Despite their reported commitment to the ILMA device, the findings of this study reflect the growing evidence base that paramedics have a strong affinity toward laryngoscopic tracheal intubation (Thomas, Abo et al. 2007) and report this as a skill which is essential for their out of hospital practice. One explanation for this strong affinity towards laryngoscope intubation is an increased level of prestige predominantly due to the
culture and history of paramedic practice. Nevertheless, the study findings also show that Tasmanian paramedics are amenable to other methods and devices to achieve successful tracheal intubation. These findings suggest that paramedics are open to new possibilities for approaching tracheal intubation for emergency airway management. In other words, they are open to the possibility of being persuaded to change the practices they have come to know and accept as the most efficient and reliable practice. Rogers (Rogers 2003) argues that when an organisation introduces a new practice individuals will consider its value and decide whether it represents a superior alternative to their current practice.
Chapter four shows paramedics recognised the ILMA as a necessary item for inclusion into the scope of their practice and they were aware they could achieve a similar tracheal intubation success rate as with the
traditional laryngoscopic tracheal intubation. The majority of the participants in this study had experience in tracheal intubation which would make the inclusion of the ILMA as an alternative device easier as the context of the procedure is already established. The rural paramedics
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involved in the ILMA study (PILMAT) had no experience in using the standard LMA, as a supra-glottic airway device was not in use in
Ambulance Tasmania15 at the time. This meant they were unfamiliar with
all aspects of ILMA use including its role, effectiveness and usability. After they were introduced to the ILMA and trained in its use they believed it was a device which has a role in providing out of hospital airway care and should be used by paramedics. After using the ILMA in their practice in various patient care situations ranging from using it as an intermediate airway through to using it to perform tracheal intubation in some of the most challenging emergency care situations, they reported the ILMA has a function in the management of the difficult tracheal intubation situation and it should be used by paramedics in specific clinical presentations. These findings reflect the various factors that converge as complexities inherent in persuading individuals to adopt or not adopt new innovation. Rogers (Rogers 2003) places particular emphasis on the adult learner during the persuasion stage whereby recognition of the need to change is isolated as an important component of the persuasion process. In other words, the finding that paramedics themselves recognise their current laryngoscopic tracheal intubation practice must change is encouraging for the field because this is a crucial step in their likely commitment to enforcing those changes to their practice.
The study findings also show there are a number of additional
complexities, such as the prestige of laryngoscopic tracheal intubation and its normal status for use in tracheal intubation by the health care system, the unpredictability of patient presentations whereby the initial patient experience could involve straightforward or a difficult tracheal intubation and a significant number of paramedics had many years’ of AAM
experience, that influence paramedics decisions about ILMA use for AAM. Indeed, Rogers (Rogers 2003) argues there are various social factors that may extend the persuasion phase when diffusing innovation. These are important considerations for the field of paramedicine because the
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complexity and importance of achieving social change to the extent that the ILMA use becomes a system norm need to be considered by training providers to effectively advance the remaining elements that determine adoption of the new activity. As discussed in the methods chapter Rogers identifies these as relative advantage, compatibility, complexity, trialability and observability.
When introducing new devices such as the ILMA or procedures for AAM the training program should be developed in ways that enable paramedics to be actively involved in the decisions to adopt or not adopt the new device and its associated procedures. These sentiments are reflected in many adult learner theories (Kolb, Knowles) that posit learners who see the relevance of the learning are often more willing and able to apply it soon after the training program. The ILMA training program reinforced the relevance during the pre-course review phase by allowing the learner to recall the critical aspects of their knowledge and skills which enlightened them to the natural advancement in their practice which was to use the ILMA for tracheal intubation. Learners who present at a training program with no introductory process will require a greater time period to reflect on their experiences, place the next learning into context, and progress through the decision making phases. According to Rogers (2003) these are ‘knowledge’, ‘persuasion’ and ‘decision’.
For ILMA paramedic training providers it is important this is not regarded as a simple and linear process. Instead, Rogers (2003) identifies four types of innovation decision making processes:
Optional - where it relies on the individual choice and is independent of others within the social structure.
Collective – where there is a decision made by a consensus of the social members and all conform once the decision is made. Authority - the decision is made by a few in power with the individual
having minimal influence on the decision but provides the fastest rate of adoption.
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Contingent - where two or more decisions are required and the final choice is made after an earlier decision has been made. The paramedics reported they had increased confidence and
comparable levels of success in the use of the ILMA despite indicating it was not easier or quicker to use than the laryngoscope for tracheal
intubation. This is despite their statement that to use the ILMA for tracheal intubation requires less training. Roger’s model (Roger’s 2003) indicates complexity as a characteristic of an innovation which influences the period required for persuasion and requires careful consideration in the process of persuasion as it does not only relate to the device but the
accompanying process and procedure.
The complexity and compatibility characteristics of the persuasion phase have been expressed by a number of factors in this study which may not easily be associated to one or the other criteria. These factors at times appear opposing and strengthen the influence the social structure and values have on the persuasion phase. For example, the paramedics reported they believed laryngoscopic tracheal intubation to be quicker than when they undertook ILMA tracheal intubation, but the scene times reflect the opposite where the paramedics spent more time on scene when performing laryngoscopic tracheal intubation.
When paramedics have a decreased confidence level in a skill such as laryngoscopic tracheal intubation the inclusion of a new device which they are confident to use and perceive of value because it provides an
alternative will produce a positive influence on their acceptance of the new device. According to Roger’s (Rogers 2003) diffusion of innovation theory the advantage provided by the new skill, ILMA tracheal intubation, is only required to be a perceived advantage to have a positive influence. The requirement to provide detailed objective advantages of a new skill is not necessary in order to influence the new skills acceptance. Furthermore, Roger’s theory suggests the uncertainty a technological change makes to the system norms can be lessened by a number of measures prior to the official use of the technology in normal practice.
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These represent one of the key social processes that will influence whether the ILMA innovation will become a system norm in paramedicine measures correspond to classroom activities and use of simulation often employed during AAM education programs. The provision of knowledge to commence cognition about the relative advantage, compatibility and complexity commences the persuasion phase and other measures which assist when the innovation is a device is the ability to trial and experiment. These are important considerations for paramedic curriculum designers because Roger’s (2003) theory states this provision of knowledge will decrease the uncertainty and lead to the learner having an increased level of acceptance as they begin along a path of persuasion. Roger’s (2003) theory states the ability for a new technique or procedure to be trialled on a limited basis causing uncertainty to be decreased and the learning to be enhanced by use in normal practice is a beneficial aspect and may
improve acceptance.
When critical clinical skills, such as AAM are introduced to paramedicine, the use of manikins and simulation can develop to a specific performance point where further increases in performance can best be achieved by workplace implementation. Here, learning by doing as described by Rogers (2003) becomes a fundamental component of the ILMA training program.
The acceptance of the innovation and the rate of adoption during the persuasion phase is known to be influenced by the characteristics of the individual or individuals who are providing the knowledge and conducting any training. During the persuasion phase the involvement of ‘champions’ key respected paramedics who would provide an important
communication channel for the users is a factor which can increase the rate of adoption. The social change is more rapid when the presenter has similar values and expectations to the learner a term Roger’s identifies as homophily. There is increased homophily when AAM training is conducted by paramedic educators in a classroom or during simulation then training provided by specialists in a foreign environment such as the theatre
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setting. The greater desire for manikin and in service training components may reflect the notion of homophily as described by Rogers (2003)
Diffusion of Innovation theory.
According to Rogers (Rogers 2003) diffusion of innovation theory the phases contained within the “innovation decision making” process of persuasion and decision which rely upon occurring in greater detail once the skill or procedure is taken into the workplace require the opportunity for performance to occur. If performance of the new skill or procedure is delayed then not only with the learning curve commence its decline but the evidence required for the learner to make these critical decisions on the adoption of the new skill or procedure will be hindered or possibly shelved causing a barrier not only to the current but also to future
implementation. This process is in line with Roger’s concept of trialability which increases the rate at which the innovation may be adopted by allowing the learner to undertake deeper and more relevant learning by using the device.
All learners will have a different time periods which they require in order to make a judgement on the value of the new skill or procedure. There will be early adopters who rapidly decrease uncertainty and are critical in the dissemination of their subjective evaluation to their peers which aids their adoption and on the other end of the categories of learners will be the traditionalists which in Rogers (Rogers 2003) and in adopter categories are known as ‘laggards’. The laggards are the last to accept and make the decision that the new skill or procedure is appropriate, they are often the learners who are removed from the regular communication channels and require the most evidence before they accept. There is a risk that the rural paramedic due to their disconnection from the mainstream peer
communication processes may have a tendance to become laggards and providing mechanisms to overcome the communication difficulties may assist in the adoption of the new skill or procedure.
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5.2.3 Educational considerations of ILMA innovation into