Evidence-Based Practice: Paramedic - Essay Example

?Running head: EVIDENCE-BASED PRACTICE: PARAMEDIC Evidence-based practice: Paramedic (school) Introduction It is important forhealth professionals, including paramedics to deliver the best possible care for patients. This study sought to identify the current practice and areas which need review, drawing on literature sources to establish if or where changes should be made. In this instance, it shall consider the protocol head traumas and the application of prehospital intubation. Literature review The reviewed studies indicated strong support for prehospital intubation for serious head traumas. Most of the studies highlighted the importance of paramedics first having adequate training and expertise in prehospital intubation before being allowed to carry out the intervention in the actual setting. The studies also set forth that prehospital intubation can best be carried out for serious head traumas and for helicopter emergency services. These studies emphasize that the prehospital intubation can potentially yield better patient outcomes with reduced risk of hypoxia and subsequent brain damage. Conclusions The protocol on head injuries can be improved to make room for emergency prehospital intubation for serious head injuries to be transported via helicopter to the nearest hospital facility. This process can be applied in order to prevent hypoxia and brain damage. Recommendations This study recommends protocol change to include prehospital intubation for patients with serious head injuries to be transported via helicopters to the nearest hospital facility. In effect, trainings for paramedics for intubation must be carried out. Paramedics equipment and facilities must therefore include tools for prehospital intubation. Evidence-based practice: Paramedic Protocol T19: Head Injuries Assessment 1: Introduction It is important for health professionals, including paramedics to deliver the best possible care for patients. For paramedics, their response to patient needs is considered part of prehospital care and their actions can often impact significantly on patient outcomes, it is therefore important for these paramedics to be equipped with the proper skills and knowledge in addressing patient needs (Badcock, 1998). All health professionals must aim to provide the best possible care to the population. Based on the current protocols and standards of the practice, there are however gaps which make the plan of care for the patients lacking or insufficient in some way. This study aims to identify the current practice and areas which need review, drawing on literature sources to establish if or where changes should be made. In this instance, it shall consider the protocol on head injuries. This paper shall be discussing Protocol T4 discussing head injuries. A head injury may be caused by an isolated incident or may be a part of a greater injury (Ambulance Service of New South Wales, 2011). Secondary brain injury can be seen after hypoxia and hypotension; it is therefore important to secure a patent airway, adequate oxygenation, and prevention of hypotension. The Sydney Local Health District (n.d) describes head injuries as injuries to the brain, the skull, or the face. These injuries may vary in severity, but they are basically classified into primary and secondary brain injuries (Rushworth, 2008). Primary brain injuries are products of the initial insult, seen with the head acquiring trauma; the secondary brain injury is seen after the injury, usually with the patient having difficulty breathing due to hypoxia (Wang, et.al., 2004). The paramedics attending to these head trauma patients are cautioned to be very suspicious of any head injuries, especially if the patient loses consciousness or has had a history of losing consciousness following the head injury (Rahm, 2004). Some patients may suffer minor head injuries without experiencing any serious trauma from their brain injury. Nevertheless, those who are suspected of traumatic brain injury must be evaluated and transported immediately to the nearest hospital facility (Garner, et.al., 1999). For patients with minor head injuries causing haematomas or contusions, they may be referred to GPs within a reasonable time frame (Bradley, et.al., 1998). The protocol for the management of head injuries includes the primary assessment or the assessment of the patient’s airway, breathing, circulation, disability, exposure and environment. After assessment of the ABCDE is carried out, treatment of associated conditions follow; associated conditions include hypoxia and hypovolaemia, as well as spinal injury. It is also important to consider the other causes of decreased LOC (Ambulance Service of New South Wales, 2011). Next, it is also important to establish the appropriate disposition for patient, whether he needs urgent transport due to decreased LOC; whether no transport is needed for patients with minor head trauma without suspicion of TBI; and whether transport is recommended based on patient assessment. In instances when the patient or carer declines of refuses assessment, treatment or transport, a patient advice card shall be issued to persons responsible (Ambulance Service of New South Wales, 2011). It is also important to regularly repeat and document the ABCD physical examinations in order to establish trends in clinical deterioration. This study seeks to consider the use of intubation during the pre-hospital setting for patients with serious head injury. As was mentioned, hypoxia must be managed in the emergency setting, and such hypoxia can be managed through intubation to prevent brain damage and further head trauma to the patient. Reference Ambulance Service of New South Wales (2011). Protocols and Pharmacology. New South Wales: Ambulance Service of New South Wales. Badcock K. (1988). Head injury in South Australia: incidence of hospital attendance and disability based on a one-year sample. Community Health Studies, volume 12: pp. 428–36. Bradley JS, Billows GL, & Olinger ML. (1998). Prehospital oral endotracheal intubation by rural basic emergency medical technicians. Ann Emerg Med, volume 32: pp. 26-32. Garner, A. Rashford, S. Lee, A. & Bartolacci R. (1999). Addition of physicians to paramedic helicopter services decreases blunt trauma mortality. Aust NZ J Surg, volume 69: pp. 697-701. Rahm, S. (2004). Paramedic Review Manual for National Certification. New South Wales: Jones & Bartlett. Rushworth, Y. (2008). Brain Injury Australia: Children, Young People and Acquired Brain Injury. Department of Families, Housing, Community Services and Indigenous Affairs. Retrieved 02 August 2011 from http://www.bia.net.au/docs/CHILDRENABIFaHCSIA300508.pdf Sydney Local Health District (n.d) Head Injury. Retrieved 02 August 2011 from http://www.sswahs.nsw.gov.au/liverpool/trauma/PDF/Head%20Injury%20-%20edit%201.pdf Wang, H., Peitzman, A., & Cassidy, L. (2004). Out-of-hospital endotracheal intuabtion and outcome after traumatic brain injury. Ann Emerg Med, volume 44: pp. 439-50. Assessment 2: Literature review Introduction This study shall consider the use of pre-hospital intubation by paramedics for severely traumatic head injury patients. Paramedics are the first responders to head trauma patients, and as such, they are in the perfect position of reducing further brain damage to the patients. Allowing and training these paramedics to intubate the patients with severe head traumas can help ensure that the patients would be adequately oxygenated during the precious minutes they would be transported to the hospital. This topic is important because it is a primary consideration which needs much attention from paramedics and health administrators. Methods This study considered the Cochrane, Medline, PubMed, BMJ, and EMA databases, where searches were carried out to locate sources of research evidence. These databases presented various evidence and researches which were considered for the topic being discussed in this paper. Relevant materials were then set aside for possible future review, depending on their relevance to the current subject matter. The authors of these studies were also evaluated based on expertise and specialties pertinent to the present subject matter. The library was first searched for relevant materials, and later an internet search was carried out using the search terms below. Search terms included the following words and/or a combination of these words: paramedic, head injury; paramedics + head injuries + intubation; ambulance services + head injuries + intubation; emergency services + head injuries + intubation; severe head injuries + intubation + paramedics. The use of the above search words were utilized to surface relevant materials for research and were also used as search words in index and table of content evaluation in hard copy journals and books. Search limitations which I applied to this search, included limitations for date searches, which were inclusive of 2001 to 2011 studies. Limitations for place published were also limited for Australia published articles only. Grey literature accessed included the Emergency Medicine Australia and the Journal of Trauma-Injury Infection and Critical Care. The British Medical Journal as well as the Google Scholar was also searched with the related search keywords in order to establish possible sources and materials which can be utilized for this research. Books and other journal articles discussing the paramedic use of intubation for head injury patients were reviewed as possible background reading for this paper. Review In a paper by Davis, et.al. (2005), the authors set out to evaluate the impact of prehospital intubation on the outcome in moderate to severe traumatic brain injury. This study covered patients with moderate to severe traumatic brain injury, exploring the impact of prehospital intubation on the patient outcomes, with assessments made on the patient’s Glasgow Coma Scale, Head/Neck AIS score, Injury Severity Score, and hypotension. The study revealed that the application of intubation on patients who had moderate traumatic brain injury made the outcomes worse for patients, sometimes causing an increase in mortality. However, for patients with severe traumatic brain injury, intubation proved to be more beneficial, reducing the hypoxia and brain damage of patients caused by the hypoxia. The study was able to reveal important details about the research topic. The authors are first and foremost, experts and specialists in their field of study. The study is also valid based on the clear and logical research processes applied by the authors. The statistical treatment was clear and appropriate and the analysis is adequate. The research requisites on validity and reliability was apparent in the research process with the authors specifying their methods of study and the interpretation made within the bounds of the research results (Cohen, et.al., 2007). All the references cited within the text are also reliable and the tables were laid out clearly with appropriate labeling and explanations (Zikmund and Babin, 2006). This study establishes a clear support for the use of intubation for those having severe traumatic brain injury, and that caution must be applied by the paramedics on the use of this method on those with moderate traumatic brain injury. In a paper by Bernard, (et.al., 2002) the authors sought to determine the impact of rapid sequence intubation among patients with severe head injury performed by paramedics on a helicopter emergency service. Patient records for patients with severe head injury undergoing rapid sequence intubation were evaluated. There were about 122 patients who were included in this study upon which rapid sequence intubation was carried out successfully. The study revealed that improvements in systolic blood pressure, oxygen saturation, and end-tidal carbon dioxide levels were higher after rapid sequence intubation, as compared to baseline levels. In effect, the authors revealed that rapid sequence intubation among patients with severe head injuries can be safely carried out by helicopter-based ambulance paramedics. This intervention helps improve oxygenation, ventilation, and blood pressure (Bernard, et.al., 2002). The above study presents a strong basis for intubation among severe brain injury patients by paramedics. The study presents a clear and relevant question which is supported by a thorough background on the subject matter. The statistical tools and methodology are appropriate tools chosen in order to establish clear answers for the question raised (Selvin, 2011). These tools are also adequately discussed by the author, providing adequate support for the discussion and the conclusions established. The ethical processes of research in terms of patient consent to the research were not seen in this paper as this is a retrospective study; nevertheless, the authors were able to establish compliance with the ethical standards required by retrospective studies (Hess, 2004). This makes the study a reliable research for this paper. In Gunning’s, et.al., (2008) study, the authors set out to establish the safety profile of emergency airway management when performed by a prehospital team which includes a doctor and a paramedic. This study was carried out as a prospective and descriptive study of three Australian helicopter emergency service bases, over the span of 9 months. Doctor-respondents were questioned in relation to endotracheal intubation attempts on patients transported, intubated, and then ventilated. The study revealed that about 114 patients were transported by the HEMS and were intubated and ventilated. There were 43 of 89 intubations carried out in the prehospital setting and no surgical airways were carried out. All in all, the study revealed that well-trained paramedics, using standard operating procedures can safely carry out rapid sequence intubation and ETI in the prehospital setting. But the authors mentioned that some prehospital doctors may not always be able to anticipate difficult airways and apply appropriate remedies. This study establishes an analysis on the expertise and skills of paramedics in the application of prehospital intubation. This study establishes a clear glimpse into doctor and paramedic expertise; it provides clear boundaries where the skills of the health professionals may be assessed. The authors utilized logical pathways in their research, using statistical tools to evaluate and analyze respondent answers (Raitzer and Norton, 2009). The conclusions and results drawn were based on the appropriate application of valid and reliable research processes. In effect, there are no logical fallacies seen and the researchers are experts in the field of study this research seeks to evaluate (Bessant and Watts, 2007). In a literature review by Bernard (2006), the author was able to establish how Australian ambulance services recommend that paramedics attempt to carry out endotracheal intubation among patients with severe head trauma. Some studies do not support the use of this approach because worse outcomes have been seen from its application, as compared to no intubation. Other countries however allow intubation assisted by sedative drugs; but low success rates have been seen in some patients who sometimes manifested with worse brain injuries. Among road-based paramedics, the use of intubation has not been highly recommended; however for chopper based paramedics, much promise and much benefit has been seen. In effect, the authors were able to establish how cumulative studies present a clearer picture of paramedic management of severe head injuries with the application of prehospital intubation. This study used credible and reliable researches and they were thoroughly reviewed based on inclusion and exclusion standards, as well as relevance to the subject matter (Hagino, 2002). The studies included were relevant and were carried out by reliable authors and published in supported publications. They helped establish a clear answer to the issue raised by the study. In a study by Garner, et.al., (2001), the authors sought to determine whether the presence prehospital critical care teams would help improve functional outcomes for severely injured head injury patients. The study covered 250 patients treated by paramedics and then transported to the hospital setting. The study revealed that the CCT treated patients, as well as those intubated in the prehospital setting had improved functional outcomes. In effect, this study established that advance treatment for severely injured head trauma patients gained better outcomes in terms of retention of functions and recovery. This study establishes a clear and comprehensive assessment of the prehospital care of critical care teams. The authors were able to apply confidential and ethical standards in their practice and they were able to ensure that the validity and reliability standards of researcher were secured during the research process. The authors correlated the entire process of research with the issue, as well as the goals of the study. Reference Bernard, S. (2006). Paramedic intubation of patients with severe head injury: a review of current Australian practice and recommendations for change. Emergency Medicine Australasia, volume 18(3), pp. 221–228. Bernard, S., Smith, K., Foster, S., Hogan, P., & Patrick, I. (2002). The use of rapid sequence intubation by ambulance paramedics for patients with severe head injury. Emergency Medicine, volume 14(4), pp. 406–411. Bessant, J. & Watts, R. (2007). Sociology Australia. New South Wales: Allen & Unwin. Cohen, L., Manion, L., & Morrison, K. (2007). Research methods in education. New South Wales: Routledge Davis, D., Peay, J., Sise, M. Vilke, G., Kennedy, F., Eastman, A., Velky, T., & Hoyt, D. (2005). The Impact of Prehospital Endotracheal Intubation on Outcome in Moderate to Severe Traumatic Brain Injury. Journal of Trauma-Injury Infection & Critical Care, volume 58(5), pp. 933-939 Garner, A., Crooks, J., Lee, A., & Bishop, R. (2001). Efficacy of prehospital critical care teams for severe blunt head injury in the Australian setting. Injury, Int. J. Care Injured, volume 32, pp. 455-460 Gunning, M., O’Loughlin, E., Fletcher, M., Crilly, J., Hooper, M. & Ellis, D. (2008). Emergency intubation: a prospective multicentre descriptive audit in an Australian helicopter emergency medical service. Emerg Med J., volume 26(1): pp. 65-9. Hagino, C. (2002). How to Appraise Research: A Guide for Chiropractic Students and Practitioners. Sydney: Elsevier Healey, J. (2011). Statistics: A Tool for Social Research. Sydney: Cengage Learning. Hess, D. (2004). Retrospective Studies and Chart Reviews. Respiratory Care, volume 49(10): pp. 1171–1174 Raitzer, D. & Norton, G. (2009). Prioritizing agricultural research for development: experiences and lessons. New South Wales: CABI Zikmund, W. & Babin, B. (2006). Exploring marketing research. Sydney: Cengage Learning. Assessment item 3 Conclusion The protocol on head injuries can be improved. Although its specific provisions already provide adequate standards for the practice, there is room for improvement which can help ensure that those who need immediate care would receive timely interventions; and that further damage is prevented on their person. The above studies cite various details on serious and traumatic injuries and how paramedics can actually provide emergency care, more specifically intubation, in order to prevent further head trauma and hypoxia. The very point of emergency care is to provide emergency relief and medical care and to improve patient outcomes. If paramedics do not have rudimentary knowledge of potentially life-saving procedures, their role in emergency health services can become counterproductive. The studies above point out that introducing prehospital intubation for serious head traumas can reduce hypoxia and prevent brain damage. The studies are not permissive in terms of applying prehospital intubation to the patients, it is actually restrictive in terms of limiting the use of prehospital intubation, making it available for those who actually need it, in this case – those who have serious brain trauma. It is therefore important for legislators and health authorities to consider the expansion of the protocol to include prehospital intubation for patients with serious head trauma. Recommendations Airway management is crucial in the out-of-hospital setting for severely injured patients, and as soon as a patent airway can be secured for these patients, the better their chances are in reducing negative patient outcomes (Nehme, n.d). It is therefore important to establish early and advanced prehospital airways for severe head trauma patients. The process for each intubation must be based on the patient situation and condition and the safety and efficacy of the process must be adequately assessed before it can be implemented (Hubble, et.al., 2010). Based on the studies cited in the literature review, prehospital intubation can be effective for patients with serious head injuries. This study therefore recommends first that the protocol be changed to include prehospital intubation procedures for patients with serious head injuries (Bushby, 2005). Legislators and health authorities therefore need to consult with each other in order to establish the legal and minimum standards for the inclusion of this additional policy in the protocol. These authorities need to consult with each other and establish the clear standards, especially on what basis such intubation can be carried out (Tintinalli, 2010). They also need to establish the procedure for the intubation and how it would be carried out by the paramedic in the prehospital setting (Bulger, et.al., 2002). The legislators need also to provide direction to the health authorities who would need to introduce changes in their system, most especially in relation to equipment and paramedic training, as well as standards in head trauma management. After the protocol has been changed and prehospital intubation for serious head traumas is included in the system, the implementation phase of the additional procedure cannot be immediately introduced into the system. There is a need for health authorities to carry out trainings for their paramedic personnel (Smith and Porter, 2010). This training would be carried out in coordination with physicians with knowledge and expertise in intubation for head trauma patients. The training has to be thorough and comprehensive in terms of theory and skill application. Such training would have to follow a standard process for all paramedics to follow. There is a need therefore to set up such training in coordination with various emergency services in various counties and regions (Walls and Murphy, 2008). Adequate training facilities have to be prepared for such training in order to implement coordinated and standard processes for prehospital intubation. Although this study concludes that prehospital intubation for serious head traumas can be properly carried out, this procedure has to be carried out by sufficient experts (Blacker, et.al., 2005). In effect, it is not a procedure which can be carried out by anyone and under any circumstances. Gunning (2008) mentions that the paramedics have to be adequately trained in prehospital intubation; they have to have sufficient knowledge and expertise in intubation in order to prevent further injuries and instead to ensure the survival of the patient beyond the prehospital setting. Bernard (2002, 2006) also mentions how prehospital intubation can be effective for the helicopter emergency services. Once again, there are specific circumstances upon which prehospital intubation can be carried out and the helicopter emergency services is one of them. Helicopter emergency services are more stable and quicker meant to transport patients (Cong, 2010). Allowing for the prehospital intubation to be carried out for these patients transported via helicopter services is a safe and sure way of improving patient survival. It is also safe to recommend for hospital emergency services being immediately available to serious head trauma patients. Initial responders can deduce the patient’s condition and immediately carry out prehospital intubation while already requesting for helicopter emergency services to be deployed (Timmerman, 2007). In this case, the communication and coordination process of the initial respondents and the helicopter emergency processes must always be open and linked. This would help ensure that helicopter emergency services are always available for head trauma patients. Emergency services also have to anticipate situations where serious head traumas are incurred by patients (Ciottone, 2006). In instances of mass casualty incidents, like road accidents, it is safe to assume that the patients may have serious brain traumas; therefore, helicopter emergency services have to be immediately dispatched to attend to their transport. This would make the process of prehospital intubation safer and more effective as an emergency remedy (Ciottone, 2006). It is also important for health authorities to equip the ambulances and the helicopter emergency services with tools for intubation, including laryngoscopes, tracheal tubes, stylets, and other necessary equipment. The training process for the paramedics would be for the span of four months, inclusive of actual simulations; it shall also include actual fielding in the ERs which would require the intubation of atleast ten patients (Warner, et.al., 2010). Airway management education will have to start during the first week of training. Initial training to the BLS and ALS management has to start early in order to ensure a significant procedural experience. The initial experience of the paramedics with intubation has to start with intensive manikin training which is supervised by paramedics teachers who shall highlight laryngoscopy skills which matches lectures on airway management and skills laboratories (Warner, et.al., 2010). The training process would have to translate to practice experience in the emergency hospital setting where students and health personnel are taught airway assessment, including bag-mask ventilation, direct laryngoscopy, and rescue techniques (Warner, et.al., 2010). After the paramedics complete a minimum of 10 successful intubations in the ERs, they are now allowed to carry out intubation in the field, under the supervision of the senior paramedics. The prehospital airway management training in the field has to extend for about eight months (Warner, et.al., 2010). Additional training in the pediatric airway management process also has to be carried out for these paramedics. These processes would help ensure adequate management for patients, regardless of age. Ongoing training is a clinical tool which can help secure competency in the clinical practice. With poor training, poor practice can result. Programs which allow for intubation training for paramedics can potentially assist in the professionalization of health care delivery in the earliest stages of care (Velde, 2009). During the training process for intubation, it is important to include actual patient intubations in the Emergency rooms and later in the actual paramedic setting. Allowing the trainees to carry out prehospital intubations after practicing on manikins is not a prudent practice because the manikin training cannot sufficiently arm the paramedics with adequate skills for actual clinical practice (Bernard, 2006). Most evidence indicates that inadequate training does not relate well with improved patient outcomes. Establishing opportunities for intubation training may involve various issues and difficulties, however other approaches to training can be given consideration. Such considerations can be based on intubation training via different designs of manikins. In the age of technological advancements, manikins which can meet with the standards of the practice are now available for training, and they simulate the actual setting for the trainee (Vincent, 2009). These manikins’ realistic nature can provide the opportunity for paramedics to train in the context of the prehospital setting. Future research on prehospital intubation can also be carried out, specifically on the actual application of the process in the field, including its success rate and rates in relation to improved patient outcomes. There is a need to carry out researches because there are gaps in the practice which need to be filled by research (Holleran, 2003). Before any procedure can be introduced into the clinical setting, proper research and clinical studies must be carried out. These researches can assess the issues encountered in the clinical setting, as well as the benefits seen from the application of such a practice (Holleran, 2003). Research ultimately helps in establishing protocols which are supported by evidence and which can be applied with anticipated benefits for the severely sick. Reference Bernard, S. (2006). Paramedic intubation of patients with severe head injury: a review of current Australian practice and recommendations for change. Emergency Medicine Australasia, volume 18(3), pp. 221–228. Bernard, S., Smith, K., Foster, S., Hogan, P., & Patrick, I. (2002). The use of rapid sequence intubation by ambulance paramedics for patients with severe head injury. Emergency Medicine, volume 14(4), pp. 406–411. Blacker, N., Pearson, L., & Walker, T. (2005). Redesigning paramedic models of care to meet rural and remote community needs. Rural health. Retrieved 09 August 2011 from http://10thnrhc.ruralhealth.org.au/papers/docs/Blacker_Natalie_D4.pdf Bulger, E., Copass, M., Maier, R., Larsen, J. Knowles, J., Jurkovich, G. (2002). An analysis of advanced prehospital airway management. J EmergMed., volume 23: pp. 183–9. Bushby, N., Fitzgerald, M., Cameron, P., Marasco, S., Bystrzycki, A. Rosenfeld, J., & Bailey, M. (2005). Prehospital intubation and chest decompression is associated with unexpected survival in major thoracic blunt trauma. Emergency Medicine Australasia, volume 17(5-6), pp. 443–449. Ciottone, G. (2006). Disaster medicine. Sydney: Elsevier Health Sciences Cong, M. (2010). Flying Doctor Service Flying doctor emergency airway registry: a 3-year, prospective, observational study of endotracheal intubation by the Queensland Section of the Royal Flying Doctor Service of Australia. Flying Doctor. Retrieved 09 August 2011 from http://www.flyingdoctor.org.au/IgnitionSuite/uploads/docs/LeCong%20Flying%20Doctor%20Emergency%20Airway%20Registry%20Qld%20EMJ%202010.pdf Gunning, M., O’Loughlin, E., Fletcher, M., Crilly, J., Hooper, M. & Ellis, D. (2008). Emergency intubation: a prospective multicentre descriptive audit in an Australian helicopter emergency medical service. Emerg Med J., volume 26(1): pp. 65-9. Holleran, R. (2003). Air and surface patient transport: principles and practice. Sydney: Mosby Hubble, M., Brown, L., Wilfong, D., Hertelendy, A., Benner, R., & Richards, M. (2010). A meta-analysis of prehospital airway control techniques Part I: orotracheal and nasotracheal intubation success rates. Prehospital Emergency Care, volume 14: pp. 377–401 Nehme, Z. (n.d). Paramedicine: more than just lights and sirens. SA Ambulance Service. Retrieved 09 August 2011 from http://www.i-studentadvisor.com/subjects/i-mhs/i-mhs-in-australia/paramedicine-more-than-just-lights-and-sirens?format=pdf Smith, J. & Porter, K. (2010). Oxford Desk Reference - Major Trauma. London: Oxford University Press Timmermann A, Russo SG, Rosenblatt W. (2007). Intubating laryngeal mask airway for difficult out-of-hospital airway management: a prospective evaluation. Br J Anaes, volume 99: p. 286 Tintinalli, J., Cameron, P., & Holliman, J. (2010). EMS: A Practical Global Guidebook. Switzerland: WHO Velde, C. (2009). International Perspectives on Competence in the Workplace: Implications for Research, Policy and Practice. Sydney: Springer Vincent, J. (2009). 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