Registered nurse (RN) insufficiency is both a major contributor to and effect of emergency department overcrowding (EDOC) in the United States and is implicated in increased patient mortality, ED wait times, and general congestion of the healthcare system. Licensed paramedics represent a viable solution to this crisis given their extensive training in emergency care by serving as RN adjuncts and alternatives in the ED setting. Paramedics utilize high-level clinical judgment and patient assessment skills to form detailed clinical impressions and employ a wide range of therapies to initiate treatment. Although they less frequently possess a college degree than their RN counterparts, paramedics complete a comparable study of medical science principles, patient assessment, and pathophysiology, and devote significantly more time to critical care and emergency medicine than RNs. Implementation of paramedics in U.S. EDs in the 1980s and 1990s highlighted their manual and technical skill prowess as well as their ability to rapidly assess emergency situations, including their unexpectedly widespread use in pediatric EDs. Modern implementation includes expansion of the psychomotor skills available to ED-based paramedics, with emphasis on medication administration and emergency procedures, but there is a significant lack of research into paramedic assessment and triage skills in the ED. Barriers to further implementation of ED paramedics include resistance from nursing advocacy organizations, regulatory and legal challenges, and public opinion and attitudes of nurses and paramedics. Nursing advocacy groups have historically opposed paramedic integration, fearing job encroachment and increased autonomy for non-nursing healthcare professionals. Regulatory challenges involve certification vs licensure discrepancies, limitations on paramedic scope of practice, and the wide-reaching effects of state Nurse Practice Acts. Societal resistance, cultural factors, and attitudes within the nursing and paramedic communities also impede further ED paramedic implementation. Practice recommendations are proposed, including the development of standardized ED orientation programs for paramedics, and redefining the minimum education for paramedics at the associate degree level. Legislative recommendations involve eliminating statutory restrictions on paramedic practice, reevaluating language in state Nurse Practice Acts, and clarifying the legal relationship between RNs and ED paramedics. The limitations of this literature-based thesis include a lack of large-scale studies, regional variability, and the absence of empirical examination of paramedic integration in reducing ED overcrowding. Future suggestions for study include randomized controlled trials comparing ED patient outcomes between RNs and paramedics, interrater reliability studies on assessment and triage skills, and comparisons of scope of practice and education between paramedics in different countries.

The pre-hospital industry is faced with many challenges, one of which is the skills shortage of advanced life support paramedics in the country. The industry has naturally dictated competition both nationally and internationally for the recruitment of these advanced life support paramedics. Staff turnover has increased as a result of this issue which also has financial implications on the individual business of constant recruitment and turnover. The purpose of this study is to investigate problems that currently exist in the industry with regards to the advanced life support paramedic employment which will provide valuable information on retention strategies and reduce staff turnover.

Bakgrund: Ambulanspersonal är en yrkesgrupp som i sitt yrkesutövanden riskerar att utsättas för traumatiska händelser som kan vara mycket påfrestande och stressfulla. Trots erfarenhet och träning blir vissa trauman stundtals övermäktiga och kan ge reaktioner som posttraumatiskt stressyndrom. Risken att utveckla PTSD ökar med antalet upplevda trauman och prevalensen i yrkesgruppen är hög. Syfte: Syftet var att beskriva vilka traumatiska händelser ambulanspersonalen upplevde som mest stressfulla. Syftet var även att beskriva ambulanspersonalens upplevelser och hantering av posttraumatiskt stressyndrom i relation till traumatiska händelser i sitt yrkesutövande. Syftet var dessutom att granska artiklarnas kvalitet utifrån den metodologiska aspekten undersökningsgrupp. Metod: Beskrivande litteraturstudie innefattande elva vetenskapliga artiklar av både kvalitativ och kvantitativ ansats sökta i medicinsk och omvårdnadsorienterade databas. Huvudresultat: Traumatiska händelser som upplevdes mest stressfulla innefattade händelser som involverade akut sjuka och allvarligt skadade barn, vilka väckte en emotionell respons och där ambulanspersonalen identifierade sig med nödställda. Upplevelser av PTSD kännetecknades av överspändhet, sämre prestation, mental avstängning och återupplevande av minnesbilder. Hantering av PTSD utmärktes av copingstrategier som känslomässig distans, fokusering, stöd, återhämtning, kontroll och förberedelse. Slutsats: Ambulanspersonal upplever i sitt yrkesutövande traumatiska händelser som kan vara mycket stressfulla och som kan leda till posttraumatiskt stressyndrom. Upplevelserna kan ge psykiska och fysiska symtom som påverkar hälsa och funktionsförmåga. Ambulanspersonalen behöver utbildning i copingstrategier för att hantera kritiska incidenter på ett gynnsamt sätt, speciellt händelser som involverar barn. Strategier behövs för att stärka känslan av kontroll och förmågan till fokusering, där förberedelse, socialt stöd och återhämtningstid är betydelsefullt.

The pre-hospital industry is faced with many challenges, one of which is the skills shortage of advanced life support paramedics in the country. The industry has naturally dictated competition both nationally and internationally for the recruitment of these advanced life support paramedics. Staff turnover has increased as a result of this issue which also has financial implications on the individual business of constant recruitment and turnover. The purpose of this study is to investigate problems that currently exist in the industry with regards to the advanced life support paramedic employment which will provide valuable information on retention strategies and reduce staff turnover.

Thesis (Master of Emergency Medical Care)--Cape Peninsula University of Technology, 2018. / For emergency medical care (EMC), clinical mentorship can be thought of as the relationship between the EMC students and qualified emergency care personnel. Through this relationship, students may be guided, supported and provided with information to develop knowledge, skills, and professional attributes needed for delivering quality clinical emergency care. However, this relationship is poorly understood and the focus of this research was to explore how this relationship enabled or constrained learning. Through having experienced mentorship, first as a student in EMC, then as an operational paramedic, mentoring students, I was privy to an insider perspective of clinical mentorship, and the experiences of fellow students‘. Through this experience the practices I observed may not have promoted learning. This is when my interest in pre-hospital clinical mentorship in relation to learning began. The aim of this research was to present a qualitative analysis of the clinical mentorship relationship in pre-hospital EMC involving the qualified pre-hospital emergency care practitioner (ECP) and the EMC student. The objectives included gaining an understanding of what enabled and/or constrained learning EMC, exploring clinical mentorship and learning in the pre-hospital EMC context, and gaining understanding of the role and scope of community members in the clinical mentorship activity system. The purpose of this study was to qualitatively document, by means of a thematic analysis, the pre-hospital clinical mentorship relationship, as well as document, by means of a Cultural Historical Activity Theory (CHAT) analysis, the clinical mentorship activity system. The focus of this qualitative documentation was the enablements and constraints to learning during clinical mentorship. This research also made possible recommendations for EMC clinical mentorship and education and may also inform (PBEC) policy, as well as work integrated learning (WIL) policy. Data collection included the use of diaries and focus group interviews. Analysis involved a two-part analysis, where data was reduced and understood with thematic analysis guided by Braun and Clarke (2006) six phase thematic analysis process (explained in Chapter three, Section 3.6). Thereafter, a CHAT analysis was conducted to uncover contradictions within the clinical mentorship activity system that made working on the object of activity difficult, thereby also uncovering constraints to learning. Inductive reasoning was applied to the thematic analysis to reduce data and identify themes and subthemes which provided insight into the enablements and constraints to learning in the pre-hospital EMC clinical mentorship relationship. The CHAT analysis of the data collected and analysed brought to surface the affordances, tensions as well as the primary-level and secondary-level contradictions of the clinical mentorship activity system. The thematic analysis of the clinical mentorship relationship provided limited understanding of the enablements and constraints to learning, and thus further motivated deeper analysis with CHAT. The results of this research included primary and secondary-level contradictions for almost all elements of the clinical mentorship activity system. Contradictions amongst the Division of Labour (DoL), the rules of the activity system, and the tools/resources of the activity system existed in that it constrained the interaction and activity of the subject and the community while working on the object of the activity system possibly achieving a lesser or undesired outcome of clinical mentorship.

Needlestick injuries (NSIs) are a recognized risk for occupationally-related transmission of bloodborne pathogens (BBP). The occurrence of NSIs and BBP exposures among firefighters (FFs) and emergency medical services (EMS) personnel has been documented. The purposes of this study were: 1) to define the problem of NSI among FFs and EMS personnel in a suburban fire department (FD) and identify practices and factors that influence sharps use and safety; 2) design and implement and intervention to promote safer sharps device usage; and 3) to measure the effectiveness of the intervention among FFs and EMS personnel. A multi-phase, mixed methods approach was used that included a diagnosis phase that utilized a mixed methods exploratory design, an intervention period, and a quantitative evaluation phase that used a before and after evaluation design. In the diagnosis phase, data regarding sharps device practices were obtained through a count of discarded sharps devices. Qualitative data regarding sharps practices and factors which influenced those practice were obtained via focus groups. The PRECEDE/PROCEED model (PPM) was used as the theoretical framework for assessment, planning, implementation, and evaluation of an intervention to increase the occurrence of safer sharps device behaviors and decrease the frequency of riskier sharps device behaviors. The evaluation phase included a post-intervention sharps count and a post-intervention survey to assess changes in sharps practices and the impact of the intervention. During the baseline sharps count, 2743 sharps devices were counted and classified according to pre-established categories of safer or risky behaviors for NSI. Altered safety devices on IV stylets were the highest count for unsafe behaviors (n=105), followed by recapped traditional needles (n= 53). A statistically significant increase in risky behaviors was observed in discarded sharps from engines, as opposed to ambulances, among all sharps devices combined (p=0.000) and IV stylets (p=0.000). When comparing advanced life support (ALS) medications to all other medications, a statistically significant increase in unsafe behaviors occurred among all sharps devices combined (p=0.000) and prefilled syringes (p=0.000). Input from eight focus groups of firefighters allowed for identification of multiple themes which guided the development of an intervention. The intervention included distribution of a hands-on training kit and booklet, expansion of an existing required BBP training, and posters to increase awareness regarding NSI prevention. In the evaluation phase, a total of 2178 sharps devices were counted and classified in a post-intervention sharps count. Altered safety devices on IV stylets were the highest count of unsafe behaviors (n=50). Recapped traditional needles were the second highest count of unsafe behaviors (n=27), but experienced an 18.7% drop in frequency when compared to baseline. When comparing riskier behaviors to the pre-intervention baseline sharps count, statistically significant decreases in risky behaviors were observed in all sharps devices combined ( 2=25.71, p=0.000), IV stylets (2=16.87, p=0.000), and traditional needles (=5.07, p=0.024). A post-intervention survey, consisting of 15 Likert scale questions, was returned by 165 out of 383 active field personnel (41.3%). Results indicated high frequencies of strongly agree and somewhat agree responses regarding risk perception; the importance of using safer needle devices; the impact of the intervention on safer needle practices and sharps safety awareness. Critical predisposing, reinforcing, enabling, and environmental factors which influenced sharps device practices were identified. This study identified factors and practices which influenced unsafe sharps device behaviors. Due to the statistically significant decreases in risky behavior in the post-intervention sharps count and the positive responses in the post-intervention survey, it can be concluded that the intervention did positively impact sharps device behavior and reduced the risk of NSI. The implications of the study are numerous and include a need to explore these practices and factors at other fire departments and EMS agencies, address gaps in regulations; promote research targeting FFs and EMS personnel in regard to NSI, and promote a nationwide effort to prevent NSI among emergency responders.

The thesis deals with emotional intelligence and coping strategies for paramedics. The theoretical part provides information on the emotional intelligence of its models and measurement capabilities. It is then discussed strategies of coping with stress on its historical and theoretical approaches and the types of strategies and also about the methods by which we discover the use of a specific coping style. It is also described the characteristics of paramedic profession, qualification requirements for the exercise of the profession, as well as competence and personal characteristics of rescuers. The aim of the empirical part is quantitatively map a degree of emotional intelligence of paramedics, preference coping styles in this population and mutual respect between the two variables.

Bakgrund: Oplanerade prehospitala förlossningar kan ske i närvaro av ambulanspersonal, vilka är avsevärt mindre utbildade för förlossningar än barnmorskor men tvingas ändå handha samma situation. Detta kan vara en dramatisk och stressande upplevelse både för födande och ambulanspersonal. Syfte: Beskriva sjuksköterskors/ambulanssjuksköterskors upplevelser, tankar och känslor om prehospitala förlossningssituationer i sitt arbete. Metod: En kvalitativ intervjustudie med deskriptiv design. Elva semistrukturerade intervjuer analyserades med kvalitativ innehållsanalys. Resultat: Förlossningssituationer beskrevs som verkligt fantastiska, häftiga, spännande, som de roligaste körningarna och som en euforisk glädje att få se ett liv ta sin början, jämfört med alla liv som ambulanspersonal ser slockna. Förlossningskörningarna benämndes som skräckblandad förtjusning, nervöst och läskigt. Dels eftersom dessa var så ovanligt förekommande och ambulanspersonalen upplevde sig underutbildade för situationen, vilket gav känslor av obehag, kompetensbrist och skräck att inte kunna hantera en eventuellt kritisk situation. Dels då körningar involverande barn gav extra kraftigt adrenalinpåslag, skärpa, närvaro och fokus. Ytterligare försvårande faktorer upplevdes vara platsbristen i en ambulans, dålig arbetsställning, underbemanning, utrustnings- och resursbrist, språksvårigheter, kulturskillnader eller sjukt/missbildat/dött/oönskat barn. Bristen på erfarenhet och kunskap var dock det primära och mer förlossningshospitering önskades. Slutsats: Förlossningssituationer väcker mycket starka känslor hos sjuksköterskor/ambulanssjuksköterskor både på ett positivt och negativt sätt. Dessa upplevs som de roligaste, mest spännande och mest glädjebringande körningar samtidigt som stressande, pressande, adrenalinframkallande samt som annorlunda alla andra körningar. Förlossningskörningar sker så sällan att det är svårt att upprätthålla en god kunskapsnivå, varför en ökning av utbildning önskas. / Background: Unplanned prehospital births can occur in the presence of ambulance staff, who are considerably less educated for childbirth than midwives but are still forced to handle the same situation, a potentially dramatic and stressful experience for both patient and paramedic. Purpose: Describing paramedics' experiences, thoughts and feelings about prehospital birth situations. Method: A qualitative interview study with descriptive design. Eleven semi-structured interviews analyzed with qualitative content analysis. Results: Childbirth situations were described as amazing, exciting and the euphoric joy seeing a life begin, compared to all lives paramedics see end. Childbirth situations were called a "horrified delight". Partly, because these were so unusual and the paramedics felt under-educated, which gave feelings of discomfort, inadequacy and fear of being unable to handle a potentially critical situation. Partly, because missions involving children gave stronger adrenaline-rushes, sharpness and focus. Further aggravating factors were the compact ambulance, poor working posture, understaffing, equipment- and resource-shortages, language difficulties, cultural differences or sick/malformed/dead/unwanted children. However, the lack of experience and knowledge was the primary one where more practical experiences at the delivery ward was desired. Conclusion: Childbirth situations evoke very strong emotions among nurses/paramedics both in positive and negative ways. These are considered the most enjoyable and exciting missions as well as stressful, pressing, adrenaline-inducing and different from all other missions. Childbirth missions are so unusual that it is difficult to maintain a good level of knowledge, which is why an increase in education is desired.

Hot och våld mot ambulanspersonal blir allt vanligare i samhället. Frekvensen av hot och våld mot ambulanspersonal är hög. Ambulanspersonal rapporteras ha den största risken att utsättas för våld på arbetsplatsen då de oftast är dem som först möter patienten när akutsjukvård behövs. Arbetsrelaterat hot och våld på arbetsplatser påverkar arbetsgivare och arbetstagare i form av trivsel, ekonomi och vårdkvalitet. Syftet var att belysa det vetenskapliga underlaget för ambulanspersonalens upplevelse och hur de påverkas av arbetsrelaterat hot och våld. Metoden var litteraturöversikt där 18 vetenskapliga artiklar ingick där resultatet analyserades med en integrerad dataanalys och redovisas i kategorier och underkategorier. I kategorin, ambulanspersonalens yttre påverkan av hot och våld som baserats på underkategorierna Oro för egen säkerhet och teamets betydelse, Risker i arbetet samt kategorin, Att kunna värna om patientsäkerheten, visade resultatet en oro för egen säkerhet, vikten av stöd från arbetsgivare och kollegor. Resultatet visade hur risken att utsättas för hot och våld ökade då patienterna var påverkade av droger eller alkohol samt arbete under natten. Möjlighet och svårigheter att kunna värna om patientsäkerheten vid våldsamma situationer uppstår. Kategorin ambulanspersonalens inre påverkan av hot och våld, baserad på underkategorierna Långvarig stress och utsatthet samt Posttraumatiskt stressyndrom PTSD, påvisade resultatet hur personalen upplevde långvarig stress, personlighetsförändring och i en del fall hade en ökad risk att utvecklade posttraumatiskt stressyndrom vid upprepad utsatthet av arbetsrelaterat hot och våld. Studiens resultat visar att arbetsrelaterat hot och våld hos ambulanspersonalen är ett stort problem både för arbetstagaren som arbetsgivaren och påverkar i sin tur patienternas omvårdnad och det egna välbefinnandet. Ambulanspersonalen påverkas både mentalt som kroppsligt av utsattheten av hot och våld. Upplevelsen av välbefinnandet för ambulanspersonalen försämras och arbetsinsatserna i omvårdnaden påverkas. / Threats and violence towards ambulance staff is getting more common within the society. The frequency of threats and violence towards ambulance staff is high. Ambulance staff are reported to have the highest risk of being exposed to threats and violence at work since they are likely the first to meet the patients in need for emergency care. Work related threats and violence at work affects employers and employees in the shape of comfort, economic and quality of care. The aim was to highlight the scientific substrate for the ambulance staff experience and how that they are affected by work related threats and violence. Method used was a literature review where 18 scientific articles were included, where the results were analyzed with an integrated data analysis and reported in categories and subcategories. In the category ambulance staff´s external impact of threats and violence based on subcategories Worries about self-safety and the importance of the team, Risks at work, and the category Being able to protect patient safety, showed concern for personal safety, the importance of support from employer and colleagues. Result showed that the risk of being exposed to threats and violence increased when patients were affected by drugs or alcohol and work at night. Opportunity and difficulty in protecting patient safety in violent situations arise. In the category ambulance staff´s internal impact of threats and violence based on subcategories Long-term stress and vulnerability as well as Post-traumatic stress disorder PTSD, showed how the staff experienced long-term stress, personality change and in some cases showed higher risk to develop posttraumatic stress syndrome at repeated work-related threats and violence. The study results show that work-related threats and violence among ambulance staff is a major problem both for employees and employers and in turn affects patients care and their well-being. Ambulance staff are affected both mentally and physically by the vulnerability of threats and violence. Well-being for the ambulance staff is impaired and the workload in nursing is affected.

Internationellt varierar ambulanspersonalens kompetensnivåer, utbildningssystem och utbildningsnivåer. I Sverige utförs ambulanssjukvård av legitimerade sjuksköterskor med eller utan specialistutbildning, vidareutbildade undersköterskor och läkare. I samband med ambulanssjukvård ska god hälso- och sjukvård utföras med hög patientsäkerhet. Ambulanspersonal behöver hög kompetens för att kunna bedöma subjektiva och objektiva data samt att vårda patienter i alla åldrar med akuta vårdbehov utifrån gällande lagstiftning, förordningar och riktlinjer. För att optimera prehospital omvårdnad kan personcentrerad vård användas för att ge vård och behandlingar ur ett holistiskt omvårdnadsperspektiv till patienter och närstående. Hot och våld vid ambulanssjukvård är ett globalt och nationellt problem som ökar i omfattning. Prehospitalt arbete kan innebära att säkerhetsläget snabbt kan ändras utan förvarning från ett lugnt läge till kaotiskt. Samtidigt finns inte tillgång till de säkerhetssystem som finns intrahospitalt. Syftet var att beskriva ambulanspersonals upplevelser och erfarenheter av prehospitalt hot och våld. Uppsatsen designades som en litteraturöversikt. Ansatsen innebar ett systematiskt och induktivt arbetssätt. Översikten omfattade 15 vetenskapliga orginalartiklar med både kvalitativ och kvantitativ metod. Artiklar söktes i databaserna MEDLINE, CINAHL och PsycINFO. Granskning av artiklarnas vetenskapliga kvalitet genomfördes med hjälp av granskningsmall för kvalitetsbedömning som fanns tillgänglig från Sophiahemmet högskola. Dataanalys utfördes genom integrerad dataanalys. Artiklar som inkluderades hade erhållit etiskt godkännande från etiska nämnder. Resultatet sammanställdes i fyra kategorier och 12 underkategorier. Ambulanspersonalens utsatthet för riskfyllda situationer påverkades av demografiska skillnader, verbala hot, fysiskt våld och osäkra platser. Hotfulla och våldsamma situationer kunde medföra negativa konsekvenser vid omvårdnad. Konsekvenserna kunde inverka på vårdrelationer och omvårdnadskvalitet, skillnad mellan oavsiktliga och avsiktliga incidenter samt brister i samverkan med larmcentraler. Utsattheten för incidenter kunde ge inverkan på välbefinnande, vilket kunde orsaka akuta behov av sjukvård och psykologiskt stöd, påverkan på psykisk och social hälsa samt utmattning och stressreaktioner. Ledarskapets betydelser inverkade på rapportering av incidenter från ambulanspersonal samt hjälp och stöd från arbetsgivare. Ambulanspersonal riskerar att utsättas för riskfyllda situationer där hotfulla och våldsamma incidenter kan uppstå. Incidenter där prehospitalt hot och våld förekommer kan orsaka att patienter erhåller omvårdnad med försämrad kvalitet och sänkt patientsäkerhet. Ambulanspersonal kan riskera sänkt välbefinnande och ohälsa som kan kvarstå under lång tid efteråt. Arbetsgivares preventiva arbete och ledarskap anses vara bristfälliga vilket orsakar att mörkertalet blir stort över inträffade incidenter. Ledarskapet i ambulansorganisationer behöver ge betydelse för ambulanspersonal för att kunna förebygga och hantera incidenter med hotfulla och våldsamma situationer. / Internationally, the level of competence of the ambulance personnel as well as education and training varies. In Sweden, ambulance care is performed by registered nurses, specially trained or not, assistant nurses and doctors. Ambulance care should provide good and safe health care based om current legislation, regulations and guidelines. Ambulance personnel need high qualifications to be able to access subjective and objective data and care for patients of all ages who need acute pre-hospital care. In order to optimize pre-hospital care person-centered care can be used to form a holistic care perspective. Ambulance personeel exposed to threat and violence has become a global and national problem that increase in scale. Pre-hospital work can involve quick changes regarding the security of the situation and place. This without the access to security systems available in the hospital. The aims were to describe the ambulance personnel’s experiences of pre-hospital threat and violence. The method was designed with a literature review. The work involved systematic and inductive methods. The review included 15 scientific original articles with both qualitative and quantitative methods. Articles were searched in the databases MEDLINE, CINAHL and PsycINFO. Review of the scientific quality of the articles was conducted using a quality assessment review template available from the Sophiahemmet University. The result was analyzed with an integrated data analysis. Articles that were included had obtained ethical approval from ethics committees. The result was described in four categories and 12 subcategories. Ambulance personnel exposure to risky situations was affected by demographic differences, verbal threats, physical violence and unsafe places. Threatening and violent situations could give negative consequences on nursing. The consequences could affect the impact of care relationships and quality of care, differences between accidental and intentional incidents and problems in cooperation with emergency centers. Ambulance personnel exposure to incidents could have an impact on well-being, which could cause acute need for healthcare and psychological support, impact on mental and social health, fatigue and stress responses. Leadership meanings influenced the reporting of incidents and help and support for ambulance personnel. Ambulance personnel are at risk of being exposed to risky situations where threatening and violent incidents can occur. Incidents with prehospital threats and violence can cause patients receive care with reduced quality and reduced patient. Ambulance personnel may risk lower well-being and illness that may persist for a long time afterwards. Employers preventive work and leadership are inadequate, causing the number of unreported cases is high over the incidents. The leadership of the ambulance organizations need to involve significant for the ambulance personnel to prevent and respond to incidents of threatening and violent situations.