who let me bring this seemingly never-ending project into the midst of our lives. Thanks for being there.  xiv  CHAPTER 1: BACKGROUND AND ORIENTATION TO THE STUDY Every time the students move from one performance domain to another, whether it’s from independent study to the classroom or from simulations to on car, it’s like they step off a cliff and fall into an abyss. Some students just need a couple of calls and off they go again. Others flounder and take longer to find their feet. And some never do make the transition. (personal communication with a paramedic instructor, February, 2005) My research explored a gap separating traditional simulation learning from field practice—a chasm between the comfort and consistency of technical competence and the complexity of professional practice. I explored this space through the lens of developing clinical competence and clinical judgment in the context of high fidelity (HF) simulations involving recruit paramedics at the Justice Institute of British Columbia (JIBC). The opening quote to this chapter took place during a discussion regarding the experience of students moving from classroom simulations to the practicum (or field) setting. Intuitively, this gap seems a simple pause as students move from one learning domain to another. Yet there is more here. Traditional paramedic programs are based on a conception of learning as progression from acquiring knowledge in the classroom and developing skills in simulation to their integration and application in the practicum. In this view, the practicum is an extension of the simulation lab, or, perhaps, simulations are a subset of field practice. The findings in this study, however, suggest that traditional simulations and the field practicum represent radically different learning environments—nested and overlapping environments sharing significant common elements, but distinct—each with its own sets of roles and expectations, patterns of practice, and methods of assessment that call on different epistemological and ontological conceptions of what constitutes competent practice, what knowledge matters most, and how learning occurs. I argue that the gap is not a semantic distinction but, rather, the tension of learners experiencing technical competence and clinical competence as different ways of knowing. 1  My research explored this tension in an effort to better understand how learning emerges in immersive HF simulation environments and how that understanding might facilitate the development of clinical judgment in paramedic recruits. This interest was spurred by increasing demands on health educational programs and recent developments in simulation technologies. Context of the Study In this study, I sought to better understand the relationships between conceptions of curriculum and the use of simulations in fostering complex forms of learning in paramedic education settings. The study was conducted with paramedic students from the JIBC, a public post-secondary educational institute in western Canada. The study was situated within a set of overlapping contexts: paramedicine, with its twin roots in the emergency services and health care; simulation as a form of created learning activity calling upon experiential learning theory; competence and clinical judgment in relationship to developing expertise within a professional domain; the use of educational technologies; and the study of curriculum in professional health education. The Practical Problem: HFS as a Link Between Classroom and Field Practice Paramedic educators, like educators from other health disciplines, are challenged to produce greater numbers of graduates who are better prepared to function in an evolving and increasingly complex health care system (Bledsoe, Porter, Cherry, & Clayden, 2005; Garrett, Tench, van der Wal, & Fretier, 2007). The practicum environment, which has long been a critical link between simulation-based learning and field practice in the health disciplines, is increasingly stressed in attempting to accommodate these rising demands and expectations (British Columbia Academic Health Council, 2005; Garrett, Tench, et al., 2007; Qayumi et al., 2012). At the same time, the simulation environment in the health disciplines has become  2  increasingly enriched through the use of standardized patients, human patient simulators, augmented reality, and virtual environments (Qayumi et al., 2012). High fidelity simulation (HFS) may hold promise as a method for reducing or replacing practicum experiences. Despite significant capital investment in HF simulation infrastructure, however, HF simulation remains an adjunct to, but not a replacement for, practicum placement (Garrett, et al., 2007; Garrett, van der Wal, & Gable, 2007; Qayumi et al., 2012). The practical problem addressed in this study, then, is the presumption that HFS can be used to reduce reliance on practicum placement. Unchallenged Assumptions: Paramedic Curriculum as Building Blocks The JIBC’s current paramedic programs embody a conception of learning as additive and stable, in which the pedagogic whole is the sum of its parts, and through which learners encounter and master curricular content in a more or less predictable progression. Curricula are envisioned and enacted as closed systems in which learners develop skills, knowledge, and judgment that are applied in, but distinct from, the context in which they will be used. Instruction, assessment, and evaluation focus on supporting learners as they accumulate progressively complicated chains of foundational knowledge and procedural skills. Classroom simulations and the field practicum are seen as linked environments, with the gap but a momentary disturbance as learners move between performance domains. This conception is embedded in Canadian professional documents such as the 2001 National Occupational Competency Profile for Paramedics in Canada (NOCP), produced by the Paramedic Association of Canada (PAC). The NOCP provides general, specific, and subcompetencies that define paramedic practice in Canada. The NOCP’s subcompetencies provide the observable behaviours by which performance is assessed. Knowledge-based criteria define and bound the required performance expectations. Competence is defined as consistent,  3  un-coached, timely, and accurate performance of the identified skills and procedures (Canadian Medical Association, 2007a). A unique feature of the NOCP is its hierarchical categorization of competencies into performance domains: awareness, academic, simulation, clinical (hospital), and practicum (field placement). Learners are expected to acquire foundational knowledge, develop skills in simulation, perform them in the controlled context of a hospital setting, then demonstrate competent performance in a practicum placement. Taken-for-Granted Conceptions: The Role of Fidelity The concept that HFS can replicate the field environment arises from taken-for-granted assumptions that increased fidelity is associated with higher order learning outcomes. Simulation is a key learning activity in the development of technical competence in paramedic education. Learners within the current curriculum encounter a structured series of practice learning activities—simulations and their derivatives—in a simple-to-complex progression. Learners develop simple skills in isolated skill stations. These skills are applied in the context of procedural algorithms (such as a patient assessment process or treatment protocol) through simple scenarios or drills. Next, learners integrate these procedures with diagnostic reasoning and clinical decision making during full-call simulations. Finally, learners apply their knowledge, skills, and judgment in performing actual ambulance calls under the guidance of experienced practitioners (preceptors) in a field practicum or preceptorship. Two related concepts appear to move in parallel in this process. Both the complexity of the procedural activities and the fidelity of the created learning environments (and, in particular, physiological and procedural fidelity) increase as learners move from skills stations towards the field setting. Thus, the literature often associates increased fidelity with more sophisticated or higher-order learning outcomes (for a critical discussion of this assumption, see Beaubien &  4  Baker, 2004; Dieckmann, Gaba, & Rall, 2007; Norman, Dore, & Grierson, 2012). This perspective, consistent with the instructional design paradigm that supports it, rests on realist ontological assumptions and a conception of learning as the acquisition of discrete and relatively stable skills and knowledge. Bridging learners from the classroom to the field is seen as a matter of performing or practicing in more realistic settings, and thus, increasing fidelity of simulation environment ought to replicate the practicum or field setting. The Dilemma: Under-theorized Practices Researchers and educational commentators have noted that although advanced technologies and HF environments are increasingly incorporated into health education programs, understanding of how learning emerges in simulation-based learning environments—the pedagogy of simulation-based learning—is less developed (Beaubien & Baker, 2004; Essington, 2010; Issenberg et al., 2005). The dilemma, then, is why? Despite increased fidelity of patient presentation (through actors and mannequins) and the physical environment (creating mock hospital wards and operating theatres), HFS is still not seen as a replacement for the practicum. What, then, is different between these two environments? What elements of the field environment are not being incorporated into HF simulation? What is different in how these elements act and interact with each other? How is the experience of participants different during simulations and in the field? In what ways are the roles, expectations, teaching and learning activities, and assessment methods different? What do learners bring to and take away from their experiences, and how does this foster learning? Point of Entry: Conceptions of Competence and Clinical Judgment The point of entry for this study involves the concepts of competence and clinical  5  judgment. Clinical judgment is an odd term—an expression that has multiple meanings and varied uses within the health disciplines. Within educational EMS (Emergency Medical Services or Emergency Medical Systems) literature clinical judgment is framed as the process a paramedic follows in diagnosing and treating a patient (Bledsoe et al., 2005; Caroline, 2010). Clinical judgment is posed as the cognitive process that guides practice; competence is the stamp of acceptable performance (Bledsoe et al., 2005; Caroline, 2010). Yet, in common conversation between paramedics, the terms competence and clinical judgment are used in ways that are intriguingly at odds with their formal descriptions. In unpublished research conducted at the JIBC, exemplar paramedics tended to use these terms as sliding scales, not binary states. They described practitioners with clinical judgment as those who employed and adapted their processes to the unique needs of a particular call or situation. Clinical judgment, in this sense, is an expression of the practitioner’s ability to see the environment, discern what is important, and construct a mental model from which not only to treat the patient’s condition, but to manage the overall situation. This use is more subjective, more subtle, and more situational. Clinical judgment is used, in effect, as an assessment of expertise within one’s professional practice. Two conceptions of competence are contrasted throughout this study. Technical competence is defined as the consistent, independent (un-coached), timely, accurate, and appropriate performance of skills, knowledge, and decision making as outlined by an external authority and assessed through observable behaviours. Clinical competence is a more holistic assessment of a practitioner’s ability to adapt and integrate procedures and strategies to the unique needs of the moment within the dynamic, social environment of field practice. Where technical competence seeks consistent performance across instances and contexts, clinical  6  competence highlights the practitioner’s ability to discern and adapt to the salient features of a particular situation. Within the context of this study, the gap between the classroom and field practice represents the tension that learners experience between these differing conceptions of technical and clinical competence. Questions and Goal of the Study If simulation-based learning environments are to supplement or replace practicum experiences effectively, they must be able to support the development of clinical judgment. Thus, the goals of this study are to explore how learning emerges in HF simulations; to examine the relationships between desired learning outcomes, the concept of fidelity, and the pedagogies of simulation; to explore the use of simulations in fostering the development of clinical judgment; and, finally, to consider the implications of these factors for how we conceive of curriculum, develop simulations, and foster learning in professional education settings. The central question of this study was, “How does a high fidelity simulation-based learning environment influence the development of clinical competence and clinical judgment in paramedic learners?” The following subquestions inform this central question: 1. What and with whom do learners interact in a high fidelity simulation-based learning environment, and how do they interact with them? 2. How are learners’ technical skills, domain knowledge, and practical judgment evident in their decision making, actions, and descriptions of their experiences in high fidelity simulation-based learning environments? 3. How do learners structure and present their experiences, decisions, and actions in a high fidelity simulation-based learning environment (e.g., patient care records, debriefings, reflective activities, interviews)? 4. How do learners perceive and describe their own sense of clinical judgment after high fidelity simulation-based experiences? Approach I approached these questions through an interpretivst epistemology, multivocal ontology, considering the learning environment as a complex adaptive system. The existing curriculum is 7  primarily based on behaviourist and cognitivist perspectives, and within that framework, successfully creates a learning environment in which students achieve technical competence as defined by the NOCP (PAC, 2011). However, I argue in Chapter 2 that conceiving of learning environments as open, complex adaptive systems better addresses the development of clinical competence and clinical judgment. Thus, I pose key concepts in this research, such as clinical competence, clinical judgment, learning, and interaction within simulation-based learning environments as complex phenomena. I used the research question and subquestions in this study to explore the relationships and interactions of participants and selected elements or agents in the simulation-based learning environment. I called upon Kincheloe’s and Berry’s (2004) concept of multivocal research to examine the concept of clinical judgment through a series of conceptual layers. The initial relationships that I chose to look at in this research included a phenomenological exploration of what and with whom the participants interacted in a simulation-based learning environment; how participants made decisions; how they structured and reported their experiences; a critical analysis of what forms of authority they based their judgments on; and to what extent they considered personal, social, and cultural factors in making patient care decisions. I develop and support the epistemological and ontological orientation and key concepts informing this research in Chapter 2. Situating Myself as the Researcher All research is grounded in choice (Doheny-Farina, 1993; Lincoln and Guba, 2003), and many of the choices in this study emerge and are informed by my background. I am intrigued, both as an instructor and a curriculum developer, at the variability in experience of participants within the same simulation. The curricular goal of consistency is constantly thwarted by the  8  interactions of different mixes of students, actors, and environmental factors despite the articulation of explicit learning goals and outcomes, the use of tightly scripted scenarios, and the rigorous efforts to control for inter-rater variation in assessment and marking. As a curriculum developer and educational administrator, I have been frustrated by the friction between course instructors and field preceptors, by the difference in advice they give students, and by the everpresent tension between the expectations of classroom simulations and practice in the field. My participation in Canadian efforts to develop paramedicine as a distinct discipline and profession has contributed to several aspects of this study. I have struggled with the emphasis on competency-based processes and documents to describe and prescribe paramedic practice and education, particularly at a time when the practice of prehospital care is emerging from its technical roots as an emergency service towards recognition as an evolving health care profession (Bilecki, 2009; Bowles, 2009). And, along with other Canadian paramedic educators, I have been dismayed by the effect of imposing behaviourist definitions of competence and evaluation onto the practicum environment (Tavares & Mausz, in press). A simulation-based learning environment that fosters the development of clinical judgment must incorporate opportunities for participants to experience and incorporate the unpredictability and interconnectedness of the dynamic factors in the field environment. Outline of the Dissertation In this chapter, I presented the question and set the context for this study. Chapter 2 presents a review of literature relevant to the theoretical perspectives that informed this study, conceptions of clinical judgment in paramedic practice, and selected perspectives of experiential learning theory. The chapter develops and articulates working definitions of competence, clinical judgment, simulation, and fidelity. In Chapter 3, I describe the process by which I gathered,  9  analyzed, interpreted, and represented the findings of the study. Chapter 4 is a descriptive analysis of three cases representing the simulation-based learning environments I encountered in the study and presents the study’s initial findings. Chapter 5 provides analysis of these findings through five conceptual categories that represent an emergent understanding of how learning develops in dynamic, interactive, simulation-based environments. In Chapter 6, I further integrate and synthesize the results of the study through a series of integrative themes. The final discussion returns to the starting questions of this study and addresses factors that influence the development of clinical competence and clinical judgment in simulation-based learning environments. I conclude with a discussion of how alternate conceptions of curriculum in professional settings might better inform the creation and use of simulation-based learning environments that foster the emergence of complex learning outcomes.  10  CHAPTER 2: REVIEW OF THE LITERATURE The first chapter set the question and provided the context for this study. In this chapter, I review selected literature that presented the theoretical perspectives that informed this study and developed the working definitions for core concepts that influenced its design and unfolding. I start by reviewing selected literature that articulates concepts of complex adaptive systems, and in particular the characteristics of complex phenomena. The second section traces concepts and definitions of competence and clinical judgment from the perspectives of EMS, health, and clinical reasoning literatures. The third section calls upon phenomenological literature on naturalistic decision making, skill acquisition, and reflective practice to develop and enrich a working conception of clinical judgment for the study. The fourth section turns to learning theory, exploring selected perspectives from experiential learning literature as a rich conceptual milieu from which to examine how learning occurs in professional and simulation-based environments. The fifth section integrates and articulates a theoretical approach to simulationbased learning. The chapter concludes by developing working definitions for the core concepts that extend throughout this study. Complex Phenomena In this study, I turned to Davis and Sumara’s (2006) articulation of complex phenomena in educational contexts to develop definitions of clinical judgment, learning, simulation-based learning environments, and fidelity as complex phenomena characterized by their situatedness, dynamic interactions, and interdependence upon other complex elements and systems. Although behaviourist, cognitivist, and constuctivist approaches have dominated 20th century educational literature, educational researchers and writers are increasingly calling upon concepts of complexity to inform educational practice (Davis & Sumara, 2006; Stanley, 2005). Weaver  11  (1949, as cited in Stanley, 2005) is credited with defining and distinguishing between simple, complicated, and complex phenomena. Complexity science emerged during the 1950s and 1960s in the study of cybernetics, physics, chaos theory, systems theory, network theory, and non-linear dynamics. Since the 1990s, concepts of complexity have increasingly become common in the social sciences, including sociology, anthropology, and education (Byrne, 1998; Clarke & Collins, 2007). Educational descriptions of complex phenomena have built on Weaver’s (as cited in Stanley, 2005) categorization (Clarke & Collins, 2007; Davis & Sumara, 2006). Fleener (as cited in Doll, Fleener, Trueit, & St. Julien, 2005) introduced three aspects of complexity as useful in educational settings: complex adaptive systems, dissipative structures, and chaos dynamics. Indeed, the language of complex systems is embedded in a diverse range of educational literature, including (but by no means limited to) situated learning (Brown, Collis, & Digluid, 1989), communities of practice (Lave & Wenger, 1991), and distributed cognition (Hollan, Hutchins, & Kirsh, 2000). Doll (1993) called upon Prigogine’s (1961) discussion of open and closed systems as an entry point for reconceptualising curriculum as an open, process-oriented system. Kincheloe and Berry (2004) situated their postmodern approach to multivocal educational research as informed by concepts from complexity studies and complex systems. Davis and Sumara (2006) have been active in bringing concepts from complexity into educational research and practice. Their description of complexity studies rested on a pragmatic epistemology and transdisciplinary approach. They claimed that a complexity-based perspective is still young and “refuses tidy descriptions and unambiguous definitions” (Davis & Sumara, 2006, p. ix) as a discipline, field, or research approach. Rather, complexity studies are characterized by their objects of study (Davis & Sumara, 2006): phenomena that exist between  12  the limits of analytic linear description and indeterminate chaos (Byrne, 1998). Approaches informed by complexity strive for multivocal perspectives that acknowledge and confront the complexity and interconnectedness of the lived world. These complex phenomena defy traditional linear, analytic analysis and cause-effect relationships (Kincheloe & Berry, 2005). Complex phenomena are dynamic systems with the ability to transform themselves through interaction with the environment around them (Doll, 1993); they are composed of, and comprise other complex, dynamic systems (Davis & Sumara, 2006); the outcomes of their interactions are unpredictable, although at key points, new, more highly organized patterns of behaviour emerge (Clarke & Collins, 2007; Doll, 1993). The local stability and global unpredictability of these complex adaptive phenomena, their interaction with both finer and broader levels of organization, and their networked organization serve as conceptual and explanatory models from which to explore the participation and interactions examined in this study. Characteristics of Complex Phenomena Davis and Sumara (2006) provided a list of characteristics of complex phenomena:          Self-organization that arises from the interlinking and co-dependence of its agents or components Bottom-up emergence of systems whose capabilities exceed the individual capabilities of its components; Short-range relationships between local elements of the system, rather than central control or top-down hierarchies; Nested structures or scale free networks in which a complex structure is composed of other complex elements, but also becomes part of other, larger complex systems or phenomena; Ambiguously bounded entities that exchanged information, energy, and matter with their surroundings; Organizationally closed forms, that are, nevertheless, inherently stable; Structure determined in that they adapt to their surroundings to remain viable; and Function far-from-equilibrium, in a constant state of change and adaptation. (pp. 5–6)  13  A core concept in this study is that of the nestedness or embeddedness of complex phenomena. Flyvberg (2001), along with Kincheloe and Berry (2004), noted that an object of study is always embedded in a context and that this context is necessary to the study of the object. Thus, complexity brings to the forefront “the role of the knower in the known, in contrast to the efforts of analytic science to erase any trace of the observer from the observation” (Davis & Sumara, 2006, p. 26). Davis and Sumara (2006) extended the idea of nestedness to metaphors and conceptions of knowledge and knowing. They stated that popular metaphors of knowledge see the knower’s subjective understanding as separate from the objective knowledge from which it is drawn. Concepts of learning associated with transmission models of instruction and building-block conceptions of knowledge construction present learning as acquisition of objective external facts. In this conception, skills that learners acquire early in a program are considered to be stable and remain unchanged as they are applied in increasingly complicated situations throughout their program. Davis and Sumara (2006), however, presented the learner’s subjective understanding as nested or embedded within the larger complex entity of a discipline’s body of objective knowledge (see Figure 1). From this view, learning emerges as interaction between the learner and the broader community or domain, seen in metaphors of learning as movement from the periphery of a discipline towards full participation within a community of practice (see, for example, Lave & Wenger, 1991). Davis and Sumara (2006) framed learning as an “ongoing [negotiation] of the perceived boundary between personal knowing and collective knowledge” (p. 27). What is known personally and within the disciplinary collective is further embedded in broader transdisciplinary, social, and cultural constructs.  14  Figure 1. Different ways of knowing. Contrast of objectivist and complexivist perspectives on the relationship of subjective to objective knowledge of a discipline. Adapted from Complexity and Education: Inquiries into Learning, Teaching, and Research, by B. Davis & D. Sumara, 2006, p. 27. Copyright 2006 by Lawrence Erlbaum Associates. Note that each of these phenomena dynamically interact (complex phenomena are not static, they function far-from-equilibrium), and as such, as the learner functions within a group, those actions change the collective body of knowledge of the discipline as well. From this perspective, prior learning is not stable—it changes as it is used within new situations. Learners must constantly adapt skills and knowledge, and develop their own personal style of practice, as they work with different partners, encounter different contexts, and approach new calls or situations, each with unique needs in-the-moment. These characteristics of complex phenomena, and in particular, that of nested structures and relationships, are employed in this study as a way of conceiving, defining, and relating central terms and concepts in this study. Conceptualizing Competence and Clinical Judgment The next section of this chapter reviews selected literature in order to describe, define, and develop conceptions of competence and clinical judgment as used within this study. The following discussion traces the tension between technical and clinical conceptions of competence from the nominal definitions of these terms through their use within specific literature.  15  Competence The tension between technical competence and clinical competence is more than a useful construct for examining learners’ progression from classroom to field practice. The difference is embedded in common language and competing conceptions of core definitions of terms we use to define and describe competence and clinical judgment. There are two general sets of nominal definitions for the term competent, one derived from a sense of rivalry or competition, and the other from a sense of fitness or adequacy (“Competent,” 2013). Several definitions pose competence as a measure of one’s performance against external standards, such as “possessing the requisite qualifications [and] adequacy of work; legitimacy of a logical conclusion” (“Competent,” 2013, para. 5). There is an objectivist tone in these definitions – an implication that competence involves the application of skills and knowledge towards predefined goals, and a sense that competence is an objective, measurable state. One is not intrinsically competent; one is competent only in comparison with some external standard. A second set of definitions draws on the sense of coming together, coinciding, or being convenient, apt, or fit. These definitions take a more pragmatic, subjective view, seeing competence as “[s]uitable, adequate, or sufficient, in amount or extent, [or] sufficient . . . fair, moderate, reasonable, enough” (“Competent,” 2013, para. 3). The first set of definitions focuses on external observation of one’s performance against a set of standards, while the second set emphasize an internal capacity that is situated in a particular sphere or domain of practice. The term judgment is older, entering English as early as the thirteenth century (“Judgment,” 2013). The definition that comes closest to paramedic use of the term focuses on the process of judgment as the “pronouncement of a deliberate opinion on a person or thing”  16  (“Judgment,” 2013, para. 6). This has a rationalist flavour, citing judgment as “exercising the mind [or] . . .mental apprehension of relationship between two objects of thought [and] . . .a function of the mind” (“Judgment,” 2013, para. 6). This sense calls to authority, reason, doctrine, and deduction. A contrasting set of definitions sets judgment as an attribute or capability—the “ability to form an opinion” (“Judgment,” 2013, para. 7). These definitions have a sense of judgment as more than the application of reason and refer to judgment as a critical faculty, employing discretion, discernment, wisdom, and understanding to reach just, righteous, and equitable decisions. While the sense of judgment as a reasoned process is here, so too is recognition that the forming of just opinions is set within a wider set of factors. Judgment involves discernment and the weighing of options, not just the act of comparing them to preset standards. As with competence, judgment can call upon two competing conceptions; judgment may be either a function that draws on external authority to arrive at conclusions dispassionately and objectively or as an internal faculty of discernment that is yet inextricably bound to the environment one functions in. In paramedic practice, the term clinical is used to distinguish field practice from more abstract or academic settings. Again, however, the term clinical has multiple meanings which speak to learners’ experience in transitioning from classroom to field practice. The first definition draws from early medical literature “pertaining to the sick-bed, [specifically] to that of indoor hospital patients; used in connexion with the practical instruction given to medical student at the sick-beds in hospitals” (“Clinical,” 2013, para. 1). A second definition refers to clinical baptism as a rite given at the sick-bed to one who is imminent danger of dying. These definitions embed and define clinical performance through its context of practice. The third sense of clinical is  17  more recent, abstracting clinical to represent “coldly detached and dispassionate, like a medical report or examination; diagnostic or therapeutic… treating a subject-matter as if it were a case of disease, especially with close attention to detail” (“Clinical,” 2013, para. 3). This definition stands in stark contrast to the situated sense that the previous definitions carried. The focus has shifted from the location (sick-bed) and state of the person (hospitalized or near death) to an abstraction of the disease process. In this sense, oddly, clinical explicitly removes the context of the situation to focus on its diagnostic or therapeutic considerations. Each of these terms—competence, judgment, and clinical—may be framed to either draw on rationalistic and objectivist performance that is judged by comparison to external standards, or as value-laden activities defined by and situated within their context of performance. The former rests comfortably with current cognitivist curriculum structures, expectations, and evaluation; the latter opens up space for examining the relationships between practitioners and their operational environment. Within this study, these contrasting conceptions are distinguished by the terms technical competence and clinical competence. Drawing upon terminology from the NOCP (CMA, 2007a), technical competence is defined in this study as the consistent, independent (un-coached), timely, accurate, and appropriate performance of skills, knowledge, and decision making as outlined by an external authority and assessed through observable behaviours. I conceive clinical competence, however, as a more social construct involving an ongoing negotiation between what the learner knows and can do with a series of overlapping relationships and expectations between the learner, her or his partner, the patient, family and bystanders, situational and environmental factors, operational guidelines and protocols, the community of practice, and social and cultural expectations. Clinical competence is defined and distinguished from technical competence as the ability of the  18  paramedic to apply, adapt, and integrate procedures and strategies within the dynamic, social environment of field practice. In this same sense, I pose clinical judgment as a complex phenomenon—a context-laden activity in which the paramedic considers the patient, protocol, procedures, personnel, past practice, and best practice. The following section explores concepts of clinical judgment with the goal of developing a working definition of clinical judgment for this study. Towards a Definition of Clinical Judgment in EMS The term clinical judgment is variously used in health disciplines as a product of clinical reasoning, a diagnostic process, as an organizing concept, and a component of larger concepts. Norman (2005) outlined the progression of research involving medical expertise, conceiving and articulating clinical reasoning—and its synonym clinical judgment—initially as a generic and abstract cognitive decision making model, then as the development of expert knowledge, and more recently as the mental schema underlying multiple cognitive problem-solving strategies. A 2007 doctoral study in medicine defined clinical judgment and clinical reasoning as components of clinical competence (Baig, 2007). Studies in nursing have used clinical judgment as a global construct supported through clinical reasoning and critical thinking (Ferguson, 2006; Lasater, 2005; Ruggenberg, 2008). Indeed, the varied literature encountered in this literature review placed clinical judgment in a nest of overlapping and sometimes contradictory terms and constructs. These studies looked at issues of expertise and clinical judgment from different perspectives, with different goals, and called upon various research traditions and methods which, in turn, rested upon different views of what constitutes knowledge and how we come to know. Each provided a different snapshot or view that explored some facet of overall professional practice. Individually these views seem inadequate to informing the task of  19  understanding the tension between technical competence and professional practice. Together, however, each helps build a more comprehensive view clinical judgment and how it develops. Clinical judgment in EMS. There is little research into clinical judgment in an EMS setting. EMS is an emerging field, yet to define itself and establish a solid foundation of academic literature (Jensen et al., 2012). Academic literature on clinical judgment in EMS has often examined whether paramedics possessed the clinical judgment to perform advanced procedures (Atherton & Johnson, 1993; Canadian Patient Safety Institute, 2010; Hall et al., 2005; Jones & Wollard, 2003; Leblanc, Macdonald, McArthur, King, & Lepine, 2005; Long, 2005; Pitt, 2002; Snooks, Halter, Lees-Mlanga, Koenig, & Miller, 2000), or the efficacy of initiating new treatments or procedures in the field (Davis, Cobaugh, Leahey, & Wax, 1999; Eckstein & Suyehara, 2002; Eo et al., 2003; Sayre, White, Brown, McHenry, & National EMS Research Agenda Writing Team, 2002; Woollard, Smith, & Elwood, 2001). These studies referred to clinical judgment as a characteristic of paramedics but did not explore its definitions or development. The term clinical judgment is also absent in formal professional literature in Canadian EMS. The NOCP does not explicitly use the terms clinical competence or clinical judgment. Clinical reasoning and clinical decision making are also absent as terms within the NOCP. However, the process of clinical reasoning is embedded as a series of steps that constitute assessing and providing care to patients with specific injuries or conditions. Clinical judgment, in EMS education literature, is the process by which a paramedic assesses the scene, develops a set of differential diagnoses, and modifies further assessment to reach a provisional diagnosis which is the basis for the development of an appropriate treatment plan. Current North American EMS texts define clinical judgment as a synonym for clinical  20  reasoning, employing “the use of knowledge and experience to diagnose patients and plan their treatment” (Bledsoe et al., 2005, p. 437). Patient assessment—the EMS umbrella term for clinical reasoning—is a rich, iterative process first learned as a procedural method, then used as a cognitive framework for deductively integrating pathophysiology and principles of management, and finally as an inductive, inquiry-based problem-solving process in field assessment (Bledsoe et al., 2005). Within this framework, clinical judgment is expressed and assessed as an application of the medical clinical reasoning process set within behaviourist and cognitivist educational constructs. The learner’s expected performance is described as a series of layered, hierarchical procedures and assessed through the use of criteria-referenced checklists. A variety of mnemonics and visual devices are used to ensure that learners can effectively remember the clinical decision-making process, then employ it in simulations and the field. The starting point for a working definition of clinical judgment for paramedics, then, is that it involves a process and procedure for patient assessment and decision making. Modern EMS emerged from advances in trauma care and cardiac resuscitation. Thus, core concepts of patient assessment and management are firmly embedded in medical perspectives and practice. The following sections extend this definition by exploring concepts from health education. Clinical judgment in physician education. Clinical judgment is most thoroughly explored within a rich and growing body of literature describing medical expertise. A variety of terms have emerged to describe expertise in clinical practice, including clinical judgment, diagnostic reasoning, and critical thinking (Moulton, Regher, Mylopoulos, & McRae, 2007), and clinical reasoning, problem-solving, decision making, and judgment (Norman, 2005). This literature has generally been set within a cognitive psychology paradigm (Mypolous & Regher,  21  2007; Norman, 2005), has called upon experimental and quasi-experimental methods (Mypolous & Regher, 2007) and has examined clinical reasoning as an overarching approach to patient assessment (Bowen, 2006; Eva, 2004), involving the use of two general strategies (Eva, 2004), and an impressive and flexible set of specific processes and cognitive constructs (Mypolous & Regher, 2007; see Figure 2).  Figure 2. Functions, processes, and resources of clinical reasoning. At its most general level, clinical reasoning involves a series of functions or activities that occur in a more-or-less predictable pattern. The practitioner encounters a patient, forms an initial impression or representation of the case, gathers data to support or discount potential causes of the patient’s presentation, and arrives at a diagnosis. Clinical reasoning is supported through the use of several analytic, non-analytic, and abductive processes and strategies (Ward & Haig, 2011). Hypothetico-deductive processes, credited to Elstein, Shulman, and Sprafka (1978) and described in the research (see, for example, Ericsson, 2007; Norman, 2005), represented an analytic approach wherein the physician identifies a series of potential diagnoses, then gathers patient data to rule in or rule out these 22  options. This process relies on an expert body of clinical science knowledge allowing practitioners to identify key signs, symptoms, and features of a situation, and some form of probability analysis to determine the most likely cause of the patient’s presentation (Eva, 2004). Non-analytic processes involve the non-conscious generation of diagnoses through pattern recognition or recollection of prior, similar cases (Eva, 2004; Norman, 2005; Norman, Young, & Brooks, 2007). Non-analytic processes rely on the ability of the practitioner to create and maintain categories of cases in memory. Patel, Arocha, and Zhang (2004) described abductive logic as a cyclical process of generating and testing diagnostic hypotheses. Diagnostic or clinical reasoning requires a foundation of knowledge in clinical sciences and a body of experiential cases. Norman (2005) stated that expertise involves the development of an extensive, multidimensional, relational database, what Myopolous and Regher (2007) referred to as a “set of impressively rich and well organized resources and processes” (p. 1159) that support clinical reasoning. Examples include illness scripts1 (Schmidt and Rikers, 2007), prototypes and exemplar cases2 (Norman et al., 2007), and semantic qualifiers3 (Bordage, 2007). These resources support both analytic and non-analytic processes. Strategies such as 1  Schmidt and Rikers (2007) focused on the role of experience in the development of memory structures in physicians. Learners initially develop rich causal models linking pathophysiology and clinical presentation. With time and experience, they restructure or “encapsulate” this basic bioscience knowledge into simplified causal models or shortcuts used to explain their patients’ presentation. Further experience with specific cases leads them to create “illness scripts” that include “a wealth of clinically relevant information about the enabling conditions of disease” (Schmidt & Rikers, 2007, p. 1135). As the physician continues in practice, specific cases that call upon an illness script become instantiated and leave an episodic or narrative trace that may be called upon for helping to diagnose future cases. 2 Prototype theory “assumes that a person’s experience with individual exemplars is averaged into a prototype of the category that contains most of the critical features of the category” (Norman, 2007, p. 1141). New instances (or, in diagnosis, the case in question) are classified into the existing category with which it has the most features in common. By contrast, exemplar theory suggests that over time, practitioners build a mental base of exemplar situations or cases through experience. New cases are categorized by “an unconscious similarity match with a particular prior example of the category” (Norman, 2007. p. 1141). 3 One of the key functions of clinical diagnosis is the translation of the patient’s story into a set of terms and constructs that facilitates clinical reasoning. Experienced clinicians, Bordage noted, tend to identify and frame key features of the patient’s presentation into medical terms set within a series of opposed diagnostic categories, such as chronic:acute, gradual:sudden onset, or distal:proximal. This framing allows the practitioner to restate the patient’s presenting complaint as a diagnostic picture that is more easily categorized.  23  translating the patient’s story to diagnostic language, determining the key features in a patient’s presentation, and recognizing situations as instances of previous exemplar cases help develop initial hypotheses (competing potential diagnoses to be differentiated). Over time, practitioners encapsulate basic science knowledge and experience with cases to develop illness scripts and prototypical cases in memory to support more holistic pattern recognition for making diagnoses. Several researchers seek to synthesize the use of analytic and non-analytic approaches within a larger process of clinical reasoning: with experience, diagnosticians tend to follow nonanalytic approaches for routine cases, but revert to more mixed and analytic strategies when presented with novel or complicated cases (see, for example, Eva, Hatala, LeBlanc, & Brooks, 2007; Moulton et al., 2007; Patel et al., 2004). Eva (2004) noted that both analytic and nonanalytic processes are involved interactively in hypothesis generation; Bowen (2006) compared the diagnostic journeys of a novice and resident practitioner to relate these processes and resources into a model of diagnostic clinical reasoning. Patel et al. (2004) described abductive reasoning as a cyclical blend of inductive and deductive reasoning employed throughout the process of diagnosis. Two features of this model are of interest to this study. First, as Norman (2005) noted, “‘expert clinical reasoning’ really amounts to expert diagnostic reasoning, usually in internal medicine” (p. 425). The patient’s personal history, social setting, and cultural background are either ignored or considered as data only if relevant to obtaining a diagnosis, and the model does not consider broader concerns of developing and implementing treatment plans, dealing with situational factors, or working within a team environment. Second, however, this model of clinical reasoning does provide rich descriptions of how medical practitioners approach diagnoses. These processes and strategies provide observable markers which may indicate the  24  use of clinical reasoning within the practitioner. Existing models of patient assessment in EMS provide procedural models for practitioners to use when managing a call. The medical expertise literature has enriched this view by providing windows into the processes and strategies that practitioners use when performing the diagnostic functions of clinical judgment. EMS and other health disciplines, however, often deal with more than the patient’s presenting problem. The following section explores clinical judgment from the perspective of other health disciplines. Clinical judgment and critical thinking in health professions. Research from medical education in clinical reasoning has served as a starting point for research into clinical judgment and clinical reasoning process in professional health programs including advanced nursing practice (Bald, 2006), community-based nursing (Bryans & McIntosh, 2007; Carr, 2004), physical therapy (Edwards, Jones, Carr, Braimack-Mayer, & Jensen, 2004), physiotherapy (Edwards, Jones, Higgs, Trede, & Jensen, 2004), and speech therapy (Hoben, Varley, & Cox, 2007). However, many of these studies adapted the clinical reasoning process to function within the broader context of practice in their setting (Nikopoulou-Smyrni & Nikopoulos, 2007). Research from the medical expertise literature has tended to focus on immediate diagnosis from the perspective of the physician. Other health disciplines tend to work with diagnosed patients during treatment, recovery, and rehabilitation over a substantial period of time. The clinical reasoning literature has left broader conceptions of ongoing patient care—which are the focus of many health disciplines—unexamined. The development of clinical competence and expertise has been studied in a nursing context by Patricia Benner (2001) and her colleagues (Benner, Tanner, & Chesla, 2009). Benner, drawing on Dreyfus and Dreyfus’ (1986) phenomenological work on skill acquisition (see the  25  following section), examined the development of clinical knowledge and set clinical judgment as a more holistic construct. Within Benner’s model, cognitive strategies and educational interventions prepare a novice nurse to enter practice as an advanced beginner. What is particularly interesting in Benner’s work is the notion that the context of practice is an element of expertise. The development of expertise requires immersion and experience within a particular setting. Benner noted that it may take two years for practitioners to become proficient and expert at practice within a particular setting. When an expert practitioner moves into a different setting, it will again take time, experience, and deliberate or reflective practice to become expert within this new context. Another strand of nursing literature has posed critical thinking as an integrative concept that entails characteristics (attitudes/behaviours), experiential and theoretical intellectual skills, technical skills, and interpersonal skills. Alfaro-LeFevre (2004), for example, defined critical thinking as the “ability to focus your thinking to get the results you need” (p. 5). She acknowledged the subjectivity of assessing critical thinking and situated critical thinking and clinical judgment within a broad set of relationships including the nursing process, scientific method, patient, family and community needs, professional standards, and ethical considerations. Clinical Judgment as More Than Clinical Reasoning In the previous section, I explored conceptions of clinical judgment from EMS and health education perspectives. Literature from EMS and clinical reasoning has tended to frame clinical judgment as a diagnostic process focused on patient assessment. What is interesting in the broader health education literature is that clinical judgment, critical thinking, and clinical reasoning are posed as constituent intellectual skills within a broader conception of professional expertise. Viewing clinical judgment as a synonym for clinical reasoning is both narrow and  26  restrictive, reducing field practice to the technical application of a generic process that differs little between novice and expert practitioners. The health education view of expertise, however, resonates better with paramedics’ everyday use of the term clinical judgment. A broader conception of clinical judgment moves the curricular end point or goal beyond competence and fosters the development of proficiency and expertise. The following section calls upon phenomenological views of naturalistic decision making, skill acquisition, and professional expertise to further develop the concept of clinical judgment in paramedicine. Phenomenological Views of Developing Expertise In this study, I posed field practice as a site of ongoing interaction between multiple participants and a dynamic environment. The processes of clinical reasoning and patient management are important, but they are not the only aspects of professional practice. Viewing clinical judgment as expertise opens a space for exploring the development of practitioners’ ability to function within the complex milieu of field practice. Norman (2005) noted that much of the research in medical expertise has been situated in cognitive and clinical psychology. Benner et al. (2009) and other researchers in clinical reasoning (see, for example, Mylopoulos & Regher, 2007) have drawn on more phenomenological approaches to better consider how practitioners make decisions and develop expertise. The following section examines three concepts drawn from phenomenological inquiry: Klein’s (1997) naturalistic decision making (NDM), the Dreyfus’ (1986) model of skill acquisition, and Schön’s (1983) description of professional practice. Klein: Naturalistic Decision Making NDM emerged from decision making literature as a separate strand of research in the late 1980s, calling upon a phenomenological exploration of “the way that people use their experience  27  to make decisions in field settings” (Zsambok, 1997, p. 3). Mainstream research in clinical reasoning and decision making focused on analytic processes from the perspective of clinical psychology (Norman, 2005; Zsambok, 1997). As Zsambok (1997) noted, decision making research used experimental methods to assess artificial tasks that did “not take into account effects of most contextual factors that accompany decision making in real-world settings, nor [did] they adequately model the adaptive characteristics of real-world behavior” (p. 4). In contrast to the hypothetical-deductive model of analytic reasoning, NDM research has indicated that experienced practitioners tend to size up a situation, creating an explanatory mental model based on previous similar situations, and then choose a course of action that will suffice to meet the unique needs of the moment (Klein, 1997, 2009). Klein (1997) described two diagnostic strategies: feature matching and story building. Practitioners most commonly use feature matching to compare key features of the current situation to previously encountered cases. Practitioners also use story building as a type of mental simulation used to create causal explanations for the features of the current situation. This story can be “run forwards [to project possible courses of action] or look backwards in time as a way of making sense of events and observations” (Klein, 1997, p. 290). Two aspects of NDM are particularly relevant to clinical judgment in paramedicine. NDM does not focus on decision making in terms of memory, attention, or cognitive processes. NDM describes what Dreyfus (as cited in Zsambok & Klein, 1997) referred to as “levels of skilled response” (p. 27) for sizing up situations characterized by “time pressure, ambiguous information, ill-defined goals, and changing conditions” (Klein, 1997, p. 285). Klein (1997) noted that NDM focused on “(a) experienced agents, working in complex, uncertain conditions, who face (b) personal consequences for their actions. [NDM] (c) tries to describe rather than  28  prescribe, and (d) it addresses situation awareness and problem-solving as part of the decision making process” (p. 287). In other words, NDM takes a phenomenological approach to examining decision making within a particular set of circumstances. A second important feature of NDM is its focus on context, environment, and events. Analytic reasoning isolates key features of a situation, compares them to prototypical cases, and selects the best available option. Clinical experiments exploring diagnostic reasoning are designed to control for context (Norman, 2005). NDM, in contrast, recognizes that the overall context of practice is a central feature of decision making and problem solving. NDM research in firefighting, army and navy command and control, commercial flight control, and nursing in intensive care settings has focused on ongoing decisions that are embedded in the unfolding of events (Klein, 1997). Models of clinical reasoning, while iterative and ongoing, focus on diagnosis and either do not include non-patient care considerations or consider them as complications. While clinical reasoning is a central aspect of clinical judgment in paramedicine, overall management of a call involves an overlapping set of complicating factors that quite comfortably fit into Klein’s (2008) description of NDM settings. Within this conception, clinical reasoning and diagnosis become part of the series of ongoing decisions that practitioners engage in during overall participation in the call. The practitioner must also determine what sources of information to consider in any particular call, and how to interact with family and bystanders, work within an interprofessional setting involving paramedics and other responders, choose and adapt equipment to the particular needs of the environment, and make decisions about when, where, and how to transport the patient. NDM extends conceptions of clinical judgment by describing decision making within  29  complex, unpredictable environments. Moulton et al. (2007) called upon the phenomenological work of Schön (1983) and Dreyfus and Dreyfus (1986) to examine how expertise develops. These concepts are further explored in the following sections of this review. Dreyfus and Dreyfus: Development of Expertise Herbert and Stuart Dreyfus (1986) presented a five-stage model of skill acquisition that has been used as a basis for studying the development of expertise in the military (Dreyfus & Dreyfus, 1986), nursing (Benner et al., 2009) and medicine (Moulton et al., 2007). The model, refined and represented by Herbert Dreyfus (2001) outlines five stages: novice, advanced beginner, competent performer, proficient performer, and finally, expertise. The learners’ performance changes along two lines—the ways in which decisions are made and the importance of context to that decision making. Novices learn context-independent rules for performing specific procedures. As they progress to the advanced beginner stage, they begin to recognize situational aspects and develop principles or maxims for dealing with common situations. Competent performers recognize, with more experience, the salient features of various situations and develop customized plans by choosing between various options for action. Over time, proficient performers intuitively recognize a situation as similar to various prior examples. They discriminate between salient features of potentially conflicting interpretations of the situation and choose or develop a plan that will work in this situation. Finally, expertise develops as the learner acquires a vast repertoire of situations and plans. These situations and plans become associated with emergent themes and categories which often are based on subtle and nuanced features of the cases (see Table 1).  30  Elements or Level Novice Context free features  Table 1. Dreyfus’ (2001) model of skill acquisition. Definition or description EMS relevant example  Elements of a situation that can be recognized without previous experience in the task domain Rules Context independent rules based on context-free features Advanced beginner Situational Features of a situation are Aspects meaningful within a specific context; requires some experience to distinguish aspects from features. Principles/ Procedures based on both Maxims situational aspects and noncontextual features; requires some understanding and experience to apply. Competence Aspects with Number of relevant factors becomes importance overwhelming, and practitioner salience must determine which are most salient or important features of a particular situation. Proficiency Situational Intuitive recognition of situation discriminations and identification of salient features based on multiple past similar experiences.  Decide based on salience  Must choose between multiple acceptable options, based on discrimination between salient features. May adapt principles to meet conflicting salient features.  Blood pressure reading: hypotension defined as a blood pressure below 90/60. If blood pressure is below 90 mmHg systolic, do not administer nitroglycerine. Pallor (pale, cool, clammy skin), which may indicate shock with a history of trauma, or may indicate fright or anxiety in an emotionally charged environment. Position hypotensive patients supine unless this might aggravate other conditions such as shortness of breath.  An elderly male with a cardiac history who complains of sharp shooting pain in his left arm may have a musculoskeletal injury or a cardiac episode. Must decide which is more salient—the description of the pain (MS) or age and cardiac history (cardiac) A pedestrian struck by a car; single long-bone fracture, but on the pavement during rush hour in the cold with light rain. Practitioner must consider nature and mechanism of injury, environmental factors, and physical safety to determine whether to transport immediately or assess and stabilize the fractures to prevent aggravating the injuries. Either treat the patient as stable and splint before moving or choose to treat the patient as unstable with minimum stabilization on scene, with further assessment and splinting once patient is in ambulance. Either is acceptable and defendable.  Continued  31  Table 1 (continued) Elements or Definition or description Level Expertise Vast repertoire Intuitive recognition of situations of intuitive and appropriate plans/perspectives perspectives based on a “bank” of previous experiences Subtle and Distinguishing of subclasses of refined types of experiences based on discriminations experience. Intuitively appropriate action  Immediate, intuitive, situational response.  EMS relevant example  Function of experience, either in the field or in simulation. Make decisions based on similarity of present case to successfully managed prior instances. Discussion based on diagnostic and situational categories rather than body system or mechanism of injury; preceptor where patient is abusive, who intuitively recognizes potential for violence. Preceptor in above situation who, without apparent thought, intervenes to ensure scene safety by cuing police officers to situation, positioning himself to block if patient starts kicking, and eventually intervenes to take over assessment of the patient.  Two aspects of this model are of interest to conceptions of clinical judgment: expertise is posed as an increasing awareness of context, and judgment involves personal choice between alternative acceptable interpretations of a situation. Within the Dreyfus (2001) model, expertise develops with time, experience, and the ability to both intuitively recognize, immediately choose, and then adapt actions to meet the requirements of a specific situation. In contrast to the pursuit of consistency which characterizes technical competence, expertise is situational, adaptive, and intuitive. Indeed, a technically competent practitioner (consistent, context-independent performance) would be considered an advanced beginner in the Dreyfus (2001) scheme. Judgment, according to Dreyfus (2001), is a function of choice: the expert practitioner— one with well-developed clinical judgment—compares, contrasts, and selects an interpretation of the situation from which to recall solutions and actions taken in prior similar episodes and develop a customized plan of action for managing the current condition. Clinical judgment framed as expertise in the Dreyfus (2001)model, then, requires experience and performance 32  within context to develop the vast repertoire of cases from which to make judgments and choices. Schön: The Gap between Technical Rationality and Professional Practice The final phenomenological approach considered in this review is Donald Schön’s (1983, 1987) work on reflective practice and professional expertise. Schön’s work spoke directly to the distinction between technical and clinical competence, contrasting traditional approaches grounded in what he terms a technical rationalist approach with a view of professional decision making as a process of discernment and adaptation. Schön (1983) described traditional views of professional education as a hierarchical progression from basic science through applied science to the training in clinical skills. Schön contrasted this view with his vision of professional knowledge based on reflective practice. Technical rationality viewed professional performance as “instrumental problem solving made rigorous by the application of scientific theory and technique” (Schön, 1983, p. 21). The application of basic science yields applied science. Applied science yields diagnostic and problem-solving techniques which are applied in turn to the actual delivery of services. The order of application is also an order of derivation and dependence… the more basic and general the knowledge, the higher the status of its producer.” (Schön, 1983, p. 24) From the perspective of technical rationality, the goal of education in the professions is technical competence, defined as context-independent practice based on generalized knowledge. Professional practice, for technical rationalists, focuses on problem-solving. Practitioners identify the key characteristics of a situation and apply the appropriate principle. The mark of the technically competent professional is the acquisition of a large, bounded, unique body of specialized knowledge and the application of standardized principles and guidelines (Schön, 1983).  33  Schön (1983), however, noted that professional practice, in practice, is less concerned with clearly defined problems that can be solved by generalized principles than it is with “phenomena – complexity, uncertainty, instability, uniqueness, and value-conflict—which do not fit the model of Technical Rationality” (p. 39). Schön’s (1983) view of expertise in professional practice focused not on problem solving, but on problem framing: “the process by which we define the decisions to be made, the ends to be achieved, the means which may be chosen” (p. 40). Professional practice, he claimed, is the domain of interpreting a problematic situation when “interactively, we name the things to which we will attend, and frame the context in which we will attend to them” (1983, p. 40). For Schön (1983), expertise is found not in the technical problems of the highlands, as claimed by technical rationality, but rather in the messy swamps of the lowlands, where the practitioner must deal with confusing questions that defy technical solution. Thus, for Schön (1983), as for Dreyfus (2001), the development of professional expertise is an increasing awareness of the context of practice and the ability to choose between an indeterminate number of potentially acceptable options to problems that are difficult to categorize. While Dreyfus (2001) presented the development of expertise as an unbroken progression, Schön (1983) referred to “a gap between professional knowledge and the demands of real world practice” (p. 45). Development of Expertise Summary: Clinical Judgment as a Complex Phenomena Klein (1997), Schön (1983), and Dreyfus (2001) presented the development of expertise and professional practice as adaptive processes that involve discerning and attending to nuance, identifying salient aspects of a situation, and developing a response that meets the needs of the moment. This characterization of expertise resonates with the conception of field practice and  34  clinical judgment as complex phenomena. And the concepts of nestedness, local interactions, and dynamism are useful for exploring both the functioning and development of clinical judgment. Clinical competence is an indicator of how well a practitioner can function in this dynamic, unpredictable milieu. And clinical judgment involves the ability to discern and consider and incorporate these relationships. In this study, then, I define clinical judgment as an integrative concept of holistic professional practice, bringing together technical performance, domain knowledge, and practical judgment to allow the practitioner to see beyond the immediate presentation of the patient—to discern what is important in any particular situation and to make decisions based on broader personal, professional, social, and cultural contexts (see Figure 3). I pose the development of clinical judgment as an emergent process characterized by the learner/practitioner’s increasing awareness of and ability to incorporate an increasingly complex set of contextual factors and relationships into his or her decisions and (inter)actions.  Figure 3. Nested relationships of clinical judgment considered in this study. Current Paramedic Education Programs Paramedic practice blends an intriguing set of applied capabilities including knowledge of clinical sciences, psychomotor skills, interpersonal interaction, and adaptive problem solving. Traditional training programs, based on classic instructional systems design models, focus on the development of knowledge, skills, and attitude. But, as developed in the previous sections, expert 35  performance is as much about adaptation and creation as it is memory and skill; more about discernment and judgment than values and attitude. In the following sections, I describe the development of EMS education and its roots in behaviourist and cognitivist learning paradigms, then call upon Fenwick’s (2003) exploration of several experiential learning perspectives that are relevant to the conceptions of clinical judgment and expertise in this study. Paramedic Training and Education: A Cognitivist Approach EMS is a relatively young discipline. Modern EMS emerged in the 1960s through the extension of lessons learned in military trauma management to the civilian setting, and the application, at the patient’s side, of CPR and advanced cardiac life support procedures previously available only in the operating theatre or intensive care unit. Early paramedic services relied on emergency medical technicians who functioned under direct supervision of physicians (by telephone and telemetry) or through written protocols. Training tended to focus on procedural skills with little theory (Bledsoe et al., 2005). The paramedic was both legally and functionally an extension of the physician, and thus paramedic training was influenced by structures and concepts drawn from medical education. Early ambulance services developed into integrated EMS that now include layered levels of response and deeper integration with the overall medical system (Bledsoe et al., 2005; Caroline, 2010; PAC, 2001). Advancing technology and evolving medical practice have led to increased expectations and a vastly expanded scope of practice for paramedics. Paramedic education has evolved from in-house, ad hoc training programs to a series of linked courses and programs leading from initial certification, advanced practice, and continuing education to undergraduate diploma and degree programs in prehospital care, such as the Diploma in Health  36  Sciences (EMS) offered by the JIBC (n.d.) and the Bachelor of Clinical Practice (Paramedic) at Charles Stuart University (2013). The curriculum of paramedic education has grown in depth, breadth, complexity, and structure, but retains a goal of technical competence as its end point. While early emergency medical technician courses focused on skills and procedures, the development of advanced life support paramedics led to broader, richer programs with a stronger foundation of clinical theory. These programs adopted curriculum formats based on traditional medical education models, with an early emphasis on didactic (theory) learning, followed by extended practicum placement. Paramedics develop domain specific knowledge from which are derived general principles of management that are then applied in the clinical setting. This structure mirrors traditional professional curricula: basic science, leading to applied science, followed by development of clinical skills (Doll, 1993; Fenwick, 2003; Schön, 1983). This format, claimed Schön (1983), rests on foundations of technical rationality and seeks, as its goal, technical competence in the form of consistent, context-independent performance. Current programs employ a blend of mastery learning and cognitivist learning strategies. The JIBC developed the current Primary Care Paramedic (PCP) program following a classic instructional design process (see, for example Dick & Carey, 1985), performing an analysis of the NOCP (PAC, 2001), industry, and practitioner needs, then sorting the results through the lens of the JIBC’s curriculum model to create an objective hierarchy, specify evaluation points and tools, establish learning and instructional strategies, and develop program materials. A cognitivist approach is employed in the pedagogic construction of the program. Content is carefully sequenced in a simple-to-complex, building block structure. The Patient Assessment Model (based on the analytic process of clinical reasoning) serves as both the  37  procedural framework for skill development and a cognitive framework for organizing and learning pathophysiology, diagnostic features, and the principles of management of classic presentations of common injuries and illnesses. The program makes liberal use of procedural guides, graphic organizers, and mnemonics to establish common patterns of practice and build mental pictures of how common illnesses and injuries commonly present and are typically managed. The program follows a recursive approach in which new content is related to the central theme, gradually adding new knowledge and skills while reinforcing previously mastered content. The program employs a staged set of learning activities employing a Mastery Learning model (Hunter, 1994) based on behaviourist and cognitivist learning perspectives. Skills and procedures are first mastered in skill stations, then chained and contextualized in drills and segmented calls or short simulations. Learners next integrate previously learned assessment and treatment procedures in the performance of complete simulated ambulance calls. Performance is guided and assessed through mastery checklists4 that focus on observable behaviours. Instructors demonstrate core procedures, guide learners through initial attempts while providing detailed performance feedback, then gradually withdraw support as learners acquire confidence and competence. The use of shaping (coaching towards desired performance), chaining, and reinforcement of previously learned material are characteristic of behaviourist approaches to skill development (Driscoll, 2000). The careful sequencing and chaining of procedural learning, along with practice that includes both repetition of previously learned skills and application in new settings, are common in cognitivist learning environments (Driscoll, 2000).  4  Mastery checklists are used to learn and evaluate skills and procedures. A procedure is broken down into steps, each of which is described as one or more observable behaviours. Evaluation is simple—acceptable performance involves performing each step according to the observable behaviours. Any deviation from the checklist results in the performance being marked as unacceptable.  38  Behaviourist, and some forms of cognitivist, perspectives are based on objectivist principles and transmission approaches to teaching and learning (Davis & Sumara, 2006; Driscoll, 2000). Knowledge is viewed as an objective, quantifiable commodity to be acquired by the learner (Davis & Sumara, 2006) and learning is defined as change in behavior (Driscoll, 2000). Taxonomies such as Bloom’s (as cited in Gronlund, 1995) have described learning as hierarchically demonstrated activity progressing from recall and comprehension to application, synthesis, and evaluation. Similarly, skill development proceeds from anticipation and guided response through increasingly independent performance towards initiation of procedures in novel situations. Evaluation is based on comparing the learner’s observable behaviours to predetermined checklists or procedural guides. Context, when addressed at all, is seen as either noise (Streufert, Satish, & Barach, 2001) or as features of a case that require the learner to adapt or modify ideal procedures—such as modifying assessment procedures for pediatric patients (PAC, 2001). Cognitivist perspectives, based on the concept of mind as analogous to a computer memory, present learning as the development of increasingly rich and complicated mental representations of the real world (Davis & Sumara, 2006). The goal of instruction is to develop mental knowledge structures similar to expert practitioners. Instructional strategies, such as sequencing, chunking, and use of multiple forms of media, focus on how learners attend to and process information, and how they store and retrieve knowledge (Driscoll, 2000). Evaluation uncovers gaps or deficiencies that can then be remediated through additional instruction (Doll, 1993). Cognitive strategies such as template matching, development of mental prototypes, and use of feature analysis (Driscoll, 2000) form the basis of descriptions of the analytic approaches in the medical clinical reasoning process. And the development of illness scripts and  39  encapsulated knowledge are consistent with cognitivist theories of mental schema in which learners develop increasingly complex mental knowledge structures, integrating their knowledge through hierarchical webs of concepts that are related to each other through key concepts or “anchoring ideas” (Driscoll, 2000, p. 119). The central metaphors of these perspectives involve construction and mathematics (Davis & Sumara, 2006). Learning is seen as the construction of skill and knowledge building blocks, which are initially derived from analysis of expert behaviour, restated as hierarchically sequenced instructional objectives, then reassembled unproblematically as increasingly complex mental representations which guide the learner’s future performance. Learning is a sum of stable skill, knowledge, and attitude-based elements and performance is an evaluation of the learner’s observable behaviours against external, objective criteria. The goal of instruction is technical competence: consistent, context-independent performance. Both cognitivist and behaviourist perspectives promote efficient, effective curriculum approaches that emphasize technical competence. However, as noted in Chapter 1, field practice is a far more subjective exercise—requiring more than mere application of procedures in a noisy, complicated environment. The next section explores concepts that situate learning as more social, more open, and more organic; better able, perhaps, to foster the dynamic approaches characteristic of clinical competence. Experiential Learning In this section, I move from the process of clinical judgment to the process of learning in simulation environments. I explore selected experiential learning theories as a rich body of literature through which to explore learning that is “located in everyday workplace tasks and interactions” (Fenwick, 2003, p. 1). Experiential learning approaches highlight the importance of  40  performance and context as the experiential glue that holds together the disparate elements of the learning environment. Experiential Learning Perspectives as Different Ways of Knowing Current literature on experiential learning has its roots in adult education and the recognition that learners must, and do, function in the world (Fenwick, 2003). Adult education strives to “celebrate and legitimate people’s experience as significant in their knowledge development . . . [and to acknowledge] the process of learning as much as the outcome” (Fenwick, 2003, p. 1). Much of what adults learn, and often where they learn it, is embedded in the everyday tasks of the workplace. Experiential learning, spurred by a desire to better prepare learners for real world practice, emerged as a celebration of learning-by-doing in contrast to traditional academic and classroom-based training. Rather than abstracting performance into chunks of skill, knowledge, and attitude which the learner must acquire, experiential learning perspectives emphasize personal, situated, social, and cultural aspects of learning and performing in the context of practice. As Fenwick (2003) noted, experience itself is a problematic term which can be expressed and used in multiple ways: direct embodied experiences are immediate encounters with the hereand-now; vicarious experiences draw on hearing, seeing, and/or imagining of other’s stories and experiences; simulated experiences involve encounters with contrived examples of some real event or situation; and more personal forms include relived or recalled experience, collaborative experiences, or introspection. What is learned from experience is necessarily affected by the purpose for which learners enter an environment, how they perceive and interpret its events, how they filter from their language and existing concepts, what they choose to engage with, and how they conceive of and enact self and society (Fenwick, 2003). Finally, context, and learners’  41  relationship to and interaction with that context, played a crucial role in this study. Fenwick (2003) noted that it is in the exploration of context “where the dimensions of power and its links to knowledge, language, and identify becomes critical in understanding learning in experience” (2003, p. 19). Here also, she insisted, is where we [as adults] must seriously consider our entanglements with our cultural contexts before we assume, unproblematically, that we simply enter an experience, reflect on it to make meaning, then apply its lessons in a process we like to think of as learning. (Fenwick, 2003, p. 19) Fenwick (2003) identified and explored five perspectives in experiential learning: constructivist, situative, psychoanalytic, critical, and complexivist. Three of these, the constructivist, situative, and complexivist views, were particularly relevant to the background, methods, analysis, and interpretation of this study. The following discussion examines these perspectives’ key concepts, views on knowledge, learning, and the role of context in learning. Constructivist Perspectives Constructivist perspectives pose learning as an active process of internal knowledge creation involving reflection on concrete experience, abstraction of mental concepts, and development of mental knowledge structures that can be “represented, expressed, and transferred to new situations” (Fenwick, 2003, p. 22). Learners experience the world, perceive or attend to specific facets of that experience, and relate them to existing knowledge and mental concepts. Learning is, in this view, personal, unique, and idiosyncratic. One can only learn or create new knowledge in relationship to what is already known. Thus, new knowledge is a function of both how individual learners engage with an experience (what that learner sees, hears, feels, does) and the existing knowledge structures that the learner has. What each individual learns in any given experience is necessarily unpredictable and unique (Fenwick, 2003). Heraclitus (as cited in Doll, 1993) claimed that one can never step in the same river twice; while the river itself is a somewhat stable geographic entity, its constituent waters 42  constantly flow, leading to a myriad of changes in any moment. Similarly, no two learners ever experience the same learning activity. They may share participation in an event, but their experiences (what they see, feel, hear, do) and their reflections, abstractions, and conceptualizations are personal and unique. Thus, what individual learners take away from a common learning activity is interpreted through their different perspectives, varied backgrounds, and idiosyncratic sensations and actions, and is shaped by their attitudes, intentions and interests. Progression of learning involves the development and extension of mental concepts and structures. Piaget (1947/2003) described two processes of assimilation and accommodation. Assimilation involves the process by which new experiences, upon reflection, are related to and incorporated into existing mental knowledge constructs (Fenwick, 2003). However, when the learner encounters sufficiently novel situations or an experience that cannot be easily incorporated into existing knowledge structures, a more dramatic restructuring or accommodation of new knowledge constructs is required (Fenwick, 2003). Thus, the progression of learning involves changes to the depth, breadth, and structure of a learner’s mental constructs. Fenwick (2003) noted constructivist conceptions in Vygotsky (1978), who held that the outcome of learning is the development of individual consciousness through reflection and inner speech. While Piaget (1947/2003) focused on development of individual learners, Vygotsky looked at how the individual was shaped and incorporated into the social collective. Driscoll (2000) noted that Vygotsky highlighted the relationship between learner and context, posing learning as a staged process in which the learner interacts with a community and its activities, tools, and artifacts. Vygotsky described a zone of proximal development, which he defined as a time- and space-bounded site of maximal learning where an individual’s existing development serves as a foundation for experiences that are sufficiently challenging to foster learning, but not  43  overwhelming (Driscoll, 2000). The role of the instructor is to challenge, guide, and coach, encouraging reflection and validating the learner’s emerging understandings (Fenwick, 2003). Constructivist views extend behaviourist and cognitivist perspectives by highlighting the relationship between context, experience, and existing learning. In contrast to constructivist views, mastery learning (Hunter, 1994) assumes that learners construct similar, stable patterns of performance that match objective, external constructs. Instructional design processes assume that learner performance remains stable in different contexts (Winn, 1993, 1996). Constructivist approaches trouble both these sets of assumptions. Learning becomes a personal activity and knowledge becomes a personal construct—focused within the individual, rather than transmission of concrete, objective, external knowledge. Context, in mastery learning, is a source of noise or complication which must be overcome by adaptation. Context, for constructivism, is important as a source of experience and what is learned may change with changing contexts. But, that context is external to the process of reflection and knowledge construction; the process of learning remains focused within the individual (Davis & Sumara, 2006). However, Fenwick (2003) noted that constructivist approaches pay inadequate attention to the social context of learning and performance. Vygotsky (as cited in Driscoll, 2000) extended narrow constructivists’ emphasis on learning as an individual process by examining how learners become part of larger social groups. His work served as a backdrop for situated learning approaches (Brown et al., 1993), which are discussed in the next section. Situated Learning Situated learning perspectives recognize that learning is always situated and embedded in “embodied, historically rooted communities of practice” (Hay, 1993, p. 91). “Knowledge is contextually situated and is fundamentally influenced by the activity, context, and culture in  44  which it is used” (McLellan, 1996a, p. 6). Learning in mastery, cognitivist, and constructivist perspectives involves the transmission, internalization, or creation of knowledge by or within the individual learner (Driscoll, 2000). A situated learning view, however, shifts the focus of knowing and cognition from the individual to sociocultural groups (Driscoll, 2000). Knowledge is not a commodity of consumption or creation; rather, knowledge is part of a process of participation within a specific context and community of practice (Fenwick, 2003). Individuals learn as they participate by interacting with a community (with its history, assumptions and cultural values, rules, and patterns of relationship), the tools at hand (including objects, technology, languages, and images), and the moment’s activity (its purposes, norms, and practical challenges). (Fenwick, 2003, p. 25) Brown et al. (1989) challenged the didactic/practical split between knowing what and knowing how, arguing that the context and social activity of learning are integral and inseparable from what is learned. The instructional design process of task analysis splits experience into skill, knowledge, and attitudinal chunks and bits for acquisition, which, in turn, leads to the development of decontextualized, inert learning (Brown et al., 1989). Learning to use a tool “involves far more than can be accounted for in a set of explicit rules” (Brown et al., 1989, p. 33). The choice, design, and use of a tool reflect and are contingent on the community or culture in which the tool emerges. Similarly, Brown et al. posed that conceptual tools reflect the wisdom, insights, and experiences of a group, and that their meaning emerges from historical and ongoing negotiation within the community. The progression of learning involves the gradual assumption of increasingly meaningful roles within a community of practice (Fenwick, 2003). A community of practice is “a set of relations among persons, activity, and world, over time and in relation with other tangential and overlapping communities of practice” (Lave & Wenger, 1991, p. 98). The community is more than a group of individuals with common purpose—it is the historical and social source of 45  interpretive support for meaning-making. Through a process of legitimate peripheral participation, newcomers move from observation and limited interaction at the periphery of a discipline towards full integration and active participation in the community (Fenwick, 2003). Learning is framed, not as acquisition or construction, but as a process of enriched meaning and participation (Lave & Wenger, 1991). Evaluation in situated learning shifts from defining the deficit of the learner from an external set of objective standards towards the development of identity and acceptance as a member or practitioner in a community (Lave & Wenger, 1991). Correct answers or actions are seen as ongoing negotiations of what is relevant or acceptable within a given context (Fenwick, 2003). Assessment, as well as learning is always situated in context, and thus assessment includes both the learner’s performance and the overall process of learning (McLellan, 1996b). The emphasis of learning is less on rules and representations than on “modes of acting and problem-solving” (Hanks, as cited in Lave & Wenger, 1991, p. 20). Lave and Wenger (1991) were careful to frame increasing learning as degrees of participation within a community of practice. There is, they claimed, no centre or core towards which learners progress, no closed domain of practice that constitutes complete participation, no linear line of skill acquisition, no end point representing completion of a learning journey. Rather, learners progress in their ability to assume new roles meaningfully within the community (Fenwick, 2003) in a process that extends throughout their careers and lives (Lave & Wenger, 1991). Lave and Wenger (1991) emphasized that all learning is situated in social, cultural, and historical contexts. They note that the term situated refers not just to locating learning in a specific time or place, nor as involving learning with other people, nor even locating within a particular social setting. Their use of the term is far broader. All learning, in their view, is situated  46  within sociocultural contexts. Learning cannot be dissociated from the contexts in which its participants engage. All learning and knowledge are relational, negotiated, and mutually constituted in the interactions between “agent, activity, and world” (Lave & Wenger, 1991, p. 33). Thus there can be no non-situated learning. Learning of skills and knowledge may be decontextualized, but that decontextualized setting is, itself, a context involving the interactions, assumptions, and norms of its participants, which are necessarily separate from the community and context from which they were extracted. Situated learning perspectives acknowledge the integral role of context in fostering learning and enacting knowledge. Learning is seen as bidirectional; participation in the community of practice changes both the learner and the community in which she or he is a part. Yet, the central actor in the situated learning perspective remains the individual learner. Davis and Sumara (2006) posed learning as the emergence of new possibilities of response in the dynamic interactions of multiple complex entities. Ecological and Complexivist Perspectives Fenwick (2003) noted that ecological and complexivist perspectives pose learning as a process that does more than link learner and context; learning emerges from mutual interaction and change that person and context trigger in each other. Davis and Sumara (2006) described complex phenomena as being comprised of and constituents of multiple other complex entities. Fenwick noted that learners are inextricably bound within a nested set of biological, psychological, and cultural contexts. Davis and Sumara (2006) extended this notion by noting that learners not only act within these contexts, they are part of the context. There is no separation between learner and environment. They comingle, coexist, and co-constitute each other. From a complexivist perspective, there is no foreground and background; there are only  47  systems of mutually interactive agents. Learning does not occur within an individual. Changes (in this context, learning) in the individual change the system the individual is a part of, which in turn triggers further change in the learner. Thus, learning is a process of coemergence: a new pattern of response of learner and context together. Maturana and Varella (1987) defined structural coupling as a history of recurrent interaction leading to change in the structure of two or more complex entities. Changes in one part of the system lead to changes, or perturbations, throughout its environment. These changes, in turn, trigger responses in other entities that affect the original agent. The result is a new pattern of response, a new structural congruence in the system composed of the two interacting entities, a structural coupling at a higher level of complexity that would not be possible for any of the constituent entities alone. According to Davis and Sumara’s (2006), knowledge refers to the stabilized but changeable patterns of acting of a complex entity. Over time and from different perspectives, what is known is malleable; the stability of knowledge (the range of responses of a complex entity) is variable. What an individual knows “tends to be seen as highly volatile (hence readily affected), whereas a body of knowledge or a body politic is usually seen as highly stable (hence as pregiven and fixed, at least insofar as curriculum development is concerned)” (Davis & Sumara, 2006, p. 29). Thus, change at the level of the individual may take weeks or months, while systemic change at a societal or cultural level may take decades, and change for a species may encompass millennia. Knowledge, from this perspective, is not only an active process, it has a history and a future (Kincheloe & Berry, 2004). In contrast to objectivist traditions that see personal knowing as separate from objective knowledge, a complexivist view sees knowledge as a series of nested, overlapping  48  understandings. There is no necessary trajectory to learning, nor does learning necessarily follow a trajectory. Learning is “understood more in terms of ongoing renegotiations of the perceived boundary between personal knowing and collective knowledge” (Davis & Sumara, 2006, p. 27), a process of “continuous invention and exploration, produced through the relations among consciousness, identity, action and interaction, objectives, and structural dynamics of complex systems” (Fenwick, 2003, p. 37). The progression of learning emerges, not as increasingly complicated chains of mental structures, but as increasingly sophisticated and flexible responses to new situations and events (Davis, Sumara, & Luce-Kapler, 2000). Several aspects of this perspective inform conceptions of simulation as a learning environment. First, a complexivist perspective recognizes—requires, even—that the learning environment involves interaction between a number of dynamic facets: the participants, the script or desired outcome of the scenario, the physical environment, and those who control or manage the simulation. Each agent or actor participates in an ongoing conversation or mutual interaction which, while following a more-or-less known script, unfolds unpredictably as participants react to each other’s performance. A complexivist perspective has the potential to allow a better view of how learning and assessment can occur in situations that involve multiple learners. Other perspectives reviewed in this chapter tend to refer to a learner and the context. A complexivist perspective removes the distinction between learner and context and recognizes the learning environment as a system including learner(s), context, and multiple participants. Davis and Sumara (2006) reframed cognition as a characteristic of the entity that is seen to be acting. Thus, in a learning environment or activity (such as a simulation), cognition resides in individual participants and their actions, but it also resides in the mutual interactions and responses of all the participants  49  and the environment in which they are participating. This self-organizing and interdependent activity results in behaviour of the new, larger entity. As such, assessment and evaluation emerges in a “series of increasingly complex systems together [inventing] changing understandings of what constitutes ‘adequate conduct’” (Fenwick, 2003, p. 37). Assessments of performance in a complex learning environment become ongoing negotiations between participants in which “claims to truth are understood as means to orient perceptions and frame interpretations” (Davis & Sumara, 2006, p. 33). The focus of evaluation moves away from outputs and behaviours of individual participants to the relationships and mutual interactions between these participants in meeting the goals of the situation. Experiential Learning Summary The learning perspectives in this section variously present learning as a commodity for transmission or acquisition; mental representations of concepts that guide thought, choice, and action; the development of increasingly meaningful action within a context; and as emergent and increasingly nuanced and sophisticated responses to new situations and perturbances. Context is presented as noise to be filtered, a source of sensory input, essential background to developing meaning, the medium in which activity gains meaning, and a dynamic element of an open system that is inseparably bound to thought and action. Each perspective provides insight to selected aspects of the teaching and learning environment. Each highlights different aspects and elements and has a varying horizon. Mastery learning and cognitivism focus on mechanisms of attention and shaping behaviour. Constructivism raises issues of identity and history of the individual in personal meaningmaking. Situated learning perspectives see beyond the individual to note social and cultural considerations. And complexivist views embed learners in a web of mutual interaction with other  50  complex entities and phenomena. These perspectives helped shape the questions, methods, and gathering, analysis, and interpretation of data that formed this study. The final section of this chapter focuses on simulation-based learning environments and the concept of fidelity. I define and describe the practice learning environment and selected practice learning activities. I present the JIBC’s Practice Ladder as a model for matching desired learning outcomes with a variety of practice learning activities. I then develop a working definition of the concept of fidelity and identify the elements of fidelity that are enhanced within this study. Conceptualizing Simulation-Based Learning If the patient is the heart of paramedic practice, then performance is its measure. EMS education has focused on performance, initially as the acquisition of skills, later as a function of the integration of assessment and treatment, and more recently as the ability to make and implement clinical decisions that meet the unique needs of the situation at hand. Practice learning activities, simulations, and their derivatives, are the experiential glue that hold together the disparate components of paramedic training, education, experience, and practice. Experiential, or applied, learning, has as its goal the ability to do real things in the real world, to know and think and make decisions, to function and perform, as do experienced practitioners in a specific domain or discipline. The British Columbia Academic Health Council (n.d.) used the term practice education to highlight this applied form of learning as “the experiential learning component of healthcare provider education that occurs in health service delivery and/or simulated settings, and that helps students learn the necessary skills, attitudes and knowledge required to practice effectively in their field” (para. 2). This definition acknowledges then extends traditional conceptions of learning by focusing on process (hands-on experience)  51  and outcome (effective practice) in the context of performance (in the field). Learning, from this perspective, is far more than memory, mastery, and values; it is a process that immerses and embeds the learners in a constantly evolving web of experience and context. Practice-based learning activities facilitate interaction between participants and the learning environment with the aim of fostering understanding, developing skills, acquiring values, changing attitudes, gaining experience, or enhancing performance. The term practice learning activities was used in this study to describe created experiences, centred on (or requiring) activity, with the goal of fostering the development of competence, proficiency, or expertise within a specific domain or community of practice. JIBC Practice Ladder Paramedic programs employ a variety of practice learning activities to help learners master skills, employ procedures, assess and treat patients, and function within their profession. The following analysis frames and describes these activities through the concept of the JIBC Practice Ladder. The JIBC Practice Ladder is an unpublished concept that was used in the development of the JIBC’s paramedic programs in the early 2000s. It is a curriculum development device that relates the pedagogical features of desired learning outcomes and common practice learning activities (see Table 2). The JIBC Practice Ladder emerged from an analysis of common practice learning activities used in JIBC paramedic programs. The NOCP (PAC, 2001) is based on a task analysis with the goal of identifying the core competencies of paramedic practice; the Practice Ladder is a parallel process that analyzed paramedic practice from a functional perspective.  52  Table 2. JICB Practice Ladder Table showing characteristics of common EMS practice learning activities, their characteristics, associated learning goals and instructional focus. Learning Characteristics Goal Focus Activity Field Placement Structured work placement with experienced Proficiency Experience (with or Practicum preceptor or mentor. Evaluation is situational, reflection) focused on proficiency within field of practice. Immersive Immersive environment in which participants Adaptation Problem-solving; Simulation role play “full call” or incident; post scenario novel situations; peer and expert debriefing against goals, outcomes, or best practice guidelines Procedural “Full-call” scenarios with goal of integrating Integration Applications within Simulation functional processes with procedural skills; context of a scenario; structured feedback using rubrics, guidelines, decision making checklists. Drill Short scenario in which one or more Sequencing Complex procedures; procedures are practiced in context; feedback multiple procedures against algorithms, checklists, guidelines. within a context Skill Station 3 Ds: demonstrate, describe, do; participants Mastery Skills and simple perform activities under close supervision, procedural chains; low evaluation and feedback from mastery context/contextchecklists. independent practice  The central premise of the Practice Ladder is that particular types of learning outcomes are best achieved by the use of specific types of practice learning activities. A given lesson may include a mix of different practice activities, drawing upon skill stations to learn new protocols, simulations to put them into practice, and case studies to discuss subtle elements of differential diagnosis. This instructional structure may be repeated across multiple lessons. The taxonomy is useful for helping curriculum developers match learning outcomes with effective strategies. The term simulation is an umbrella term that, in practice, represents a wide range of practice learning activities. The Practice Ladder presents a set of these activities, names them, and identifies some of their characteristics. This analysis, however, uncovers the contested meanings that the term simulation may represent. The following discussion explores the use of the term and develops a set of definitions used to refer to practice learning activities in this study.  53  Simulation The term simulation, drawn from the old French simulacion, is a noun derived from the verb simulate, which is based on the Latin stem of simulāre, defined as “the action or practice of simulating, with intent to deceive” (“Simulation,” 2013, para. 1, a.). Within the context of medical education, the term to simulate is best expressed as “the technique of imitating the behaviour of some situation or process (whether economic, military, mechanical, etc.) by means of a suitably analogous situation or apparatus, esp. for the purpose of study or personnel training” (“Simulate,” 2013, para. 1, d.). Sauvé, Renaud, and Kaufman (1985, as cited in Kaufman & Sauvé, 2010) identified two general forms of simulations:    Exploratory or explanatory simulations designed to explore or develop understanding, test theories, or conduct experiments (for example, animations, computer models, business/economic spreadsheets); or Performance-based simulations designed to practice and develop competence, proficiency or expertise.  Simulations that foster understanding may be physical or virtual activities designed to model some aspect of the world. Participants observe or participate with the goal of developing mental models or understanding of how some aspect of the world functions. For example, an animation may model the functioning of lung tissue and gaseous exchange. An accounting form may allow users to see how various pricing or inventory strategies play out in practice. Performance-based simulations create a representation of a physical system in which participants can master, integrate, and adapt skills, knowledge, and judgment through performance, such as setting up a mock Emergency Operations Centre or assessing managing a patient with shortness of breath. Sauvé et al. (1985, as cited in Kaufman & Sauvé, 2010) viewed simulation environments  54  as a system and identified the following essential elements:      A model of representation (a contrived or constructed system); Simplification (a simulation selectively focuses on specific elements); Dynamism (these elements interact to greater or lesser degrees—e.g., closed systems vs. open systems); and Reality defined as a system (there are rules that mimic some aspect of reality; e.g., stop bleeding within 4 minutes or the patient loses consciousness).  Simulations and gaming activities are commonly employed in medicine, aviation, leadership and management, aeronautical engineering, disaster management, and complex military environments (Roscoe, 1991; Streufert et al., 2001). Recorded instances of dramatic performance and reenactments for teaching purposes reach back to Aristotle and mannequins or phantoms were used for obstetrical training as early as the 16th century (Barach et al., 2001). Simulations play a key role in health and medical education (Crookall & Zhou, 2001; Garrett, et al., 2007; Kneebone et al., 2006; Larew, Lessans, Spunt, Foster, & Covington, 2006), bridging theory and practice. Medical simulations purposefully isolate or replicate essential elements of an everyday situation (Streufert et al., 2001) and allow learners to encounter a broad range of patient conditions and injuries. The role of the learner in a simulation is to develop or display a role, function, or duty to the best the learner’s ability (Jones, 1997). Simulations are valuable whenever the learning outcome requires dynamism, complexity, hazard, or risk (Streufert et al., 2001), allowing learners to practice, receive feedback, and learn from their mistakes within a controlled and safe environment. Simulations are built around an instructional problem or learning outcome, which may isolate a particular type of patient encounter, focus on assessment and management of conditions, develop specific skills or procedures, or blend all these elements in more open-ended integrative scenarios (Kneebone et al., 2006). Medical simulations allow repeated practice and the development of individual and team skills. The depth, breadth, and richness of the scenario are determined by the requirements of the 55  educational problem. Simulations are used most effectively when they complement other forms of learning and assessment (Barak, Satish, & Streufert, 2001; Squire & The Games-to-Teach Research Team, 2003). Squire and The Games-to-Teach Research Team (2003) noted that when used within “pedagogical approaches such as case-based learning, goal-based scenarios, anchored instruction, and problem-based learning” (p. 8), simulations and games allow learners to apply content within authentic contexts. The advent of mannequins and task trainers that realistically simulate complex physiological responses to assessment and treatment has led to research into the validity and acceptance of these technologies (Tsai, Harasym, Nyssen-Jordan, Jennett, & Powell, 2003), the effectiveness of these enhanced simulation environments in developing specific skills (Leblanc et al., 2005; Long, 2005), and their impact on critical thinking (Lasater, 2006; Rhodes & Curran, 2005). Within medical education, there is increasing use of standardized patients to assess clinical reasoning and skills (Adamo, 2003), as well as critical thinking and affective skills (Larew et al., 2006). Within this study, the term simulation was defined both as a verb and a noun. The act of educational simulation was the purposeful development of a learning environment that created a system of selected elements and relationships allowing learners, participants, and physical elements to interact and function dynamically with the goal of developing understanding/meaning or changing practice/performance within a desired context. A simulation in this study was a three-phase learning activity, designed around a pedagogical goal, in which participants interacted with other participants, the environment, and an instructor in the context of performing a call or managing an incident. Some or all of the participants and physical elements of the environment may have been represented through simulation. Existing  56  simulations within paramedic education tend to be closed systems, designed around a known problem with predetermined desired outcomes and expectations. Learners follow a carefully crafted curriculum, first mastering specific skills and procedures in skill stations and drills, then integrating them in the performance of procedural simulations. The final discussion in this section moves from the structure and use of simulation to conceptions of fidelity. Conceptions of fidelity are a core element of this study. The JIBC Practice Ladder implies that more complex simulation environments are associated with achievement of higher order learning outcomes. This implies that the higher the fidelity of a simulation, the more learners will gain from the experience. However, the findings in this study suggest that it is difficult to speak of the fidelity of a simulation and that effective practice learning environments employ a variable range of fidelity of different elements. Fidelity The patient is at the heart of paramedic practice, and it is no surprise that fidelity in much of current medical literature focuses on the physiological and procedural realism of mannequins and actors as patients. Yet, fidelity is a far more complex and porous concept than it first appears. Fidelity is not a unitary or even a unifying concept. In fact, patient encounters in simulations and practicum environments involve the interplay of a number of elements, each of which has different degrees of fidelity to calls in the field. The OED includes several definitions for the term fidelity. The best, perhaps, for this discussion is the “degree to which a sound or picture reproduced or transmitted by any device resembles the original” (“Fidelity,” 2013, para. 1, c.). Other, older definitions of fidelity imply “honesty, truthfulness, trustworthiness, veracity” (“Fidelity,” 2013, para. 2), and involve faithfulness and loyalty.  57  Within medical education, fidelity has traditionally indicated the degree of realism of a simulation or scenario to field practice (see, for example, Gaba, 2004). But fidelity extends beyond the presentation of the patient. While much of the medical literature on simulation has focused on the ability of human patient simulators (computerized mannequins) to present complex physiological and procedural accuracy (McFetrich, 2006), other authors have situated fidelity as a broader construct, such as Garrett, et al.’s (2007) definition of fidelity as “the degree to which a simulation provides an accurate and truthful representation of the original phenomenon” (p. 10). Beaubien and Baker (2004) cautioned that unidimensional definitions of fidelity conflate the affordances of instructional technologies with the overall effectiveness of simulations, implying that the use of higher fidelity mannequins leads to improved learning outcomes. They noted that a variety of models of fidelity have been proposed. Norman et al. (2012) reviewed studies on medical simulation that called upon work from simulation in aviation to distinguish between “‘engineering fidelity’, which refers to whether the simulation looks realistic, and ‘psychological fidelity’, which concerns whether the simulator contains accurate simulations of the critical elements that will demand specific behaviours to complete the task” (p. 645). Beaubien and Baker outlined Rehmann et al.’s typology of equipment, environmental, and psychological fidelity as a model that more robustly considers the multidimensional aspects of fidelity. Similarly, Gaba (2004) noted 11 factors for consideration in the development of simulations. Typical procedural simulations in the classroom environment focus on the patient and the physiological condition being studied. By contrast, learners in the practicum environment are assessed against a set of criteria based on the NOCP’s (PAC, 2011) seven competency areas.  58  Areas 4 and 5 deal with typical aspects of patient care: assessment and treatment. These are the aspects of fidelity highlighted in existing simulations that promote technical competence. Area 2, however, includes competencies that require the paramedic to interact effectively with the patient, family members, and other health care providers and emergency responders. Areas 1 and 7 include competencies involving dealing with environmental factors, such as gaining access to the patient, packaging, and transporting. Area 6, integration, requires practitioners to function within the principles, protocols, and operational guidelines of their workplace. Together, these competencies extend far past the presentation of the patient or the ability of the practitioner to perform invasive procedures in a realistic manner. Simulations designed to meet these broader competencies must also create opportunities to engage with the physical environment; deal with patients with rich personal, health, and social histories; interact with bystanders and other responders; function within expected curricular or operational guidelines; and consider social and cultural factors. Viewing fidelity as a complex phenomenon expresses the multidimensional conception of fidelity as a set of nested relationships that form a simulation experience. Thus, the aspects of the environment that experienced practitioners would interact with and consider in their decision making form the basis for choosing which aspects of fidelity are relevant in designing a simulation. The following section explores the concept of fidelity as a complex construct of nested interrelationships, which in this study are organized into categories involving the patient, the context, the curriculum, the community of practice, and broader social/cultural factors (see Figure 4).  59  Figure 4. Layers of fidelity considered in this study. Patient fidelity. Fidelity in medical simulation often focuses on three aspects of patient fidelity: physiological, procedural, and interpersonal. Physiological fidelity refers to the accuracy with which patients exhibit physical symptoms and display vital signs indicative of particular injuries or conditions and the ability to change that presentation in response to participant activities (e.g., administering medications). Procedural fidelity is an indication of how closely an activity in a simulation resembles its performance in everyday practice. The interpersonal fidelity of a situation refers to the interactions between participants, including channels of communication such as verbal, physical, facial expression, body language, etc. Thus, task trainers such as an IV arm allow high procedural fidelity (the user can see and feel when the catheter pops into the vein), but limited physiological fidelity (the mannequin does not flinch or respond to the procedure) and no interpersonal fidelity (the interactions with the patient are usually not part of practicing with the IV arm or, if the arm is used in a scenario, the patient response is verbalized by the call manager or actor playing the patient). By contrast, HF mannequins may allow a wide range of realistic procedures (such as taking vital signs, monitoring ECGs, administering medications) and display accurate and dynamic vital signs (either preprogrammed by computer or manually by a call manager). However, the mannequins have poor interpersonal fidelity (no facial movement or body language; note that some  60  mannequins have speakers allowing an instructor to provide the voice for the patient). Actors have high interpersonal fidelity, but their procedural and physiological fidelity is variable. Physical findings (such as pallor,5 bruising, or even fractures) may be simulated by moulage (theatrical makeup) and prosthetics. However, a call manager may have to verbally provide abnormal vital sign readings and physical findings. And of course, invasive procedures cannot be performed on actors. Context fidelity. A second set of relationships focuses on the scenario itself, its physical setting, and the presence and role of different participants. Environmental fidelity refers to the physical context or setting of the scenario. Participant fidelity indicates the degree to which various participants who would be present in a field setting are included in the scenario. Role fidelity refers to the degree to which the roles of participants in field practice are modified or constrained in a simulation. Skill laboratories often include multiple stations with a variety of task trainers that allow learners to practice performing specific skills and procedures with minimal context and low environmental, participant, and role fidelity. Immersive simulations provide high participant fidelity through the use of actors portraying the parts of patients, bystanders, additional rescuers, and hospital personnel. Many medical and health simulation laboratories recreate mock hospital wards or operating theatres. Environmental fidelity for prehospital education is increased by staging scenarios in realistic settings or purpose-built rooms that simulate residential or commercial spaces. In simple drills or simulations, role fidelity is constrained by asking participants to verbalize actions or think aloud so that instructors can assess their decision making processes. Role fidelity is increased by allowing participants to function as they would in everyday practice. When role fidelity is high, participants remain in their roles through the entire 5  Pallor: pale, cool, sweaty skin, which may indicate that the patient needs immediate treatment.  61  scenario and have little direct interaction with the instructor or evaluator. Curricular fidelity. Curricular fidelity refers to the degree that a simulation meets its pedagogical intent. Simulations are learning activities staged at specific location in a curriculum, each with a specific set of learning goals, such as skill acquisition (e.g., integrate airway management procedures with the Primary Survey), integration (e.g., demonstrate the assessment and management of chest pain patients using PCP protocols and procedures), or adaptation (e.g., manage a patient with musculoskeletal injuries in a practicum placement). Two elements are particularly relevant: the structure of the case and the richness of its presentation. Cases can be structured as exemplars or more ambiguous presentations of an injury or condition. In addition, the intended flow and outcome of a case can be straightforward or complex. Simple calls present classic presentations with predictable outcomes to the intended treatment. More complex calls may include multiple conditions, atypical presentations, or complicated responses in which the desired treatment initiates a new treatment problem. Another element of curricular fidelity is the richness or complexity of information in the case. A case with higher fidelity in terms of richness would present a robust, comprehensive patient history and a well-developed story. A rich case contains data that are not necessarily relevant to the presenting problem of the case, but provide an aura of authenticity due to their comprehensiveness. Case studies or drills with lower fidelity may have very abbreviated data that focus primarily on the particular issue or condition that the case is addressing. Professional fidelity. Professional fidelity is the degree to which a simulation represents or requires the learner to practice within a particular context or community of practice. The context of practice refers to the operational setting of a simulation. All paramedics follow general principles of management for assessing and managing a variety of injuries and  62  pathophysiological conditions. However, the specific practices they follow vary according to the context in which they practice. These differences can include location, operational role, types of calls that are typically encountered, types of equipment that are available, and protocols and procedures specific to the operational setting or agency.6 The general principles of managing a patient with a closed head injury and bleeding in the skull are common across fields. But calls involving that same injury may unfold very differently in different contexts.7 Social and cultural fidelity. The fidelity of a simulation is also set within broader social and cultural spheres. The fidelity of a simulation must also consider the diversity and distribution of different call types, patient backgrounds, and cultural norms. Social fidelity considers the degree to which the simulations in a program reflect relevant societal and social factors. A particular curriculum may be designed to cover a broad range of injuries and conditions, set within the operational context of one or more professional settings. But actual practice can vary through a number of social and cultural domains. The range and characteristics of actual calls vary with the local social and economic factors, along with the demographics of its inhabitants and their ethnic and cultural practices. Thus, practice in communities in the north of Canada that area focused on the oil industry will tend to involve a younger population, with a focus on industrial injury, drug and alcohol use, and, potentially, interpersonal violence more so than a rural community with a large population of retirees. The social and cultural fidelity of a scenario extend to interactions between the participants in the scenario. Expectations and relationships are quite different for various cultural  6  For example, paramedics may function in diverse settings such as search and rescue, industrial or occupational first aid, ski patrol, lifeguard, first response, primary care paramedic, advanced care paramedic, and community care. 7 A pedestrian struck by a vehicle and a pilot from a crashed ultralight may both have a closed head injury. Yet, the priorities, actions, and specific protocols used by a paramedic responding to a pedestrian struck call in downtown Vancouver are very different than those of a search and rescue technician who parachutes into the scene of a crashed ultralight plane at dusk.  63  groups. For example, when working with paramedics who will practice in Singapore, a call involving a Muslim woman who collapses in her home with a vaginal bleed or impending birth presents different challenges to an all-male paramedic crew and a crew with a female member. Simulation-Based Learning Summary: Simulation and Fidelity as Complex Constructs Fidelity in a simulation is far more than a function of the technology and setting in which a patient encounter is staged. Despite its potential and recent growth, many health education researchers caution that the simulation environment is poorly understood and its theoretical foundations are as yet underdeveloped (see Bradley & Postlethwaite, 2003; Garrett, et al., 2007; Kneebone et al., 2006). These voices have echoed similar calls in broader educational technology literature. In their time, radio, educational television, and film were all hailed as prompters of radical change in education (Bates, 2000). The slow initial incorporation of multimedia and computer-based learning spurred a spirited set of discussions on the role of media and technology in learning.8 These discussions highlighted the importance of placing any educational technology in the context of its use. While different technologies have different affordances (Franklin, 1999), their use is neither neutral nor benign (Postman, 1992). Proponents of new technologies look for problems to which they can apply their practice. Educational technologists caution to ask first what one wants to do, then choose the technologies that best meet one’s needs (Bates, 2000; Heinich, Molenda, Russell, & Smaldino, 1999). My research explored how HF simulation might help to bridge the gap between technical competence and professional practice. A key element of this research asked, what are the affordances of simulation and how can simulation environments help meet differing learning  8  Clark (1984, 1993) posed that media merely delivered a particular learning activity and that learning was a function of the instructional interactions themselves, not the media in which they were developed. Kozma (1991) challenged this assertion, seeing learning as a constructive activity involving interaction between the learner and the content, which includes its delivery media or technology.  64  goals in EMS? In this sense, the fidelity of any learning experience, such as a simulation, is better conceived of as its fit with its pedagogical intent or purpose. In other words, different learning goals may require different blends of fidelity, focusing on different aspects of the environment. This expression views technology through the lens of learning, rather than subordinating learning to the affordances of a particular technology. Viewing simulation and fidelity as complex phenomena allows educators to acknowledge the open-endedness of participation in these practice learning activities. A simulation environment that fosters interaction between learners and a broad range of contextual elements requires a rich milieu in which participants and elements are allowed to play their parts outwards from a starting set of conditions, rather than being constrained within the limits of the script. Complex phenomena exist in co-dependent interaction (Davis & Sumara, 2006) from which learning emerges as new patterns of practice within an expanding sphere of possible actions. In this sense, the fidelity of any learning experience, such as a simulation, is conceived in this study as its fit with its pedagogical intent or purpose. The conceptions of developing clinical judgment as increasing awareness of context, simulation as the creation of conditions from which elements and participants can dynamically engage, and fidelity as a set of dynamic, overlapping, nested relationships between selected elements in a learning environment and the field setting it is representing, serve as organizing concepts in the creation of the simulations in this study, gathering and analysis of data, and interpretations of its findings. Problematic Terms Several problematic terms are used throughout this thesis. The study explores two overlapping but fundamentally different ways of conceiving expertise and learning. Terms such as truth, reality, experience, authentic, and mastery are associated with positivist views of  65  knowledge that underlie assumptions of technical rationality and inform a cognitivist learning theory upon which much of current Canadian paramedic education is based. The sense of objectivity and universality implied by these terms are problematic from the interpretivist, multivocal perspectives that informed this study. However, it is difficult to describe the current program, or its conceptual understandings and practices, without using these terms. I use these terms in this document when speaking or describing facets of the study and its findings with a cognitivist voice. Further, I employ these terms with hesitation and with an awareness of their troublesome conceptual foundations. Two terms, in particular, are deeply embedded in the language of simulation and paramedic education respectively. The following definitions are offered for authentic and mastery as used in this study. Simulation literature often uses the term authentic to describe practices and conditions found in everyday practice. Simulation environments deliberately re-create situations which, to greater or lesser degrees, contrive or control facets of a situation. For example, current classroom-based simulations constrain the role of the paramedic driver in order to focus educational assessment and evaluation on the attendant. Thus, the driver in a simulation is restricted from providing correction or advice to the attendant. In field practice, a more authentic role allows the partner to critique, offer advice, provide correction, and act collaboratively. In this sense, I use the term authentic in this study to describe the everyday aspects of some function or activity as generally understood by practitioners in that context. For example, an authentic location refers to the type of physical location and environment in which a paramedic practitioner would expect to perform a particular type of call. An authentic location for a patient experiencing a heart attack could include a middle-aged male in an office setting or in the home.  66  Mastery learning methods as articulated by, for example, Hunter (1994), are deeply embedded in the language and practice of paramedic education, particularly in the development of core skills and procedures. I use the term mastery, and the verb to master, in this study in the sense of learning a skill or procedure through guided practice, repetition, and internalization. Mastery, from a cognitivist perspective, is demonstrated through achievement of technical competence: consistent, independent (uncoached), timely, accurate, and appropriate performance of a procedure compared to a clearly articulated set of observable behaviours. Chapter Summary I have presented, in this chapter, literature from which to develop and support the core concepts and perspectives that informed my decisions, methods, analysis, and interpretation in this research. Postmodern theorists inspired my choice of a multiple perspective approach and an iterative, inductive exploration of the development of clinical judgment in dynamic, immersive simulation environments. I developed my definition of clinical judgment as a form of expertise involving discernment of contextual factors from a complexivist reading of literature from EMS, health and medical education, clinical reasoning, and naturalistic decision making. I drew upon models of skill acquisition and professional expertise, along with concepts from experiential learning literature, to pose learning in simulation as a complex phenomenon involving the development of increasingly nuanced responses to dynamic environments. Finally, in this chapter, I posed a working definition of fidelity as a set of complex and dynamic relationships between desired learning outcomes and selected elements of the learning environment. Having set the background and theoretical perspectives for this study, I turn next to describing the study itself. In the next chapter, I present my research approach and methods and outline the unfolding of the data collection, analysis, and interpretation.  67  CHAPTER 3: METHODS The questions in this study explored the relationships and interactions of participants and selected elements or agents in the simulation environment. I set my research as a mixed-method multiple-case study (Yin, 1994a). I called upon Kincheloe’s and Berry’s (2004) concept of multivocal research to examine the concept of clinical judgment through a series of conceptual layers. The initial relationships that I chose to look at in this research included a phenomenological exploration of who and with what the participants interact in a simulation environment; how participants make decisions; how they structure and report their experiences; a critical analysis of what forms of authority they base their judgments on; and to what extent they consider personal, social, and cultural factors in making patient care decisions. I gathered data from two sets of scheduled classroom simulations in the PCP program and from a new HF simulation module developed for this study. I used observation and video recordings of simulations within the natural setting of the curriculum and focus group interviews to collect data that explored how the various agents and participants in the simulations acted and interacted, what sources of authority they called upon, what forms and substance their reports and discussions took, and what artefacts they created. I developed descriptive statistics from questionnaires and quantitative examination of specific activities and functions observed in the video recordings and interviews. Analysis and interpretation was a purposeful synthesis of method aimed at emergent theory and understanding of the phenomena at hand (Kincheloe & Berry, 2004). Following a postmodern approach, I engaged in deliberate exploration of selected aspects of data with the pragmatic goal of developing and refining insight into the concepts of complex simulation-based learning environments, as well as the relationships between participants and elements of these  68  environments (Creswell, 2012). I employed an inductive and iterative approach to analysis, remaining open to the emergence of understandings in an interpretivist reconstruction and reconceptualization of my core concepts. Thematic analysis included use of both emergent and theoretical coding (Creswell, 2012; Merriam, 1988). Dreyfus and Dreyfus’ (1986) and Dreyfus’ (2001) model of skill acquisition served as a backdrop for looking at the progression of learning and differentiating between performance in classroom and HF simulations. Schön’s (1983) phenomenological work on the development of expertise informed exploration of how the participants interacted to foster learning in HF simulation settings. I used phenomenological description and critical analysis in posing the development of professional practice as an intersection of knowledge, performance, and authority. Riessman’s (1993) framework for narrative analysis provided an approach for uncovering evidence of clinical reasoning in the reports and documentation of the participants. Design The primary data for this study came from two days of HF simulations conducted in New Westminster and Kelowna, British Columbia, along with simulations conducted as part of ongoing PCP cohorts in New Westminster, British Columbia. I also gathered data from semistructured focus group sessions conducted at the end of each simulation day and an unstructured interview with a group of participants six months after the HF simulations. The study was designed as a multiple-case study (Yin, 1994a) exploring individual simulations as objects of study that are embedded in, and in which are embedded, other possible objects of study. The primary case in this study consisted of an individual simulation, which included the setup, the scenario itself (including all the participants and their interactions), the debriefing session following the call, and all documentation related to the call (see Figure 5).  69  Figure 5. Simulations as individual cases. I examined a number of cases or simulations and the interactions of the participants in those cases. While temporally bounded as an object of study (Merriam, 1988; Yin, 1994b), each case was also set within a pedagogical context as part of a series of planned learning activities, taking the learners on a journey from the textbook to the street. The pedagogic goal of any particular simulation was also set within a larger construct of cases designed to develop a set of prototypical experiences and mental representations which, in turn, became part of the corpus of experiences upon which the learners will draw in their future practice (Norman, 2005). Each simulation occurred at a specific point in time, but its experience was set within a series of simulations that occurred during a simulation day, which itself included set-up and debrief discussions. Each day formed part of a larger map that was nested within the courses, programs, and eventual experiences that will form the participants’ careers. In addition, the goal of the HF simulations in the new curriculum module was to bridge out from the confines and evaluative expectations of a closed curriculum and place the learners in situations in which they could/should act within broader professional, social, and cultural considerations. Each participant entered the simulation with his or her own unique histories, perspectives, learning goals, and intents (Mylopoulos & Regher, 2007). Each brought his or her past performance, previous experiences, and personal learning profiles into the moment.  70  My primary object of study was the processes by which participants engaged and interacted with each other and with selected elements of the simulation environment to foster learning. My analysis explored how participants functioned in HF simulation, how they engaged with the environment, how they made decisions, and what they perceived to be real or true in simulation. My interpretation investigated the progression of learning, fidelity, discernment, different ways of knowing, and fostering the development of clinical judgment. I followed an iterative and emergent process in the analysis and interpretation of the data. I employed a systematic approach to qualitative research (Creswell, 2012; Huberman & Miles, 1983; Merriam, 2008). Following Kincheloe and Berry (2004), I purposefully employed several analytic methods, drawing on a number of theoretical models and concepts to answer specific subquestions as the process unfolded. This process consisted of a series or rounds or phases of analysis and interpretation:        Descriptive analysis; Refinement of subquestions and selection of analytic strategies and tools; Coding and analysis (theoretical and emergent); Identification and exploration of patterns and themes; Development of conceptual categories related to the research question and goal; and Interpretation and discussion.  This list presents the steps of analysis and interpretation in a much more linear manner than that in which the activities occurred. Creswell (2012) noted that qualitative analysis is iterative and cyclical in several dimensions. He referred to the “data analysis spiral” (Creswell, 2012, p. 183) as a process of interrelated, often simultaneous or overlapping activities that involve organizing, reading, describing, classifying, and interpreting data in a successive consolidation and narrowing of data towards findings and theory. While there is an overall flow to the process, the phases blend into each other and the researcher may return to previous phases  71  as emergent questions or meanings emerge. For example, the gathering and articulation of descriptive data and the coding process in this study are described as initial stages of the process. Yet, I continually returned to and refined these activities as I progressed through the overall process of analysis and interpretation. Many of the emergent codes and data tables developed through articulation of subquestions; the emergence of other codes spurred the articulation or abandonment of different subquestions. Thus descriptive, coding, and analytic activities are better conceived of as activities that were initiated early in the process, but continually embedded within broader and ongoing analytic and interpretive methods. Development of Simulations in the Study The following sections describe selected characteristics of several types of simulations encountered in this study. The Core Skills and Classic Case simulations are part of the PCP curriculum, while the HF simulations were created for this study. Location of simulations in the curriculum. The PCP program is designed on a building block metaphor. The program consists of nine courses delivered over 20 weeks, followed by a three-month practicum. Program content is structured from simple to complex and generic to specific. Students initially learn the core skills and procedures of paramedic practice, then integrate these into the recognition and treatment of classic presentations of common injuries and medical conditions. Next, they adapt their approach to deal with cases complicated by special situations (e.g., vehicle extrication) or special populations (treating pediatric patients). Finally, the students move to clinical practice in hospital and field placements. The simulations in this study were drawn from three points in this process: the end of the Core Skills component, during the Classic Case phase, and at the end of the classroom courses but before learners moved to the field practicum (see Figure 6).  72  Figure 6. Location of simulations within curriculum. Characteristics of simulations in the study. All three forms of simulation shared characteristics. Each created a space where paramedic students encountered a contrived environment, interacted with a mock patient, performed tasks in a more-or-less realistic manner, made decisions, and then discussed or reflected on their performance. However, various types of simulation created very different learning environments. The intent of the Core Skills simulations was to practice core ambulance procedures in the context of a simple call. The Core Skills simulations in this study covered basic wound management, fracture management, and cardiac arrest. By contrast, Classic Case 253 was a summative course in which students performed a set of procedural simulations. Classic Case simulations were more complex than Core Skills calls. The learners integrated their knowledge of pathophysiology and their skills in assessment and treatment to manage common illnesses and injuries. Classic Case simulations focused on integration and clinical decision making.  73  Design of HF simulations. I developed a one-day HFS module, creating an immersive environment that increased the fidelity of selected elements related to my conception of clinical judgment. HF simulations that foster the development of clinical judgment should more closely represent the noise, complexity, and unpredictability of field practice. This section describes my decisions related to developing the HFS environment. The fidelity of a simulation may be considered the intersection of a set of factors that match different blends of realism to the educational and curricular requirements of each call. I considered the following elements in designing the HF simulations. Setting. Both the Core Skills and Classic Case simulations were designed to simulate an operational field setting in which two students play the roles of attendant and driver. The call manager and/or instructor are not active participants in the call, intervening only when necessary to provide verbal information not available in the simulation itself. I chose to set the HF simulations in the practicum environment, where the two students would function alongside a practicing paramedic in the role of preceptor. In this environment, the preceptor explicitly functions as a mentor and helps bridge the student from the classroom to the field practice. Students could function in operational roles set within an environment that more closely represented the field setting, while still situated within an educational context. The activities of coaching, providing feedback, questioning, explanation, and evaluation are all expected and a normal part of a practicum experience. Thus, I could observe the students performing within a simulated practice setting and explore their thoughts, rationale, and experiences within an environment that seemed—to the participants—familiar. Role fidelity. I sought to have the participants in the HFS environment function in a more natural manner by allowing the attendant, driver, and preceptor to perform as a team. The focus  74  of most classroom simulations is on the one student who is being evaluated; in EMS terminology, he or she is “in charge” of the call. In the field, crews function both more independently and more collaboratively. The attendant is in charge of the call; however, in practice, all members of the crew (which, in a practicum includes the preceptor as well as the student in the role of the attendant) contribute to decision making and completing the various tasks. I explicitly asked the participants within the HF simulations to take on roles that more closely resembled field practice. Interpersonal fidelity. Calls in the field are often situated in public spaces with bystanders or in homes with family members. In addition, paramedics often function in a complex milieu involving first responders (fire fighters, life guards, search and rescue personnel), police, nurses, physicians, and dispatchers. In classroom simulations the activities of these people are usually provided by the instructor/call manager as verbal information. I chose to increase the fidelity of these interactions by richly populating the HFS calls with secondary participants playing a wide range of roles. Social/cultural fidelity. My intent was to create a rich, social HFS environment in which the participants would have opportunities to interact and function. The inclusion of multiple people in the simulations also provided opportunity to increase the social and cultural fidelity of the simulations. I chose to situate the calls, and the people in them, in a range of situations that included chronically or terminally ill patients who could no longer cope in their homes, patients with minor injuries set within domestic abuse contexts, homeless patients, patients involved in interpersonal conflicts after a minor motor vehicle accident, and patients in very public spaces. I also chose to develop and run the scenarios as ongoing incidents. Several scenarios were staged as police or life guarding incidents that ran for several minutes before the arrival of the  75  paramedic crew. Thus, the paramedic participants became part of an ongoing situation, but they were not the central participants. Environmental fidelity. Core Skills calls performed in classrooms had very low environmental fidelity, while the Classic Case calls were staged in both classrooms and alternate locations across the campus. In classroom simulations, the environmental information is provided by the call manager. Note, however, that some environmental information (e.g., location in the community that the scene represents, time of year, time of day, etc.) was provided verbally, even when scenarios were staged around the campus. In general, the students worked with actual equipment, used in a realistic manner (with the exception of performing invasive procedures such as starting intravenous lines or administrating medications). Whenever possible task trainers (such as IV arms) or mannequins were used to increase the procedural fidelity of the simulations. I staged the HFS calls in environments appropriate to the call type (e.g., a pedestrian struck scenario in a parking lot) and included props and peripheral equipment. I also set up a staging area for the ambulance crews and a hospital triage station. I had initially planned to have ambulances so that the crews were able to load and drive to the hospital. Unfortunately, the HF module was staged shortly after the start of job action between the local ambulance service and its union. I was unable to use ambulances for either HFS day. Instead, we set up mock ambulances in the gymnasium. The crews loaded their patient on scene, moved to the mock ambulance to simulate transport, then unloaded and took their patients to the triage station. Patient presentation. Classroom simulations are designed to provide prototypical examples of common injuries and conditions. In general, the calls are designed to reduce noise or distractions in the form of atypical presentations or extraneous environmental factors. In practice,  76  however, patients present with a wide range of signs and symptoms, with considerable variation in the acuity of their condition, and an entire life and health history that compounds and confounds their presentation. In constructing the simulations for the HF days, I chose to have four levels of patient acuity, ranging from calls in which no transport was required (either the patient had no illness or injury or the presentation did not warrant further medical attention) to several cases of traumatic and/or cardiac arrest. While classroom simulations focused on serious conditions requiring complex treatment, I weighted the calls in the HF days towards fewer critical calls, reflecting more closely a typical day in the field. In addition, the presentation of the calls was complicated by a variety of environmental, social, and cultural factors. Physiological and procedural fidelity. In this study, I placed an increased emphasis on role and interpersonal, environmental, and social/cultural fidelity. This led to some tension with regards to the physiological and procedural fidelity of the simulations. While HF mannequins provide high procedural and physiological fidelity, they are less effective for situations requiring interpersonal interaction or movement. However, using actors limits the ability of participants to perform invasive procedures or administer medications. And, if the vital signs in the scenario script are outside the actor’s normal range, then this information must be provided verbally. I chose to use a mix of mannequins and actors for the HF scenarios. The majority of calls in the HF days did not require invasive procedures. My definition of clinical judgment emphasizes interaction between participants and the importance of increased role, social, and interpersonal fidelity over procedural fidelity. Thus, I felt that actors should be used whenever possible. I limited mannequin use to those calls in which the patient had a decreased level of consciousness, the vital signs were abnormal, and/or the call required advanced or invasive procedures (intubation, IV access, defibrillation). On one call, an actor role played a patient with  77  chest pain who collapsed in cardiac arrest partway through the scenario. At that point, we replaced the actor with a mannequin. Call type: Injury/condition. I analyzed the types of simulations in the curriculum and the types of calls that practitioners encounter in practice. Simulations in the curriculum are specified by the NOCP (PAC, 2001) and structured to sample the skills and procedures that define a paramedic’s scope of practice. However, ambulance calls are usually dispatched on the basis of the patient’s presenting symptoms (chest pain, unconscious collapse) or mechanism of injury (motor vehicle incident, fall from a height). Distinguishing between call type and the patient’s underlying medical condition is the basis of clinical reasoning. Thus, I chose to base the selection of scenarios for the HF simulations around call types rather than specific injuries or conditions. Selection and creation of the HF simulations. I envisioned the HF simulation module as “a day at work”—an experience of a typical shift for a paramedic in an urban setting. British Columbia Ambulance Service (2003) statistics indicated that a typical shift consisted of eight to 10 ambulance calls, of which three would not involve transport (for example, calls with no patient found, no injuries, or a patient not requiring further medical care). Of the remaining calls, only one or two would be serious enough to warrant the use of protocols or advanced procedures. Typically one in five involved trauma; another one in nine involved chest pain. The remaining calls were distributed across the scope of practice. I chose a series of basic call scenarios that would allow for significant variability in outcome. Ideally, the calls should allow students to encounter a diverse set of experiences that included innocuous to critical medical conditions; interesting environmental considerations; interactions with a wide variety of other responders, bystanders, and family members; and complications from interpersonal and social/cultural factors. I chose a series of motor vehicle  78  and/or pedestrian/vehicle incidents, man [sic] down calls (collapse on the street), several incidents at a local swimming pool, domestic disputes, falls, chest pain, shortness of breath, and several sick NYD (not yet diagnosed) calls. I created a matrix of call types and categories of acuity. I met with a group of instructors to brainstorm realistic possibilities for each cell in the matrix. We added additional scenario factors so that the calls would be interesting and challenging, but not overly contrived or unrealistic. The matrix listed 35 possible calls, allowing different blends of calls for each of the three crews in the Vancouver cohort. I gained access to sites across the JIBC’s New Westminster campus in which to simulate park settings, a cafeteria, office space, an intersection, a parking lot, an industrial site, meeting rooms, an apartment (purpose-built simulation room with kitchen, living room, bedroom, and washroom), gymnasium, and public spaces. We also arranged to do several calls with lifeguards in the community swimming pool adjacent to the JIBC. In Kelowna, I had access to fewer personnel and more limited locations. We chose to create four basic calls that employed the same set of actors. The crews rotated through the calls. However, we encouraged the participants to vary elements of the scenario between iterations— the intent was to create dynamic situations and have personnel respond to the actions and interactions of the other participants, not try to recreate the same call across different groups of students. The Kelowna calls included a patient with (noncardiac) chest pain walking in a residential neighbourhood, a domestic dispute in a trailer configured as an apartment, a pedestrian/vehicle accident in a parking lot, and a collapse on the street. The final call of the day was a multiple shooting call in which all crews participated. Ethical Considerations I followed the principles of the Tri-Council Policy Statement: Ethical Conduct for  79  Research Involving Humans (Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, & Social Sciences and Humanities Research Council of Canada, 2010) and met all requirements of both the University of British Columbia Behavioural Research Ethics Board and the JIBC Ethics Review Committee. I used a variety of methods to ensure that participants provided voluntary and informed consent to participation in the study. I informed the participants, both in person and in writing, that their participation was voluntary and that they could remove themselves and their contributions to the study at any time. I outlined the background, purpose, procedures, and ethical implications of the study in person when initially meeting the classes, by providing an information sheet, and through the informed consent form (see Appendix A). I described the data collection methods and outlined the procedures that would be followed to protect their identity and maintain confidentiality. The study involved both group participation, focus group interviews, and use of audio and video recordings. Thus it would not be possible to ensure that participants could not be identified, either in the transcripts and narrative descriptions of simulations or in the use of media in activities that emerged from the study. In addition to the informed consent form, all participants signed a media release allowing their images, audio, and video recordings to be used in publications and presentations (see Appendix A). I followed several procedures to maintain participant confidentiality in this dissertation. I replaced participant names in the transcripts and narratives, identifying participants with pseudonyms or by their roles in the activity (for example, students in the roles of attendant and driver/partner are referred to as PCP1 and PCP2 or as the attendant and the driver; preceptors are referred to as the Preceptor). In some instances, I created pseudonyms for particular participants when it was necessary to use names. All data from the study will be maintained in a locked filing  80  cabinet or in password protected hard drives in my locked office for a period of five years, after which time the data will be destroyed. Sample I collected data from 75 simulations. I recorded simulations from two courses in the ongoing PCP program: Core Skills 220 (CS220) and Classic Case 253 (CC253). In addition, I created a series of HF simulations that were conducted during one-day sessions in New Westminster and Kelowna. While the simulations in the HF simulation module were created specifically for this study, I had no choice on what simulations were used on the Core Skills and Classic Case simulation days. The Core Skills and Classic Case simulation days were the scheduled simulations at the time of the study. Thus, the initial population of simulations I could draw from included both purposive (Palys & Atchison, 2008) and haphazard or convenience cases (Merriam, 1988). I subsequently employed several theoretical (Palys & Atchison, 2008) and purposive sampling strategies to focus analysis on selected cases that best provided useful data for specific subquestions in the study (Merriam, 1988). Study Participants There were two groups of personnel in this study: study participants and simulation participants. The distinction between these groups was sometimes difficult to maintain. The study examined the interaction of the study participants with features and other participants in the simulations. For the purposes of the following discussion, the study participants include the students acting as paramedic crew during simulations along with the instructors and preceptors who provided instruction, assessment, and guidance during the simulations. Recruitment of study participants. Creswell (2003) advocated the purposeful selection of sites and individuals in order to best develop understanding of the research question and  81  subquestions. I did not seek cross-case comparison of specific preselected variables, nor was I focused on validating or exploring the representativeness of my initial categories. Thus, I did not employ quota, identical case (Palys & Atchison, 2008), maximum variation, or homogeneity strategies (Creswell, 2012). I did, however, employ a purposive strategy to identify potential participants. The tension between technical competence and clinical competence may best be observed in participants for whom this gap is most apparent—those new to the domain. The JIBC provides recruit training for both Primary Care (PCP) and Advanced Care paramedics (ACP). Students in the PCP program have variable backgrounds in emergency medical training, generally with limited experience in an ambulance setting. Thus, I chose to work primarily with PCP students in the study. However, I did stage several calls involving layered response with ACP crews. I recruited several ACP students to staff the ACP crew, and thus did observe the performance of ACP students in the HF environment. While using a purposive strategy to identify the potential sample group, I employed a convenience strategy (Palys & Atchison, 2008) for recruiting actual participants from the PCP program at the J