Paramedics under pressure: A case study for systems thinking

Learning systems thinking is best done by doing. Case studies are useful ways to understand some basic principles, and I find that it can be useful to use case studies from other sectors, especially with a mixed audience. Cases that are very specific to (some of) the participants can be problematic for learning, for a few reasons. First, they can tend to bias toward the expertise of some people in the room, putting others at a disadvantage. As an example, with a mixed group of air traffic controllers, maintenance technicians, aeronautical information specialists, meteorological specialists, an air traffic incident will often illicit much more discussion from air traffic controllers, putting the others in a disadvantaged position. This tends to close down discussion from some, leaving them disengaged. But the mix itself is – usually – advantageous. Second, participant-specific case studies can rouse particular emotions. A safety occurrence or forthcoming organisational change can bring about all kinds of upset, which can be counterproductive to initial learning. Third, specific case studies can focus attention on microscopic factual and counterfactual details, and again distract from learning. So for these and other reasons, I find that learning about systems thinking can usefully start with cases that are inclusive to all group participants, that will not bring about heated debate, and that will keep a wide focus on holism and interactions.

A few weeks ago, I facilitated a workshop on systems thinking for safety investigators and safety assessors, most of whom were primarily operational or technical specialists with part-time safety-related roles. We used a case study from healthcare (which often borrows from aviation). The case presented was a BBC Radio 4 podcast from the The Report, called Paramedics Under Pressure (available to listen here).

Paramedics Under Pressure - The Report - BBC Radio 4

Paramedics Under Pressure – The Report – BBC Radio 4

From the BBC Radio 4 ‘The Report’ website:

Medical emergency 999 calls are at an all-time high, with around 9 million calls a year, creating an unprecedented workload for ambulance paramedics around the UK. As a result, many are quitting their job in increasing numbers, burnt out and unable to keep up with the pace of work now demanded of them.

Adrian Goldberg investigates what’s behind this growing demand for emergency medical assistance, and asks why the recruitment of emergency paramedics has not kept pace with pressure on the service. Serving staff as well as those who have quit their job reveal a target-driven culture which sees them sent from job to job to job, where a lunch break is seen as a luxury. The finger is also pointed at some members of the public, who dial 999 to demand an ambulance for trivial injuries and illnesses.

Senior managers working for ambulance service trusts around the country say there is no quick fix for this rising exodus of staff – especially now paramedic training requires a university degree course. This has led some trusts to look as far afield as Australia and New Zealand for new recruits to plug the gap.

The NHS is planning an enhanced role for paramedics where they will be required to treat more patients in the field, to ease the pressure on over-stretched A&E departments. But with staff retention and recruitment an on-going issue for several ambulance services around the country, will they be able to meet these new expectations and will new recruits burn out too?

We listened to the podcast and read a transcript, to help follow and remember the narrative (it also helped because the group members were not native English speakers in this case). We then, in small groups, discussed the issues in light of the Systems Thinking for Safety: Ten Principles. Each group used the Systems Thinking Learning Cards as social objects, with and through which to discuss the issues and the interactions between the issues. The groups also used a simple A3 wheel diagram of the ten principles, to map the interactions between the issues. We found the exercise useful, and it has been repeated elsewhere using the same format and materials. (It could be used with other podcasts or programmes, of course.)

Here are some tips in case you would like to do a similar exercise:

  • Download the podcast (or another radio/film programme that is rich in systems concepts) onto a device (e.g. iPlayer Radio for Apple or Android or Windows phone), in case you lose internet connection and in case it disappears from the website.
  • Give everyone a copy of a:
    • the transcript (or a transcript for whatever programme you are using; sometimes these are provided, otherwise DIY…). This helps to follow and recall the narrative.
    • the Systems Thinking Learning Cards. These are available in two formats here.
    • the A3 wheel diagram of the ten principles.
    • sticky notes and pens to write notes on how the principles apply, and interactions.
  • Ask participants, in one or several small groups, to discuss the case in terms of the ten principles. We preferred not to have a fixed starting point, but to allow each groups to find its own starting points to make sense of the narrative.
  • Map the interactions between the principles onto the wheel, annotating the arrows.
  • Discuss these interactions as a group. These might include the relationships between pressure, resources and trade-offs, for example. Note the nature and direction of the influences and interactions. The interactions may be one to many, many to many, and may link two or more principles. We found it best to best to keep group feedback discussion at the level of interactions between principles, not the individual principles.
  • Other methods can also be used (by other groups, or in place of the Ten Principles, or subsequent to them). Some of these are listed here. Particularly useful for this particular case could be AcciMaps, Influence Diagrams, Causal Loop Diagrams, and Rich Pictures.

About stevenshorrock

I am a systems ergonomist/human factors specialist and work psychologist with a background in practice and research in safety-critical industries. My main interest is human and system behaviour in the context of safety-related organisations. I seek to enable improvement via a combination of systems thinking, design thinking and humanistic thinking. I am a Chartered Ergonomist and Human Factors Specialist with the CIEHF and a Chartered Psychologist with the British Psychological Society. I currently work as a human factors and safety specialist in air traffic control in Europe. I am also Adjunct Associate Professor at University of the Sunshine Coast, Centre for Human Factors & Sociotechnical Systems. I blog in a personal capacity. Views expressed here are mine and not those of any affiliated organisation, unless stated otherwise. You can find me on twitter at @stevenshorrock
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3 Responses to Paramedics under pressure: A case study for systems thinking

  1. Frank Verschueren says:

    Hey Steven,

    I am VERY interested in your workshop System but I see that you gave à good description above.

    I hope you suucceed in your project !!!

    Best regards , Frank

  2. Frank Verschueren says:

    Please report your results in à further communication , if you please

  3. Frank Verschueren says:

    Maybe I could participate ? You could count on à very thorough feedback.

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