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UBC Theses and Dissertations

From diagnosis to discernment : fostering the development of clinical judgment of paramedic learners in immersive high fidelity simulations Bowles, Ronald Robin


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 multiple-case 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 context-independent skill performance to the socially constructed adaptation of procedures and protocols in dynamic simulations, and, finally, to the socially negotiated understandings arising from co-emergent 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 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.

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