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Shifting the Paradigm for Systems Thinking in Pre-hospital Care


Several authors are credited with founding contributions to the field of systems thinking (ST) and systems dynamics, however, it is Barry Richmond who is credited with first devising the term ‘systems thinking’.1  Richmond used the label to describe the need to consider how different components impact and influence each other within what he saw as increasingly complex and interconnected systems.  Since then there have been attempts made to accurately define what is meant by ST.  In 2015, Arnold & Wade1 undertook a lengthy scientific process to determine the best possible definition, finally deciding that “Systems thinking is a set of synergistic analytic skills used to improve the capability of identifying and understanding systems, predicting their behaviors, and devising modifications to them in order to produce desired effects.  These skills work together as a system.”.  In this definition, ST consists of three main components: distinct elements that need to be understood, interconnections between those elements, and an overall function or purpose that is clear.1-4  It is the concurrent functioning of these components that creates the level of complexity that makes ST necessary.

The multiple layers of large systems make it difficult for each element to identify what the ultimate purpose may be.  In the example of a complex healthcare environment, different elements could be specific departments or professions.  Following the healthcare example, even if the purpose is clear it can be even more difficult to define exactly what role each department plays, or should play in the system, and then have those roles understood by other departments.  In the absence of a clear purpose, setting goals and decision-making become nearly impossible as the priorities of the person making decisions may be very different from those of the system.

In complex systems, like healthcare, significant real time decision-making must occur on the frontlines, often far away from the top levels of leadership.  This makes leading in a complex organization difficult as leaders are not sure what approach to take, knowing that too much control can hinder staff from making rapid decisions and too little control can cause risks to patients and the organization.  This conundrum means leaders must be constantly adapting, balancing the needs of patients, staff, and the organization in decision-making.3,4  In worst case scenarios leaders become hamstrung and decision-making stops.  Leaders in this type of environment need to be adept and vigilant to ensure they create clear vision and expectations, and to communicate effectively at all levels, to those tasked with carrying the vision out.  

Emergency Medical Services (EMS), as a system, has always been complicated.  Often unacknowledged as a true healthcare service, EMS has historically functioned mainly as a triplet of emergency services, along with siblings, fire and police services.3  While functioning in this type of fast-paced, high stress environment was challenging complexity was mitigated by the fact that the purpose of EMS was clear – respond to emergencies and take patients to the hospital.  While this may be an oversimplification the point is that EMS had a collective purpose and identity.5,6  Over the past few decades we’ve experienced a movement of pre-hospital care into folds of the greater healthcare system; a morphing of the traditional urgent care only transport service (you call, we haul!) towards a highly skilled, complex profession that some may recognize as a sub-specialty in its own right.5  In many areas EMS now exists with one foot rooted in its traditional role of emergency services and another foot in the brave ‘new world’ of a healthcare system that doesn’t quite know what to do with us yet, nor have we advised our health partners about what the role of EMS could or should look like.  The skillset of the modern day paramedic lends itself to many different roles in primary care.5,6  Arguably, EMS has long functioned as a proverbial ‘stop-gap’, filling in the cracks to help bridge patients in the community with primary health care services, and supporting the obligation of a healthcare system to ensure access for those who may otherwise be without medical support.  We are beginning to recognize that for many patients EMS acts as a gateway into the healthcare system, integrally interconnected with the other components of the system.  EMS is often the first point-of-contact that influences the journey of that patient through the rest of their healthcare experience and can cause ripple effects in the system that is working to provide healthcare services to many others.

Paramedicine has many positive contributions to make to healthcare, but being the new kid on the block in a well-established neighborhood has challenges.  The profession itself is trying to get a grip on a new identity that sees many of its members working in roles that are unfamiliar.5-7  In this way the historic identity of paramedics, the individual ideas about the purpose of paramedicine, and the goals they set due to those beliefs adds complexity and impacts the decisions they make, even with regards to patient care.

ST is still relatively new and poorly understood in the context of healthcare, in general.4,5,7-9  However, researchers and authors have wasted no time in aiming their flashlights on paramedicine to identify how it fits into the model of ST.  At this early stage ST has been identified as an integral concept that acts as a basis for critical thinking, clinical decision-making, and professionalism overall.3,7,8,10,11  Richmond12 goes as far as to say that critical thinking is not possible without ST.  As critical thinking is imperative to clinical decision-making it is easy to see the link to ST.  Similarly, some of the most recent research in applying ST to healthcare places ST as essential to effective quality improvement and system-based practice.5

Paramedicine does not operate in a silo and must be viewed through the lens of the overall healthcare system.  As Newton & Harris3(p.88) state, there is a “need for a change of paradigm from transport to treatment at the point of contact for the ambulance service and paramedics, placing this in the context of systematic organisational changes designed to move the focus from hospitals to a reformed and reinforced set of community services”. 

Increasing the capacity of paramedics to apply ST can be accomplished through a few different approaches.  Clinical decision support tools, in the form of protocols, guidelines, and triage systems10 are a great way to support ST by reducing practitioner’s cognitive load.  These tools help to avoid or mitigate some of the cognitive bias pitfalls that plague critical, strategic, clinical decision making.  When frontline practitioners are making rapid decisions it can be very difficult, if not impossible to critically analyze all impacts to the system, including their own emotional influences and come up with the best overall decision in such a time dependent situation.  Clinical decision support tools are developed through extensive analysis of the system as a whole, including consultation and input from other departments and care areas, determining models of resource availability, and predicting the most probable flow of care for specific care needs.

Although our understanding is growing, there is still a lack of research on how ST functions in healthcare relative to other fields.  As such, it stands to reason that there is also a lack of education for health providers on ST during formal training. 4-6,8  Each discipline is expected to function in an interdisciplinary environment as soon as they enter the workforce but are exposed to little, if any, interdisciplinary education.  This is starting to change as medical schools recognize that understanding systems is part of a foundational skill set that builds the capacity of individuals to function effectively in today’s multi-dimensional environments.5  As we move forward health education programs are going to be called to play a stronger role in preparing graduates to meet the challenge of their roles, to build competency and professionalism through teaching ST concepts, and to create inter-professional practice learning opportunities into their programs.4,5,8 To help meet this challenge researchers Dolansky, Moore, Palmieri, & Singh have developed and validated a tool to measure ST ability and the effect of ST education on building ST capacity (more information can be found at: Systems Thinking Scale Manual | Frances Payne Bolton School of Nursing (

It is incumbent upon EMS leaders to cultivate an environment where paramedics can understand ST in order to function effectively in a complex healthcare system and perceive their own role within it.  Many factors that impact the system overall are actually decisions made by individuals on the frontline which, in aggregate over time, work to drive the system, for better or worse.  Leaders, educational institutions, and regulatory bodies have a part to play here to strongly incorporate systems thinking into their vision, expectations, training programs, competency profiles, code of ethics, and standards of practice.  It is the role of every paramedic to consider the impact of their care and decisions on both the patient and the system in which they function, in order to preserve it for the patients who come next.


  1. Arnold RD, Wade JP. A definition of systems thinking: A systems approach. Procedia computer science. 2015 Jan 1;44:669-78.

  2. Meadows DH. Thinking in systems: A primer. chelsea green publishing; 2008.

  3. Newton A, Harris G. Leadership and system thinking in the modern ambulance service. InAmbulance Services 2015 (pp. 81-93). Springer, Cham.

  4. Rusoja E, Haynie D, Sievers J, Mustafee N, Nelson F, Reynolds M, Sarriot E, Swanson RC, Williams B. Thinking about complexity in health: A systematic review of the key systems thinking and complexity ideas in health. Journal of evaluation in clinical practice. 2018 Jun;24(3):600-6.

  5. Dolansky MA, Moore SM, Palmieri PA, Singh MK. Development and validation of the Systems Thinking Scale. Journal of general internal medicine. 2020 Aug;35(8):2314-20.

  6. Bowles RR, van Beek C, Anderson GS. Four dimensions of paramedic practice in Canada: defining and describing the profession. Australasian Journal of Paramedicine. 2017 Aug 7;14(3).

  7. Reed B, Cowin LS, O’Meara P, Wilson IG. Professionalism and professionalisation in the discipline of paramedicine.

  8. Clark K, Hoffman A. Educating healthcare students: Strategies to teach systems thinking to prepare new healthcare graduates. Journal of Professional Nursing. 2019 May 1;35(3):195-200.

  9. Belrhiti Z, Giralt AN, Marchal B. Complex leadership in healthcare: a scoping review. International journal of health policy and management. 2018 Dec;7(12):1073.

  10. Bashiri A, Savareh BA, Ghazisaeedi M. Promotion of prehospital emergency care through clinical decision support systems: opportunities and challenges. Clinical and experimental emergency medicine. 2019 Dec;6(4):288.

  11. Bijani M, Abedi S, Karimi S, Tehranineshat B. Major challenges and barriers in clinical decision-making as perceived by emergency medical services personnel: a qualitative content analysis. BMC emergency medicine. 2021 Dec;21(1):1-2.

  12. Richmond B. The “thinking” in systems thinking: how can we make it easier to master. The Systems Thinker. 1997 Mar;8(2):1-5.

Angeline Abela

Angeline Abela

Angeline is a safety leader with 22 years of experience in EMS. She is an author and international speaker, holding a Master of Arts degree in Leadership with a main research interest in women’s leadership development and employment interview process design. She does work on multiple groups focused on diversity and inclusion, and on increasing research capacity in prehospital care.

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Women in Paramedicine

Women in Paramedicine

Women in Paramedicine is compromised of dozens of women in the paramedical field across Canada. Since 2019, they have been sharing their research, point of view, thoughts, and strength to Canadian Paramedicine through their voice and words.

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