A new model for structured reflection
in Pre-Hospital Care...
developed by Ambulance Paramedics in the UK
Introduction
This article outlines the background to, and development of, a
structured reflective model for use in pre-hospital care practice.
The model is called ‘CRASHED’, an acronym which can
be used to guide the reflective process:
C - Communications
R - Response
A - Actions
S - Subsequent Actions
H - Hospital
E - Evaluation and Ethics
D - Discussion
Background
Salmon stated in 1985 “the passing of years does not necessarily
bring gifts of understanding within one’s own life. Twenty
years experience, it has been said, may be no more than one years
experience repeated twenty times”(p.21). If this statement
can be considered truthful, surely there must be some way in which
a bridge between understanding and experience can be made. Could
it be that reflection offers this bridge? This work was guided
by the members of a group of pre-hospital care students who are
engaging in learning about reflective practice through doing structured
reflection on action using Benner’s (1984) and Johns (1995a)
model. One of the problems noted by students was that the existing
reflective models are aimed predominately at nursing and as such
do not fully meet the needs for the pre- hospital provider who
wishes to reflect.
Reflection is well established in nursing and as such has become
a core aspect in nurse education. Its use allows a way for the
individual to become what has been termed a “Thinking Practitioner”
permitting them to identify strengths or shortcomings within their
own practice and therefore allowing them to improve the standard
of care they are able to offer patients.
The emphasis throughout the literature is on the willingness,
motivation and capabilities of the practitioner to learn through
reflective practice. However, many may find it difficult and even
painful to disclose events when emotions have been aroused. Participants
may not want to relive or resurrect buried experiences. Hulatt
(1995) suggests that there are many good reasons why nurses may
choose not to disclose experiences they would sooner leave buried,
and this has to be respected. The same could be said for paramedics,
and this is an important consideration, which is covered by agreed
ground rules and the development of a supportive environment for
reflection to occur, notably confidentiality and a non-judgemental
attitude Structured reflection has been used for a number of years
to enhance professional development and education in teaching,
nursing and some allied health care professions. Retrospective
analysis of a situation or event where the practitioner is one
step removed from the situation would appear to be a more comfortable
and controlled way of gaining knowledge from past events. This
is referred to generally as reflection-on-action. Also relevant
is reflection-in-action where a practitioner recognises a new
situation or problem and has to think and deal with it while still.
acting. (Boud, Keogh and Walker, 1985; Benner & Tanner, 1987;
Ford & Walsh 1994; Johns, 1995a) Anecdotal evidence would
suggest that reflection has been used by Ambulance Staff for many
years, where cases that the crews have encountered have been discussed
in the vehicle or over a cup of tea back at the ambulance station.
It is thought that if reflection is to be used properly to improve
practice then a structured model of reflection should be used.
However, as previously noted a structured model aimed specifically
for the pre-hospital provider was not available. It was considered
essential to develop something that was relevant, easy to use,
and grounded in pre-hospital care practice.
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A model for structured reflection
The CRASHED model of reflection provides a simple reflective framework.
It incorporates important elements of the Johns (1995a) model
of reflection, in that it allows for analysis of reflection prior
to action, reflection in action, reflection on action and reflection
upon reflection. It can be used by an individual wishing to reflect
singularly or as a tool with which Operational Based Assessors
for example may facilitate reflection with staff members either
as a hot de-brief immediately following a case, or in more depth
later on.
The CRASHED method has been kept as simple as possible using
plain language, which it is envisaged, should allow for quicker
assimilation and easier acceptance by all levels of staff. Each
phase of a call is divided up and examined by answering a number
of questions; the amount of consideration given to each question
may vary from case to case. The individual may find that they
are only able to give single word answers to some questions, or
they may feel that the questions prompt further exploration to
seek personal answers or solutions related to practice.
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CRASHED REFLECTION
Communications
Do you feel that the case was communicated to you sufficiently?
Did you make any specific request, were they met?
Do you feel there are any requests you should have made?
Response
What were your personal feelings upon receiving the call?
If you drove can you identify any difficulties encountered en-route?
Did you revisit any previous cases in order to prepare yourself
for this one?
Did you undertake any preparation en-route i.e. drug calculations
or making ready equipment?
Actions
What did you find on initial patient contact?
Did the environment impact on you in a positive or negative way?
What patient treatment decisions were made and how did you reach
them?
Did your theoretical knowledge fall short, meet or exceed your
practical skills?
Was the correct equipment instantly available to carry out your
task?
Subsequent Actions
What manual handling techniques did you employ?
What transportation decisions were made, how did you reach them?
What effect did your interventions have on the patient’s
condition?
Did you have to re-evaluate or change your treatment at any stage?
Was a Hospital pre-alert given, or any specific requests made?
Hospital
Was the receiving hospital adequately prepared for your arrival?
Did you give a suitable hand-over to a suitable person, were your
findings
considered?
Did you integrate as a team player?
Has your knowledge improved as a result of anything seen or heard
at hospital?
Evaluation and Ethics
What went well?
What could have gone better?
What have I learnt?
Did your actions meet your ethics?
Discussion
Could this reflection lead to a change in your own practice?
Would the case benefit from peer review or Critical Incident Stress
De-brief?
Does the reflection highlight any wider implications for pre-hospital
care?
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Conclusion
As can be seen CRASHED works in a logical sequence following the
call through from its initial receipt until its end. It encompasses
communication issues, individual feelings, driving skills, manual
handling, patient treatment, the decision making process, hospital
interaction, educational issues, ethical considerations, efficacy
of peer review or Critical Incident Stress De-brief (CISD) and
it also allows for consideration of wider implications of pre-hospital
care.
It could be argued that getting reflective practice accepted and
used to its full potential is not something that is likely to
happen over-night within the ambulance service. This could partly
be because of a lack of awareness amongst ambulance personnel
that such a thing exists, and also the fact that in order to see
the benefits of it you must use reflection personally. It is hoped
that because of its simplicity, CRASHED reflection will be readily
accessible to staff and they will feel encouraged to use it and
benefit from it.
With the changing role of the ambulance service and with it the
change in role of the pre-hospital care provider, hopefully CRASHED
reflection will become a vital part in the continued education
of ambulance staff and their lifelong learning.
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References
Benner, P. (1984) From Novice to Expert: Excellence and power
in clinical nursing practice. Addison-Wesley Publishing Company
Inc: Menlo Park
Benner, P. and Tanner, C. (1987) Clinical judgement: how expert
nurses use intuition . American Journal of Nursing. 87,1, 23-31.
Boud, D, Keogh, R. and Walker, D. (eds) (1985) Reflection: Turning
experience into learning. Kogan Page: London.
Ford, P. and Walsh, M. (1994) New Rituals for Old: Nursing through
the looking glass. Butterworth Heineman: Oxford.
Hulatt, I. (1995) A Sad Reflection. Nursing Standard 9,20, 22-23.
Johns, C.C. (1995a) Framing Learning through Reflection within
Carper’s
Fundamental ways of Knowing in Nursing. Journal of Advanced Nursing
22, 226- 234.
Kolb, D. and Fry, R. (1975) Towards an applied theory of experiential
learning in: Cooper, C.L. (ed) Theories of Group Processes, John
Wiley & Sons: London.
Salmon, P. (1985) Living in Time. J.M. Dent & Sons Ltd.
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