Healthcare organisations have started to examine the impact that the human worker has on patient safety. Adopting the Crew Resource Management (CRM) approach, used in aviation, the CRM or non-technical skills of anaesthetists, surgeons, scrub practitioners and emergency physicians have recently been identified to assist in their training and assessment. Paramedics are exposed to dynamic and dangerous situations where patients have to be managed, often with life-threatening injuries or illness. As in other safety-critical domains, the technical skills of paramedics are complemented by effective non-technical skills. The aim of this paper was to review the literature on the non-technical (social and cognitive) skills used by paramedics. This review was undertaken as part of a task analysis to identify the non-technical skills used by paramedics. Of the seven papers reviewed, the results have shown very little research on this topic and so reveal a gap in the understanding of paramedic non-technical skills.
- Crew resource management
- patient safety
- paramedic non-technical skills
- error avoidance
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The British Paramedic Association states that ‘Paramedics are independent practitioners that manage individuals and groups of people whose ages range from the preterm infant to the older adult. Managed care may involve the assessment, treatment and management of relatively minor nature through to a complex major injury affecting either one, or occurring in many patients such as those resulting from a major incident. Given the complex nature of out-of-hospital unscheduled care and the diversity of healthcare situations encountered, paramedics must be well educated, skilled and knowledgeable practitioners in a range of subjects and be able to appraise and adopt an enquiry-based approach to the delivery of care’.1
In addition to the technical knowledge and skills described above, which are specified in the Health Professions Council standards of proficiency for paramedics,2 there may be an additional requirement for a set of non-technical skills. Flin et al 3 define non-technical skills as, ‘the cognitive and social skills that complement a worker's technical skills’ (p1) and suggest that these skills ‘are not new or mysterious but are what the best practitioners do in order to achieve consistently high performance and what the rest of us do on a good day’. (p1). This paper presents a literature review of the available evidence on non-technical skills used by paramedics but first considers the background to this safety management approach from other industries.
It has been proposed by Weick,4 that organisations which can be labelled ‘high reliability organisations’ operate in high stakes environments, with relatively low accident rates. These environments include; aviation, nuclear power and the oil industry and the safety record of most organisations in these fields is attributed to an understanding of, among other things, the non-technical skills of their workforce.5
By examining one of these industries in more detail, namely aviation, lessons can be learnt for the higher risk domains of medicine6 (including emergency medicine in the prehospital setting). Aviation has a history of understanding non-technical skills which spans more than 40 years; this is in response to approximately 70%–80% of aviation incidents and accidents being attributed to human error linked to deficiencies in these skills.7 One error management measure used in aviation is an approach called Crew Resource Management (CRM) which can be traced back to its inception by the National Aeronautics and Space Administration in 1979.8
Crew resource management
CRM focuses on the training and assessment of non-technical, (ie, cognitive, social and personal resource) skills. A typical generic set of seven CRM or non-technical skills, listed by Flin et al 3 is: Situation awareness; Decision making; Communication; Teamwork; Leadership; Managing stress; Coping with fatigue.
CRM training is mandated by many aviation regulators, such as the UK Civil Aviation Authority (CAA), for commercial pilots and the CAA places responsibility for CRM training of flight crew with the airline operator. Recurrent training is required for flight crew once every three years where the major CRM topics are covered.9 The CRM course syllabus is designed in such a way so as to allow each member of a flight crew to function as part of an intact team, not simply as a collection of technically competent individuals.7 This team-working aspect of CRM is of great importance because in the larger airlines flight crews often come together, having never worked or met before.
According to the UK CAA, there are four instances when pilots would receive assessment of their non-technical skills; Licence Skill Test, Licence Proficiency Check, Operators Proficiency Check and Line Check. The non-technical skills of individual crew members can be evaluated from ratings of observed behaviour while flying (or in the simulator), using a behavioural marker system which provides a taxonomy of good and poor behaviours for each skill element which in turn indicate the standard of the individual's non-technical skills.10 Assessment of an individual's non-technical skills is made against a required standard with remedial training given to a crew member who falls below this standard. After approximately 20 years of CRM being delivered to aviators, what is known is that CRM training is received positively by aircrews and has been effective in improving knowledge and attitudes. Positive behaviours, associated with safe flight operations have also been observed both in simulations and real time.11 ,12
Adverse events in healthcare
In 2000, it was estimated in a report by the Department of Health in England that approximately 10% of patients who are admitted to NHS hospitals are harmed because of an adverse event; 50% of these are deemed to be preventable. This 10% represents in excess of 850 000 patients per annum and costs around £2 million a year in hospital stays alone,13 not to mention the devastating effect these adverse events have on the patients themselves, their families and the clinicians involved.14
As was the case in aviation, healthcare organisations have started to examine the impact that the human worker has on safety and high reliability, given recent concern with these rates of adverse events. Adopting the CRM approach described above, research has been conducted into the non-technical skills of individual members of operating theatre staff teams resulting in the development of skills taxonomies and behaviour rating tools such as Anaesthetists' Non-Technical Skills,15 Non-Technical Skills for Surgeons16 and Scrub Practitioners' List of Intraoperative Non-Technical Skills.17 In emergency medicine, non-technical skill sets have recently been identified for emergency physicians18 and for doctors and nurses engaged in resuscitation.19 For some specialties, these skills are being formally incorporated into new curricula, for example, in 2010 the Royal College of Anaesthetists published the updated curriculum of core competencies leading to a certificate of completion of training in anaesthetics which refers to non-technical skills.20 There are also similar tools available to rate non-technical skills at the team or subteam level, such as the Observational Teamwork Assessment for Surgery21 and the Observational Skill-based Clinical Assessment tool for Resuscitation.22
The role of a paramedic
Paramedics are undoubtedly exposed to dynamic and dangerous situations where patients have to be managed, often with life-threatening injuries or illness. It is not uncommon for the paramedic on scene at a road traffic collision to lead a multidisciplinary team consisting of fire-fighters, police officers and other rescue providers in the patient care aspect of an incident. Prehospital patients are treated by the current technical skill set of the paramedic who attends them. As in other safety-critical occupations, these technical skills are complemented by effective non-technical skills which are acquired through years of experience and exposure to critical situations and patients. No training exists in the UK at present on non-technical skills for paramedics in the prehospital environment.23 Furthermore, there is no taxonomy or skill set of the paramedic's non-technical skills which could be used for the development of a training syllabus and evaluation tools. With the longer term objective of developing a taxonomy of non-technical skills for paramedics,10 this literature review was undertaken as part of the process of task analysis to identify the non-technical (cognitive and social) skills used by an individual paramedic who will normally be working as part of a team. The composition of this team is likely to change regularly and so, as in aviation, the focus is on the non-technical skills of the individual paramedic, rather than at the team level.
This review was conducted using a search strategy informed by the Cochrane method24 and also followed the design used for similar reviews of anaesthetists'25 surgeons'26 and scrub practitioners'17 non-technical skills. As in previous studies, the search was restricted to key behavioural categories rather than attempting to encompass all the human and organisational factors that might influence the performance of paramedics. These earlier medical studies informed the non-technical skills categories to be searched for paramedics. The skill categories searched and a definition of each were:
Situation Awareness—The skill of gathering information relating to the immediate environment, interpreting this information and predicting/anticipating future states.
Decision Making—The skill of reaching a judgement or choosing a course of action based on the needs of the current situation.
Communication—The skill of exchanging information between different parties.
Team working—The skill of working in a group with cohesion towards a common goal.
Leadership—The skill of motivating, directing and setting the standards of a group or team.
Online and journal sources were searched using the following search terms: paramedic/prehospital/non-technical/skills/crew resource management skills/situation awareness/decision making/leadership/teamwork/communication/skills/paramedic. There were no date restrictions applied and the search was conducted in November 2011.
Only papers published in English which provided empirical data related to paramedic non-technical skills were included in this review. The categories of Managing Stress and Coping with Fatigue were excluded as these skill categories are difficult to observe and will influence other behaviours that were already included.3 Table 1 outlines the screening process used to evaluate the suitability of the literature.
Only seven papers were identified that met the specified criteria and the skills examined in each are shown in table 2 which also indicates the method applied.
Only three studies related to all five aspects of paramedic non-technical skills; two others exclusively examined situation awareness and another two related solely to paramedic decision making and communication skills respectively. The reviewed papers are discussed below.
Flin et al 3 indicate that the most common definition of situation awareness is that of Endsley33 who states that situation awareness is, ‘the perception of the elements in the environment within a volume of space and time, the comprehension of their meaning and the projection of their status in the near future’ (p36). With this in mind it is easy to understand why a paramedic with a critically-ill or life-threatening patient should have effective situation-awareness skills and five of the studies examined this cognitive skill. In an observation study carried out by Hamid et al,29 emergency care practitioners working in the East Midlands Ambulance Service were observed during operational shifts responding to 999 calls. They found that an emergency care practitioner's situational awareness would be enhanced by having access to each patient's electronic patient record. The East Midlands Ambulance Service at the time of the observation was considering the introduction of access to electronic patient records.
The second paper was a pilot study conducted by Batchelder et al 27 that examined the effects of simulation training on CRM skills (ie, non-technical skills) during doctor-paramedic team, prehospital rapid sequence induction. The teams were exposed to high fidelity simulations of various prehospital emergencies that required advanced airway management techniques. Participants were assessed on day 4 of the course and day 9/10 of the course. Assessments on day 9/10 showed a reduction in safety critical errors associated with the induction of the casualty. CRM behaviours increased from 5.0 on day 4 to 5.6 on day 9/10. Interestingly, the time on-scene to Endotracheal Tube (ET) cuff inflation also increased by 3 min 24 s which was possibly associated with the improved safety of the teams. There was no behavioural rating system used for the rating of CRM skills during this study and the ratings that were made by the assessors were subjectively made.
Campeau28 introduces us to the ‘space-control theory of paramedic scene management’ which centres on a paramedic securing control over the immediate workspace (wherever this may be) in order to create an environment that supports the delivery of emergency patient care. A sample of 24 paramedics of varying experience, ranging from novice to expert was interviewed from urban, suburban and rural areas of practice. The interviews were subjected to three rounds of analysis to elicit scene management techniques, which the author describes as ‘a dynamic social activity comprised of social processes’ (p214). Campeau further illustrates the theory by means of a diagram; which on examination suggests that a paramedic is required to have situation awareness in the dynamic situations encountered to enable effective scene management.
The Delphi study by Kilner30 provides examples of situation awareness for paramedics. This was conducted with a cohort of experts, namely chief executives and clinical directors of UK ambulance trusts, along with examiners for the Diploma in immediate medical care, Royal College of Surgeons, Edinburgh. The experts were asked to list the attributes they felt important for ambulance technicians, paramedics and ambulance clinical supervisors. Listed by the panel for each of the skill sets were ‘intellectual skills to enable the interpretation of clinical data’, suggesting that the panel valued the ability of situation awareness on the part of clinicians.
During the course of an emergency call, paramedics are required to take numerous decisions on how best to deal with the situation in front of them. These decisions include how to treat the patient's presenting condition, whether to provide treatment on scene (stay and play) or to provide it on route to hospital (scoop and run). Of the seven papers reviewed, the clinical decision making of paramedics featured in four of them. In one paper, Jensen34 investigated how Canadian paramedics carry out clinical decision making during a think aloud study. They were asked to voice their thinking while dealing with two simulated incidents. He found that, depending on the incident, paramedics ‘straddle the line between the intuitive reasoning strategies of nurses and the analytical processes physicians tend to use’. (p73) He merely comments on the theoretical decision making strategies used by paramedics and does not discuss decision making from a behavioural rating point of view.
According to Street,35 in Foundations for Paramedic Practice, communication is placed at the forefront of the paramedic skill set. He describes the importance of effective communication that is sensitive to the situation; its main view point for discussion is communication between paramedic and patient. There is however a short comparison made between communication differences between clinician to clinician and clinician to patient. The focus of non-technical skills communication in this review is communication between two or more clinicians, specifically paramedics and four papers considered this. Scott et al 31 analysed paramedic verbal reports to physicians in the trauma department in a hospital in North Carolina. They examined physician recall of paramedic handovers before and after communication training for the paramedics involved. There was no improvement on physician recall of the paramedic handovers. The authors suggest that this could have been due to poor listening skills on the part of the physicians, as well as poor communication skills on the part of the paramedics. In the same paper, they cite an Australian study which observed paramedic handovers over a period of 7 days. The conclusion drawn from this observation study was that handovers fell into two distinct categories—detailed handovers and minimal handovers. The detailed handovers resulted in decreased nursing time and an enhanced patient care process, while the minimal handovers led to poor patient care. The implication of these studies towards patient care among paramedics shows that there is scope for improvement of paramedic communication skills. While the study by Scott et al 31 focused on communication between paramedic and a receiving clinician in hospital, parallels can be drawn in the prehospital setting. Paramedics who operate rapid response type vehicles are often required to hand over a patient to another paramedic for continuation of patient care and transport to hospital. Patient handovers are a distinct aspect of clinical practice that is and has received specific research and focus. It is not within the remit of this study to examine patient handover in great detail.
St Pierre et al 5 define a team in healthcare as a ‘distinguishable set of two or more people……who interact dynamically and adaptively towards a common and valued goal, objective or mission’ (p135). Prehospital clinicians, including paramedics, are accustomed to working in teams of two or more and are used to working with people who they meet infrequently. Communication between staff was considered in four of the papers. From the Delphi study conducted by Kilner,30 being a team player was cited as an important attribute for paramedics and ambulance clinical supervisors. The Health Professions Council2 in their standards of proficiency for paramedics state that a paramedic must be able to, ‘understand the need to build and sustain professional relationships as both an independent practitioner and collaboratively as a member of a team’. (p6)
Leadership skills feature in three of the seven reviewed papers. In Kilner's30 Delphi study, the expert panel valued qualities such as, role model to others, non-discriminatory or judgemental, leadership, mentoring, supervision and personnel management in both a paramedic and ambulance clinical supervisor. The assessment tool featured in the study by Batchelder et al 27 required a specific rating on the leadership skills of the doctor-paramedic team. Leadership ratings using this tool are subjective in the sense that no guidance is given to the assessor on what constitutes poor or excellent leadership skills or behaviours resulting in a zero or seven score respectively. The checklist for the rating of non-technical skills by Wyl et al 32 splits non-technical skills into six dimensions. Leadership skills weigh heavily in three of the six dimensions and assist the assessor in the use of the checklist by giving the definitions of leadership attitude, task delegation and team leader's communication. Each of the definitions is rated using a 5-point Likert scale. Consequently it appears that leadership is likely to be a key non-technical skill for paramedics.
It is apparent from the very few empirical studies identified, that the study of paramedic non-technical skills is an area that has had little attention in the past. What has been observed from the reviewed papers is that there is scope for the wider understanding of paramedic non-technical skills. This is drawn from the fact that the papers reviewed have featured to some extent non-technical skills although they have on the whole been subjective measurements or opinion surveys. What has not been found is a systematic attempt to identify this important skill set. Examination of clinical complaints, clinical error investigations and fatal accident enquiries involving paramedics could also be used to elicit non-technical skills through documented failures, with a view to highlighting any common non-technical skills gaps in current paramedic practice.
While it might be possible to redesign an existing tool such as those mentioned above for use by paramedics, this is not recommended practice.3 The risk is that a rating tool designed for a specific discipline or team contains behaviours specific to that group of practitioners. While some of the non-technical skill behaviours will be similar at the category level across disciplines, discipline-specific skills at the element and behavioural marker level also need to be identified.
It can be concluded that there would be value in conducting research for the purpose of identifying relevant paramedic non-technical skills with a view to developing a behavioural taxonomy and rating system similar to those now used by anaesthetists, emergency physicians and other clinicians. This behavioural taxonomy could be used as a foundation to train paramedics in a similar way to pilots' CRM training with a view to establishing competency ratings, which in the future could be linked to paramedic re/registration. This would not only benefit the paramedic profession but more importantly the safety of patients in the high risk, prehospital stage of their treatment.
The authors would like to acknowledge the assistance of Dr Lucy Mitchell in the preparation of this review.
Competing interests None.
Ethics approval This study has been approved by Aberdeen University, School of Psychology ethics Committee as having no ethical concerns. In addition to this the research protocol was produced to the East of Scotland Research Ethics Service who judged that this study does not require ethical review under the terms of the Governance Arrangements for Research Ethics Committees (GAfREC) in the UK. A copy of this letter can be produced along with School of Psychology Review.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement At this moment in time no other data is available, however this submission will form the basis of a thesis submission as part of a Master of Science.
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