Paramedic judgement, decision-making and cognitive processing: a review of the literature

Meriem Perona, Muhammad Aziz Rahman, Peter O'Meara



Paramedics routinely perform multiple time-sensitive decisions in dynamic environments, often with limited information and equipment. Paramount to patient safety, how paramedics make judgements and decisions within their uncertain environment is important. The primary aim of this review was to identify, examine and synthesise the published literature on how paramedics working in the out-of-hospital environment use judgement and make decisions.


Databases Medline, PubMed, CINAHL, Embase were searched and common themes pertaining to paramedic decision-making were identified. Full text original research articles that focussed on how paramedics perform decision-making in the out-of-hospital environment were included. Papers excluded were non-English; those examining emergency medical technicians, nurse- or physician-led ambulances; paramedics operating in hospital or clinic-based environment; and studies of purely paramedic student populations. Data were managed using the ‘preview, question, read, summarise’ approach.


A total of 362 abstracts and titles were reviewed; six were found to address the research aim. Of those six, four were qualitative in approach, one quantitative and one was mixed-methods. Overall, paramedics displayed the application of subconscious (intuitive) and conscious (analytical) thought processes – consistent with dual-process theory – with experience and formal education influencing factors. Paramedics gathered cues, problem solved, critically analysed, reasoned and displayed aptitude at rapid clinical impressions in critically ill patients with minimal information. Expert paramedics collected, processed and utilised information differently to novices portraying an interconnectedness of conscious and sub-conscious processing.


Paramedic judgement and decision-making is complex and multifaceted with multiple layers of knowledge interwoven. Implications for practice include better cognitive performance; educational course structure guidance; encouraging implementation of routine reflection and feedback, thus promoting continued improvement and better patient outcomes. Despite its importance, research was lacking.


emergency medical services; paramedic; ambulance; decision-making; critical thinking

Full Text:



Ball L. Setting the scene for the paramedic in primary care: a review of the literature. Emerg Med J 2005;22:896-900.

Bowles RR, van Beek C, Andersen GS. Four dimensions of paramedic practice in Canada: defining and describing the profession. Australasian Journal of Paramedicine 2017;14(3).

Paramedic – Scope of Practice Policy. Bridgwater, England: College of Paramedics, 2015.

Bigham B, Welsford M. Applying hospital evidence to paramedicine: issues of indirectness, validity and knowledge translation. CJEM 2015;17:281-5.

Carter H, Thompson J. Defining the paramedic process. Australian Journal of Primary Health 2015;21:22-6.

Harenčárová H. Managing uncertainty in paramedics’ decision making. J Cogn Eng Decis Mak 2016;11:42-62.

LeBlanc VR, MacDonald RD, McArthur B, King K, Lepine T. Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator. Prehosp Emerg Care 2005;9(4):439-44.

Patterson PD, Weaver MD, Frank RC, et al. Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers. ibid. 2012;16:86-97.

Williamson A, Feyer A. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med 2000;57:649-55.

Jensen JL, Croskerry P, Travers AH. Consensus on paramedic clinical decisions during high-acuity emergency calls: results of a Canadian Delphi study. Can J Emerg Med 2011;13:310-8.

Atack L, Maher J. Emergency medical and health providers' perceptions of key issues in prehospital patient safety. Prehosp Emerg Care 2010;14:95-102.

Shaban R. Mental health and mental illness in paramedic practice: A warrant for research and inquiry into accounts of paramedic clinical judgment and decision-making. Journal of Emergency Primary Health Care 2004;2(3-4).

Evans JS. Dual-processing accounts of reasoning, judgment, and social cognition. Annu Rev Psychol 2008;59:255-78.

Croskerry P, Nimmo GR. Better clinical decision making and reducing diagnostic error. J R Coll Physicians Edinb 2011;41:155-62.

Price R, Bendall JC, Patterson JA, Middleton PM. What causes adverse events in prehospital care? A human-factors approach. Emerg Med J 2013;30:583-8.

Terkelsen CJ, Lassen JF, Norgaard BL, et al. Reduction of treatment delay in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutanous coronary intervention. Eur Heart J 2005;26:770-7.

Johnston S, Brightwell R, Ziman M. Paramedics and pre-hospital management of acute myocardial infarction: diagnosis and reperfusion. Emerg Med J 2006;23:331-4.

Jensen JL. Paramedic clinical decision making [Masters]. Dalehousie University, Halifax, Nova Scotia; 2010.

Masci K, Fitzgerald M, Cooper DJ, et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg 2010;252:959-65.

Heegaard W, Hildebrandt D, Spear D, Chason K, Nelson B, Ho J. Prehospital ultrasound by paramedics: results of field trial. Acad Emerg Med 2010;17:624-30.

Walcher F, Weinlich M, Conrad G, et al. Prehospital ultrasound imaging improves management of abdominal trauma. Br J Surg 2006;93:238-42.

O’Brien K, Moore A, Dawson D, Hartley P. An Australian story: paramedic education and practice in transition. Australasian Journal of Paramedicine 2014;11(3).

Williams B, Brown T, Onsman A. Is the Australian paramedic discipline a full profession? ibid. 2012;(1):3.

O'Meara P. Paramedics marching toward professionalism. ibid. 2009;7(1).

Evans R, McGovern R, Birch J, Newbury-Birch D. Which extended paramedic skills are making an impact in emergency care and can be related to the UK paramedic system? A systematic review of the literature. Emerg Med J 2013.

Munro G, O'Meara P, Kenny A. Paramedic transition into an academic role in universities: a demographic and qualification survey of paramedic academics in Australia and New Zealand. Irish Journal of Paramedicine 2016;1(2).

O'Meara P, Tourle V, Stirling C, Walker J, Pedler D. Extending the paramedic role in rural Australia: a story of flexibility and innovation. Rural Remote Health 2012;12:1-13.

Abrashkin KA, Washko J, Zhang J, Poku A, Kim H, Smith KL. Providing acute care at home: Community Paramedics Enhance an Advanced Illness Management Program-Preliminary Data. J Am Geriatr Soc 2016;64:2572-6.

O'Meara P, Stirling C, Ruest M, Martin A. Community paramedicine model of care: an observational, ethnographic case study. BMC Health Serv Res 2016;16:39.

Pearson KB, Gale J, Shaler G. Community paramedicine in rural areas: state and local findings and the role of the State Flex Program. Portland: Maine Rural Health Research Center, Team FM; February 2014.

O'Meara P. Community paramedics: a scoping review of their emergence and potential impact. International Paramedic Practice 2014;4:5-12.

Christie G. Independent non-medical prescribing for paramedics. Nurs Stand 2015;29:36-9.

Savage ML, Poon KK, Johnston EM, et al. Pre-hospital ambulance notification and initiation of treatment of ST elevation myocardial infarction is associated with significant reduction in door-to-balloon time for primary PCI. Heart Lung Circ 2014;23:435-43.

Jensen JL, Calder LA, Walker M, et al. Experiential and rational clinical decision making: a survey to determine decision-making styles of paramedics. Can J Emerg Med 2013;15:S41.

Bigham BL, Bull E, Morrison M, et al. Patient safety in emergency medical services: Executive Summary and Recommendations from the Niagara Summit. ibid. 2011;13:13-8.

Mellifont D, Barr N, Dunn P. A systems approach to learning, practice and reflection in emergency primary health care: student perspectives. Australasian Journal of Paramedicine 2014;11(3):1-8.

Baumeister RF, Leary MR. Writing narrative literature reviews. Rev Gen Psychol 1997;1:311-20.

Gunnarsson BM, Warrén Stomberg M. Factors influencing decision making among ambulance nurses in emergency care situations. International Emerg Nurs 2009;17:83-9.

Halter M, Vernon S, Snooks H, et al. Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: a qualitative study. Emerg Med J 2011;28:44-50.

Newgard CD, Nelson MJ, Kampp M, et al. Out-of-hospital decision making and factors influencing the regional distribution of injured patients in a trauma system. J Trauma 2011;70:1345-53.

Jensen JL, Croskerry P, Travers AH. Paramedic clinical decision making during high acuity emergency calls: design and methodology of a Delphi study. BMC Emerg Med 2009;9:17.

Nilsson T, Lindstrom V. Clinical decision-making described by Swedish prehospital emergency care nurse students – an exploratory study. Int Emerg Nurs 2016;27:46-50.

Jensen JL, Bienkowski A, Travers AH, et al. A survey to determine decision-making styles of working paramedics and student paramedics. CJEM 2016;18:213-22.

Cronin P, Ryan F, Coughlan M. Undertaking a literature review: a step-by-step approach. Br J Nurs 2008;17:38-43.

Patrick LJ, Munro S. The literature review: demystifying the literature search. Diabetes Educ 2004;30:30-8.

Programme CAS. CASP Qualitative Checklist 2018. Available at:

Jensen JL, Tavares W, Calder LA, et al. A survey to determine decision-making styles of working paramedics and student paramedics. Can J Emerg Med 2016;18:213-22.

Jones CMC, Cushman JT, Lerner EB, et al. Prehospital trauma triage decision-making: a model of what happens between the 9-1-1 call and the hospital. Prehosp Emerg Care 2016;20:6-14.

Smith MW, Bentley MA, Fernandez AR, Gibson G, Schweikhart SB, Woods DD. Performance of experienced versus less experienced paramedics in managing challenging scenarios: a cognitive task analysis study. Ann Emerg Med 2013;62:367-79.

Wyatt A. Paramedic practice – knowledge invested in action. Australasian Journal of Paramedicine 2003;1(3).

Shaban RZ. Paramedic clinical judgement and decision-making of mental illness in the pre-hospital emergency care setting: a case study of accounts of practice: Griffith University; 2011.

Ryan L, Halliwell D. Paramedic decision-making: how is it done? Journal of Paramedic Practice 2012;4:343.

Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract 2009;14(Suppl 1):27-35.

Jensen JL. Paramedic clinical decision-making: result of two Canadian studies. International Paramedic Practice 2011;1:63-71.

Kahneman D. A perspective on judgment and choice: mapping bounded rationality. Am Psychol 2003;58:697-720.

Gauffroy C, Barrouillet P. Heuristic and analytic processes in mental models for conditionals: an integrative developmental theory. Dev Rev 2009;29:249-82.

Croskerry P. A universal model of diagnostic reasoning. Acad Med 2009;84:1022-8.

Hammond KR, Hamm RM, Grassia J, Pearson T. The relative efficacy of intuitive and analytical cognition: a second direct comparison. Boulder, Colorado: Centre for Research on Judgement and Policy, Institute of Cognitive Science, Colorado Uo; 1984. Report No.: CRJP 252.

Stanovich KE. The robot's rebellion: finding meaning in the age of Darwin. Chicago, IL: University of Chicago Press; 2004.

Graber ML. Educational strategies to reduce diagnostic error: can you teach this stuff? Adv Health Sci Educ Theory Pract 2009;14(Suppl 1):63-9.

Marcum JA. An integrated model of clinical reasoning: dual-process theory of cognition and metacognition. J Eval Clin Pract 2012;18:954-61.

Croskerry P. ED cognition: any decision by anyone at any time. Can J Emerg Med 2014;16:13-9.

Kahneman D, Frederick S. Representativeness revisited: attribute substitution in intuitive judgment. New York: Cambridge University Press; 2002 September, 2001.

Hoffman R. How Can Expertise be Defined? Implications of research from cognitive psychology. Exploring expertise. London: Palgrave Macmillan; 1996.

Waller MJ, Gupta N, Giambatista RC. Effects of adaptive behaviors and shared mental models on control crew performance. Manage Sci 2004;50:1534-44.

Tschan F, Semmer NK, Gurtner A, et al. Explicit reasoning, confirmation bias, and illusory transactive memory: a simulation study of group medical decision making. Small Group Res 2009;40:271-300.

Schmidt HG, Rikers RM. How expertise develops in medicine: knowledge encapsulation and illness script formation. Med Educ 2007;41:1133-9.

Sandars J. The use of reflection in medical education: AMEE Guide No. 44. Med Teach 2009;31:685-95.

Croskerry P. The feedback sanction. Acad Emerg Med 2000;7:1232-8.

Katajavuori N, Lindblom-Ylänne S, Hirvonen J. The significance of practical training in linking theoretical studies with practice. High Educ 2006;51:439-64.

Burrell L, Noble A, Ridsdale L. Decision-making by ambulance clinicians in London when managing patients with epilepsy: a qualitative study. Emerg Med J 2013;30:236-40.

Athari ZS, Sharif SM, Nasr AR, Nematbakhsh M. Assessing critical thinking in medical sciences students in two sequential semesters: does it improve? J Educ Health Promot 2013;2:5.

Hou XY, Rego J, Service M. Review article: paramedic education opportunities and challenges in Australia. Emerg Med Australas 2013;25:114-9.

O’Meara P, Furness S, Gleeson R. Educating paramedics for the future: a holistic approach. J Health Human Serv Adm 2017;40:219-51.

Woodford P. The decision is yours. Journal of Paramedic Practice 2015;7:90-4.

Pelaccia T, Tardif J, Triby E, Charlin B. An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Med Educ Online 2011;16.

WHO nursing and midwifery progress report 2008-2017. Geneva, Switzerland: World Health Organisation; 2013.

Snooks HA. On-scene alternatives for emergency ambulance crews attending patients who do not need to travel to the accident and emergency department: a review of the literature. Emerg Med J 2004;21:212-5.

Mulholland SA, Gabbe BJ, Cameron P. Is paramedic judgement useful in prehospital trauma triage? Injury 2005;36:1298-305.

Karthikeyan G, Pais P. Clinical judgement & evidence-based medicine: time for reconciliation. Indian J Med Res 2010;132:623-6.

Krch D. Cognitive processing. In: Kreutzer JS, DeLuca J, Caplan B, editors. Encyclopedia of Clinical Neuropsychology. New York, NY: Springer New York; 2011. p. 627.

Scriven M, Paul R, editors. Defining critical thinking. 8th Annual International Conference on Critical Thinking and Education Reform; Summer 1987: The Foundation for Critical Thinking.

Wang Y, Liu D, Ruhe G, editors. Formal description of the cognitive process of decision making. Proceedings of the Third IEEE International Conference on Cognitive Informatics; 2004; Victoria, Canada.



  • There are currently no refbacks.

The Official Journal of Paramedics Australasia © 2019                           ISSN: 2202-7270


Crossref Member Badge