A comparative study on the frequency of simulation-based training and assessment of non-technical skills in the Norwegian ground ambulance services and helicopter emergency medical services

Setting

The Norwegian GEMS is considered the backbone of the Norwegian EMS [35]. The most common staffing in the Norwegian GEMS is either one paramedic and one emergency medical technician (EMT) or two EMTs [36], at least one of whom is an authorized EMT [3]. Norwegian EMTs (“Ambulansepersonell”) undergo two years of vocational high school, followed by two years of practical on-the-job training, working as an EMT apprentice, to become authorized. The primary responsibilities of the EMT are transportation, primary survey, initiating medical care and triage on-scene. A paramedic needs an EMT licence and a university college degree of 60 to 180 European Credit Transfer and Accumulation System (ECTS) points [36]. In addition to paramedics and EMTs, physicians and nurses with or without additional authorization as an EMT or other speciality training (e.g. anaesthesia) may supplement the Norwegian GEMS staffing. Professional GEMS groups, employed by the Norwegian health trusts, of interest in the present study are paramedics, EMTs, EMT apprentices, nurses with authorizations as an EMT (referred to as EMT nurses within this paper) and nurses without an EMT certificate (referred to as nurses).

In Norway, the physician-manned HEMS supports the GEMS in emergency missions for patient care and retrieval, in addition to inter-hospital transportation of patients [34], especially when the time dimension is critical. A HEMS crew consists of three members, each of whom belongs to a different profession. The helicopter pilot acts as mission leader, primarily focusing on navigation and flight safety. The HEMS crewmember (HCM) performs rescue operations and has a supporting role in respect of the pilot and physician in different phases of the mission. The physician, who is a certified or in-training anaesthesiologist, is responsible for patient care and medical treatment, both on-scene and during transportation. The Norwegian commercial flight operator employs the pilots and HCMs, whereas the physicians are employed by the local health trusts.

Questionnaire

The basis of this study was a Norwegian Hospital Survey on Patient Safety Culture (HSOPSC) conducted in 2016, which included data regarding the self-reported frequency of training in and assessment of NTSs during 2015 among EMS professions. The primary focus of the present paper originates from two question categories addressing the extent of simulation-based training in, and assessment of, seven generic NTSs during 2015. The questions were: “How many times during 2015 did you participate in multi-professional prehospital simulation-based training in the following skill?” and “How many times during 2015 were the following of your prehospital skills systematically observed and evaluated?”. In this text, the formative debriefing of systematic observation and evaluation of NTSs is referred to as the assessment of NTSs. The skills referred to are the following NTSs: decision-making, leadership, communication, situation awareness, teamwork, managing stress, and coping with fatigue. Each question item was answered across a four-point Likert scale (0, 1–2, 3–5, > 5).

Data collection

Data were collected between October and December 2016. The survey was distributed by e-mail, with a link to a web-based questionnaire (SurveyXact), to all prehospital personnel in the Norwegian HEMS and GEMS. Non-responders received up to five reminders before they were excluded from the study. Employees in the Norwegian Search and Rescue (SAR) services and medical airplanes were not invited, thus leading to an exclusion if such occupations were found among the respondents. Questionnaires returned with unknown profession or occupation were also excluded by listwise removal.

Statistical analysis

To assess possible differences we dichotomized the question items into “some training/assessment” and “no training/assessment”. Similarities, or dissimilarities, between professions or EMSs of interest are visually presented in bar charts as proportions of individuals (in %) within the respective group.

To support the visual comparison of professional groups, the dichotomized items were used in several two-sided Fisher’s exact tests. Results are presented as numbers (ratios) and p-values, where a p-value less than 0.05 is considered as statistically significant throughout the paper.

Calculated odds ratios (ORs) present the differences within all six professions working in the health trust, with physicians as the reference group. The results are presented as ORs with associated p-values. We used the dichotomized items as dependent variables in a series of logistic regressions, with the professional groups as explanatory variables, to obtain the p-values.

We used the freeware R 3.4.2 for calculations and visualizations of all the results presented in the present paper.

Ethics, consent and participants

This study was conducted on the approval obtained from the Norwegian Social Science Data Services (NSD; project number 45723). The Regional Committee for Medical and Health Research West-Norway (REK West) evaluated this project as “not mandatory to submit” (Ref. number 2015/2249). All the participants received information about the purpose of the study, and written consent to participate was given at the start of the study, stating that no participants could be identified in published material. The digital questionnaires were treated in confidence.

Comparison of HEMS and GEMS

The physical environment and task-related differences between HEMS and GEMS may demand different levels of training in NTSs. However, the fact that both prehospital services perform safety-critical operations with a low tolerance of error implies a need for training [11]. One appealing reason for the observed variation in training is the safety culture. NTSs and CRM have been essential features in preventing errors in the aviation industry for a long time [11]. The acknowledgement of human limitations has promoted the need to invest resources in training in NTSs [39]. There is a lack of such strong traditions in GEMS [6], when compared with HEMS, and this may be an explanation of the observed results. Some of the aviation-related tasks performed in HEMS are claimed to be more procedure-based, thus simplifying the simulations and assessments [34]. Training on the base may also be easier to conduct for HEMS than for GEMS, due to the dynamics of the working environment [34].

Comparison of the health trust and flight operator

Compared with flight operator employees, i.e. pilots and HCMs, our data indicate that personnel in the health trust undergo training and assessment significantly less frequently. A possible explanation is the difference in safety culture, as already mentioned. However, a strong safety culture is not a persistent quality that a group achieves automatically. It is a result of focus, resources and commitment over time. In the Norwegian HEMS, significant amounts of resources have been allocated in recent years to enhance training and NTSs [46]. Daily clinical duties in the health trust appear to be less suitable for simulation-based training [34], as it will be too time-consuming and costly, hampering the amount of CRM interventions. However, in situ simulation-based training during on-call hours in the Norwegian HEMS has proven to be feasible [47]. Future research may address the possibility for the health trust to learn from HEMS and adopt similar interventions in their daily duties.

Comparison of health trust employees

Among the health trust employees, physicians appear to undergo the greatest amount of training in and assessment of NTSs. The intuitive explanation is the close relationship these physicians have to the aviation safety culture through their experience from HEMS. Although the anaesthesiologists are not obligated to participate in the training conducted in HEMS, which is mandatory for the pilots and HCMs, it is strongly recommended. Opportunities to participate in training and being a member of a culture with a focus on NTSs may have induced an awareness of training and assessment among the physicians.

Equal backgrounds and similarities in responsibility may hamper the development and learning within the team. Diversity in a team can raise awareness of differences and has a positive effect on learning [51, 52]. For GEMS, it can be beneficial to establish a closer relationship with HEMS, with respect to training, in order to promote awareness of their own capabilities and NTSs.

There is an ongoing debate in the Norwegian prehospital domain regarding EMT apprentices conducting on-the-job practice (following the first draft of the Norwegian prehospital emergency medicine regulation [3]), as they are still pursuing their licence. If NTSs are considered to be one of the vaguely stated “required qualities” in the Norwegian prehospital emergency medicine regulation for EMS personnel [3], we may question whether EMT apprentices are eligible to participate in emergency missions. The frequency of training in and assessment of NTSs for EMT apprentices indicates a substantial lack of focus on NTSs and CRM interventions in their education. Our data imply a potential for improvement of simulation-based training in and assessment of NTSs among the EMT apprentices, which the educational programmes in Norway need to be aware of.

An opportunity for GEMS

There has been an increasing focus on the importance of NTSs and simulations to ensure safety within the Norwegian HEMS over recent years. Specific initiatives have been launched to increase the frequency of training in and assessment of NTSs. In 2011, the Norwegian air ambulance foundation established Camp Torpomoen [53], which is an intensive training programme, in which pilots, HCMs and anaesthesiologists practise together on rare and challenging tasks in safe environments. Another NTS-related initiative in HEMS is the Fatigue Risk Management Programme, initiated in 2013, with the purpose of documenting the physical impact of the working environment and sleep deprivation.

Interestingly, our data imply that the frequency of simulation-based training and assessment observed in HEMS during 2011 [34] is statistically insignificantly different from the frequency observed in GEMS during 2015 (Fig. 4 and Table 4), except for the cases of communication and coping with fatigue. The tendency is that GEMS underwent both training and assessment more frequently during 2015 than HEMS did in 2011. Before the great NTSs-offensive in the Norwegian HEMS, the data indicate that there was no particular association between working in either HEMS or GEMS and the frequency of simulation-based training in and assessment of NTSs. Based on this study, there are now reasons to think otherwise. The potential for learning across the EMSs appears to be present, and it may be a great opportunity for GEMS to gain experience from HEMS. However, the practice applied in HEMS should be adjusted to better fit the GEMS environment, as simulations need to be specifically designed to incorporate significant differences across the two domains [6, 20].

Limitations and strengths of the study

The response rate among HEMS employees was substantially lower than for the previous study in 2011. This calls into question the representativeness of the 2015 HEMS population. Only one fourth of the GEMS population was included in this study. It is ambitious not to consider non-respondents bias having an impact on the results. However, the observed trends are consistent and unambiguous.

The number of respondents who answered “Other” about their profession, due to having achieved/executing more than one, was significant (n = 63). Respondents with “Other” as a profession were categorized manually based on specifications in a free text answer. We had also omitted “EMT apprentice” in the predefined professions in the questionnaire. 24 respondents wrote “EMT apprentice” (“Ambulanselærling”) in a free text field, which we manually categorized as a unique group.

Comparing professions in HEMS and GEMS involves a challenge in sample sizes. It is reasonable to believe that the smaller sub-populations, e.g. pilots, have affected the significance of some results. On the other hand, non-parametric statistical tests, such as the Fisher’s exact test and odds ratio, are resilient to different sample size, strengthening our results.

Dichotomizing the question items into no training/assessment and some training/assessment, reduced the possibility of over- or underreporting, due to respondents not remembering how many times they actually underwent training or assessment.

The questionnaire was tested on a group of seven prehospital healthcare workers to ensure correct terminology. We assumed that all the respondents understood the questions, as no additional explanations and definitions were provided. HEMS employees are more familiar with CRM training and may have better understood what the questions were referring to. The possibility that respondents did not report truthfully is also present.

A weakness of the study, which was not the intention, is the possibility of making strong conclusions regarding the quality of NTSs among the EMSs in Norway. Ultimately, it is the quality, and not the frequency of training and assessment, of the NTSs that the individuals possess which is important.