• C.R.A.S.H.E.D – A model for structured reflection in prehospital care.

    by Jamie Todd. Last modified: 14/04/14



    Following on from our Introduction to Reflective Practice for Paramedics post, Jamie takes a look at the C.R.A.S.H.E.D model developed by a group of BSc Paramedic students in the UK in 2001.

    This article outlines the background to the development of a structured reflective model for use in Pre-Hospital Care practice. It was originally published in June 2001 (Holland, Todd, Kinsella: Ambulance UK) and was guided by the experiences of some of the first UK paramedics to enter a degree level education programme. With the majority of pre-hospital practitioners now being trained through this route it was felt that this work was even more relevant today than ever before.”

    The model is named CRASHED which is an acronym designed to guide the reflective process.

    • Communications
    • Response
    • Actions
    • Subsequent actions
    • Hospital
    • Evaluation & Ethics
    • Discussion


    Salmon stated in 1985 ‘the passing of years does not necessarily bring gifts of understanding within one’s own life. Twenty year experience, it has been said, may be no more than one year experience repeated twenty times’. If this statement can be considered truthful, surely there must be some way in which a bridge between understanding and experience can be made and it has become well accepted that reflection can be this bridge.

    The original work was guided from 1998-2002 by a group of paramedics who were the very first cohort of BSc (Hons) students at UWS Swansea. They were engaging in the process of reflective practice through the completion of a year’s worth of reflective practice through structured reflection on action using Benner’s (1984) and John’s (1995a) models. The students quickly noticed that the existing reflective models were aimed predominately at nursing and as such did not meet the needs of the modern pre-hospital care practitioner who wishes to use reflection to mould and guide their clinical practice.

    Reflection is well established in nursing and as such has become a core aspect in nurse education and development. Its use allows a way for the individual to become what has become termed a ‘Thinking Practitioner’ permitting them to identify strengths or shortcomings within their own practice and therefore allowing them work towards improving the standards of patient care they can offer. The emphasis throughout the literature is on the willingness, motivation and capability of the practitioner to learn through reflective practice. However many may find it difficult and even painful to disclose events when emotions have been aroused and participants may not wish to relive or resurrect buried experiences.

    Hulatt (1995) suggests that there are many good reasons why nurses may choose not to disclose experiences they would sooner leave buried and this has to be respected. The same could be said for pre-hospital care practitioners and this is an important consideration which has to be covered by agreed grounds rules in reflective practice. This includes the development of a supportive environment for reflection, notably in this environment this should include confidentiality and a non-judgemental attitude.

    Structured reflection has been used for a number of years to enhance the education and professional development in teaching, nursing and some allied health professions. Retrospective analysis of a situation, event and/or interaction where the practitioner is one step removed from the situation would appear to be a more comfortable and controlled way of gaining knowledge from past events. This is referred to generally as reflection on action. Also relevant is reflection in action where a practitioner recognises a new situation or problem and has to analyse and be inventive while still acting. (Boud, Keogh and Walker, 1995, Benner and Tanner, 1987, Ford and Walsh, 1994, Johns, 1995a)

    Anecdotal evidence would suggest that reflection is often used informally by pre-hospital practitioners, especially in ambulance services where cases that crews have encountered have been discussed on completion in the vehicle or over a cup of tea back at the ambulance station. However if we wish to use the full power of reflection to improve clinical practice then a structured model of reflection may need to be used. However as previously noted a structured model aimed specifically at the pre-hospital practitioner was not available and it was considered important to develop a model that was relevant, easy to use and grounded in pre-hospital care practice.

    A Model For Structured Reflection


    The CRASHED model of reflection that was developed provides a simple reflective framework. It incorporates an important element of the Johns (1995a) model of reflection in that it allows for analysis of reflection prior to action, reflection in action, reflection on action and reflection upon reflection. It can be used by an individual wishing to reflect singularly or as a tool for use by in clinical practice assessors or mentors, who for example may facilitate reflection with practitioners either as a ‘Hot debrief’ immediately following action or in more depth later on.

    The CRASHED model has been kept as simple as possible using plain language to ensure it is easy to use, because if the model was complex and cumbersome then reflection would become an onerous chore. Each phase of a clinical case is divided up and examined by answering a number of short questions and the amount of consideration given to each question will however vary from case to case. The reflective individual may find that they are only able to give single word answers to some questions or they may feel that the questions prompt further exploration to seek solutions related to their reflection.


    As can be seen the CRASHED model works in a logical sequence following the call through from its initial receipt to its end. It encompasses communication issues, driving skills, manual handling, patient treatment, the decision making process, hospital interaction, educational issues, ethical considerations, the consideration of peer review and the consideration of wider practice implications.

    It can be argued that the use of a formal model of reflective practice is not going to become universal in pre-hospital care practice, but it is hoped that due to the simplicity of the CRASHED model and its appropriateness that it will help bring changes to practice which can positively influence the overall development of this clinical field.

    The CRASHED model is an open resource and is free for individuals and organisations to use as they see fit. Should any user wish to provide feedback in order to further develop the model please contact me via jamie@prehospitalcareconsultancy.co.uk

    Thanks to the 1998 cohort UWS BSc (Hons) Pre-Hospital Care, you know who you are!

    References (non-PubMed)

    Benner P. (1984) From novice to expert: Excellence and power in clinical nursing practice. Addison-Wesley publishing company Inc: Menlo Park.

    Boud D. Keogh R. and Walker D. (eds) (1985) Reflection: Turning experience into learning. Kogan Page: London.

    Ford P. and Walsh M. (1994) New rituals for old: Nursing through the looking glass. Butterworth Heineman: Oxford.

    Kolb D. and Fry R. (1975) Towards an applied theory of experiential learning in Cooper (ed) Theories of group processes, John Wiley & Sons: London.

    Salmon P. (1985). Living in time, JM Dent & Sons Ltd.



    Benner P, Tanner C. Clinical judgment: how expert nurses use intuition. Am J Nurs. 1987 Jan;87(1):23-31. PMID: 3642979.


    Hulatt I. A sad reflection. Nurs Stand. 1995 Feb 8-14;9(20):22-3. PMID: 7703090.


    Johns C. Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. J Adv Nurs. 1995 Aug;22(2):226-34. PMID: 7593941.

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    Jamie Todd
    Jamie is a UK registered paramedic and Prehospital Care Consultant with extensive EMS experience with the ambulance service and in remote medicine and pre-hospital care education . He has a particular interest in Difficult Airway management in Pre-hospital care.

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    5 thoughts on “C.R.A.S.H.E.D – A model for structured reflection in prehospital care.

    • Steve holland says:

      Nice to see this work resurface. The E in crashed ales stands for Education, as in what did I learn or what else do I need to learn. Likewise if anyone wants to contact me regarding this I can be reached at Steve.holland.icare@gmail.com

      • Alan Batt Alan Batt says:

        Thanks for your feedback Steve, nice to get input from the original authors. Definitely a useful model for prehospital reflective practice! Well done to you and the others!

    • Caryll Overy says:

      Hi, I am wishing to Cite this model. How should it be referenced please (Authors, date and publisher)?
      Many thanks, Caryll

    • Alan Batt Alan Batt says:

      Hi Caryll,

      The citation is

      Holland S, Todd J, Kinsella F. (2001) C.R.A.S.H.E.D – A model for structured reflection in prehospital care. Ambulance UK

    • Stef says:

      Trying to find original article (Holland S, Todd J, Kinsella F. (2001) C.R.A.S.H.E.D – A model for structured reflection in prehospital care. Ambulance UK) and cannot seem to find it. Is there a link available

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