Where Critical Analysis Becomes Critically Unhealthy

15/12/2021

 

A practice educator’s perspective of student paramedics and newly-qualified staff regarding pre-hospital thinking and personal wellbeing.

By Carl Betts MCPara, Quality Improvement Lead Paramedic, Yorkshire Ambulance Service.

Within this piece, I aim to highlight concerns relating to premature burnout of student paramedics and Newly Qualified Paramedics (NQPs), although they are equally relevant to all clinicians.

As an experienced paramedic, I have regular conversations with student paramedics and NQPs who struggle to manage the pressures of their chosen role. Throughout these anecdotal discussions it is apparent that a plethora of issues are affecting their mental health. Some of these issues are personal, but many stem from inexperienced colleagues displaying high levels of self-critical analysis. Ideally, this analysis should result in positive self-esteem and learning, but sadly, many experience the complete opposite.

The Paramedic Profession

The expected skill set of the ambulance paramedic has grown dramatically in recent years. Working in small teams of one to three people can feel very isolating and stressful, especially with the potential for back-to-back incidents. The scope of incidents attended and the limited time we have with a patient often leaves us wondering if we did the right thing, and we usually never find out. These thoughts are understandable as we regularly make complex decisions which can have profound consequences on the lives of our patients, their families and ourselves. Once a patient is handed over, the only time we receive any feedback is if we a) receive a letter of thanks, b) are requested to write a statement for the incident, or c) re-attend the address at a later date. Whilst these may shed some light on a crew’s performance, it can be difficult to obtain constructive feedback. This leads to staff over-thinking their actions and concentrating on the ‘what ifs’ as opposed to ‘this incident went well because of …..’
Paramedic Education

Nine years ago, my university student paramedic training cohort comprised 20 students, with 18 of us graduating. We now see multiple cohorts each year with an excess of 60 to 70 students at a time. As such, I feel that student paramedics are not receiving the same level of support that was offered to the smaller cohorts of previous years and that this may negatively impact their educational journey.

Within modern paramedic education, critical analysis is vital for students to develop into successful and current clinicians. The ability to reflect, analyse and learn from both our own, and our colleagues’ actions is key to providing the best emergency and urgent care to our patients. Using critical analysis as a tool is encouraged in all study modules to evidence continual learning and produce succinct, constructive written essays and reflective pieces. 

Yet this perceived requirement to continually self-critique may be an important cause of our inexperienced and younger colleagues going through mental health struggles early in their careers. This perpetual analysis leads to an overwhelming burden as they try to maintain a constant, heightened level of awareness which doesn’t allow time to develop and consolidate their reflective and analytical thoughts. We need to actively teach that it is not healthy to over-analyse the details of every single incident, and instead concentrate on incidents where there are real positives for constructive learning to take place. I feel that a discussion is required to flip the cultural negative framing of reflective thinking on its head and turn this critical analysis tool into a positive one.

Reflective Thinking

A key feature of reflective thinking is having a focus, and this is something that seems to be missing within our students’ and NQPs’ toolbox. This focus allows a person to understand the parameters of what they are analysing and leads to a successful reflective experience without having to overthink every interaction with a patient.

One key ‘take home’ message that I stress to my newer colleagues is that we should not be fixating on the parts of an incident that have not gone well. These experiences are important, but the thought process needs to be a balance of both positive and negative. By dwelling on the negative aspects of incidents we condition our mind to always hunt out the negatives first. I personally believe that we should be focusing on the positives, followed by the negatives, and then finish with how we can flip the negative into a positive for future incidents. I actively question my colleagues to think of the positives that they can take from their experiences to break the typical negative focus. This builds confidence in their reflective abilities and enables them to become reflective practitioners over time. By allowing students to develop these skills, they will develop a more positive critical analysis and a healthier mindset. 

My lived Personal Reflective Experience

Whilst writing this article, I attended an incident which involved a traumatic paediatric cardiac arrest. This was a stressful and profound incident for me in many ways and sadly, it did not have a successful outcome for the patient. However, from a reflective viewpoint, this incident was a highly-valuable experience. During reflection, I understood that I made a dosage error during drug administration, and I found myself fixating on this mistake whilst churning over the emotional turmoil of treating a child the same age as my own. After a discussion with a friend and senior colleague, he highlighted all the positive aspects of the incident, which I was aware of, but I chose not to concentrate on initially. This highlights that even experienced members of staff sometimes need guidance from others to help process our thoughts in tough circumstances. Thankfully, I have spent time processing the positives and negatives of this incident and have managed to successfully organise my thoughts and feelings.

I liken this reflective process to going through a filing cabinet that represents my mental wellbeing. After attending an incident, the cabinet is in disarray with the drawers open, files all over the desk, and leaves me with a feeling of chaos. Reflecting on the good and bad, I can organise these files, throw away meaningless thoughts, and file away useful experiences and lessons learned into an ordered system. Once consolidated, the drawer is closed for that incident and recuperation can take place. All my thoughts, feelings, and actions are now stored away in an organised manner so that when I open them later, the feeling of chaos is replaced with clarity. Without this process, these jumbled thoughts and feelings would not have been properly digested and consequently, the filing cabinet would not close. This would result in continued chaos and disorder, leading to anxiety, confusion, and stress, as the mind churns over the incidents. New generations of clinicians, without this learned reflective process, may be unable to close the drawer, eventually leading to mental health and confidence issues.

Changes to be made

I feel that universities, educational providers, ambulance trusts and colleagues all have a duty to prepare our new paramedics not only to look after their patients, but to also look after themselves. There should be a real emphasis on acknowledging that poor reflection can be as detrimental as doing no reflection at all. There needs to be a clear focus in all educational critical analysis activities for them to be meaningful and constructive, enabling learning and progression to take place. Alongside this, we should also encourage students to re-frame incidents to facilitate positive reflective experiences. We need to equip our newly-appointed paramedics with the right skills to support them throughout their future careers and create an open and honest culture to assist with handling difficult incidents or when mistakes have been made. 

I understand that critical analysis and over-analysis are not the only contributing factors for the negative mindset shown by some of our new staff. However, I do believe that they have a significant impact by causing low confidence, increased anxiety, and a general fear of our role. I strongly feel that current reflection processes need to be altered so that universities can equip students with the skills to reflect positively and progress with lifelong learning. This has the potential to greatly improve the mental wellbeing of student paramedics and with our duty of care, we need to provide the tools to ensure that they can thrive within their working environment.

Conclusion

In conclusion, it is vital that clinical reflection is utilised within our profession in all clinical settings. However, we all have a duty to support and set the example to our colleagues on how to reflect healthily. There needs to be a focus on learning from the negatives to create a positive mindset and we can do this by working together to pinpoint these positives and share learned experiences. This will break through the common isolated mindset and will support our newly-appointed colleagues.

Let us come together to change this cultural barrier and start organising our mental filing cabinets to create a positive learning environment in clinical practice.