title: A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety.
abstract: OBJECTIVE
  Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors.
  
  
  METHODS
  An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff.
  
  
  RESULTS
  Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven overarching systemic influences and risk factors potentially influencing decision making were identified: demand; performance priorities; access to care options; risk tolerance; training and development; communication and feedback and resources.
  
  
  CONCLUSIONS
  Use of multiple methods provided a consistent picture of key systemic influences and potential risk factors. The study highlighted the increased complexity of paramedic decisions and multi-level system influences that may exacerbate risk. The findings have implications at the level of individual NHS Ambulance Service Trusts (e.g. ensuring an appropriately skilled workforce to manage diverse patient needs and reduce emergency department conveyance) and at the wider prehospital emergency care system level (e.g. ensuring access to appropriate patient care options as alternatives to the emergency department).
authors.affiliation: Lecturer in Public Health, Public Health Section, ScHARR, University of Sheffield, UK r.ohara@sheffield.ac.uk.
authors.forename: Rachel
authors.initials: R
authors.lastname: O'Hara
authors.affiliation: Research Fellow, Public Health Section, ScHARR, University of Sheffield, UK.
authors.forename: Maxine
authors.initials: M
authors.lastname: Johnson
authors.affiliation: Professor of Primary and Prehospital Health Care, Community and Health Research Unit, College of Social Science, University of Lincoln, UK.
authors.forename: A Niroshan
authors.initials: AN
authors.lastname: Siriwardena
authors.affiliation: Senior Lecturer in Psychology, Department of Psychology, University of Bath, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Weyman
authors.affiliation: Senior Research Fellow, Health Services Research Section, ScHARR, University of Sheffield, UK.
authors.forename: Janette
authors.initials: J
authors.lastname: Turner
authors.affiliation: Research Manager, East Midlands Ambulance Service NHS Trust, UK.
authors.forename: Deborah
authors.initials: D
authors.lastname: Shaw
authors.affiliation: Research & Development Manager, Yorkshire Ambulance Service NHS Trust, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Mortimer
authors.affiliation: Paramedic, South East Coast Ambulance Service NHS Trust, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Newman
authors.affiliation: PPI/Service User Representative, Sheffield Emergency Care Forum, UK.
authors.forename: Enid
authors.initials: E
authors.lastname: Hirst
authors.affiliation: Paramedic, Yorkshire Ambulance Service NHS Trust, UK.
authors.forename: Matthew
authors.initials: M
authors.lastname: Storey
authors.affiliation: Professor of Emergency Medicine, Health Services Research Section, ScHARR, University of Sheffield, UK.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Mason
authors.affiliation: Professor of Clinical Practice, Faculty of Health and Medical Sciences, University of Surrey, UK.
authors.forename: Tom
authors.initials: T
authors.lastname: Quinn
authors.affiliation: Head of Research & Development, Yorkshire Ambulance Service NHS Trust, UK.
authors.forename: Jane
authors.initials: J
authors.lastname: Shewan
mesh_terms: D003142:Communication; D003657:Decision Making; D004632:Emergency Medical Services / Q000458:organization & administration; D004634:Emergency Medical Technicians / Q000523:psychology*; D004739:England; D005246:Feedback; D006297:Health Services Accessibility; D006302:Health Services Research; D006801:Humans; D007318:Inservice Training; D061214:Patient Safety; D010360:Patient Transfer / Q000458:organization & administration*; D036301:Qualitative Research; D012307:Risk Factors; D013222:State Medicine / Q000458:organization & administration
keywords: decision making; paramedic; patient safety; system risk factors