|Year : 2017 | Volume
| Issue : 6 | Page : 1691-1697
|A study of emergency medical technicians' cognitive and practical skills in airway management and its relationship with some related factors in emergency medical centers selected in Isfahan in the year 2015–2016
Habiballah Alikhanizadeh1, Fakhri Sabouhi2, Fariba Haghani3, Hojat Allah Yusefi4
1 Department of Adult Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences Isfahan, Isfahan, Iran
2 Nursing and Midwifery Care Research Center, Department of Adult Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Medical Education,Medical Education Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
4 Nursing and Midwifery wound Research Center, Department of Adult Nursing ,School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
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|Date of Web Publication||11-Jan-2018|
| Abstract|| |
Introduction: Prehospital care is a fundamental and decisive component in the treatment of emergency patients. In accidents, the first contact with emergency patients is by emergency prehospital staff. Hence, they must have sufficient knowledge and skills in all fields with airway management been one of the important measures. Various factors are involved in emergency personnel's knowledge and skills whereas the evidences show that staff performance is not desirable. This study aimed to investigate emergency medical technicians' cognitive and practical skills in airway management and its relationship with some related factors. Materials and Methods: This study is a cross-sectional, descriptive-analytical research. Sixty-eight emergency medical technicians were randomly selected by simple convenience sampling method. The tools used for data collection were personal and demographic characteristics form, cognitive skills inventory, and clinical skills checklist, including five skills in airway management. Face and content validities of tools were investigated and verified by ten experts and lecturers. The data were collected using personal and demographic characteristics form, cognitive skills inventory, and filling out the clinical skills checklist and observing the skills performed by technicians and then analyzed by SPSS version 20 software. Results: The results showed that, in airway management, 49.2% of technicians had good cognitive skills and 81% of them had practical skills. There was a direct relationship between the score of cognitive skills and the score practical skills (P < 0.001; r = 0.556). Conclusion: Although emergency medical technicians' practical skills were in good range, they got low scores in inserting the laryngeal mask airway, and it is required that they are trained in this field.
Keywords: Airway management, cognitive skills, emergency medical technicians, practical skills
|How to cite this article:|
Alikhanizadeh H, Sabouhi F, Haghani F, Yusefi HA. A study of emergency medical technicians' cognitive and practical skills in airway management and its relationship with some related factors in emergency medical centers selected in Isfahan in the year 2015–2016. Ann Trop Med Public Health 2017;10:1691-7
|How to cite this URL:|
Alikhanizadeh H, Sabouhi F, Haghani F, Yusefi HA. A study of emergency medical technicians' cognitive and practical skills in airway management and its relationship with some related factors in emergency medical centers selected in Isfahan in the year 2015–2016. Ann Trop Med Public Health [serial online] 2017 [cited 2018 Aug 15];10:1691-7. Available from: http://www.atmph.org/text.asp?2017/10/6/1691/222698
| Introduction|| |
Emergency situations are solemn occasions where individuals' physical or mental conditions are suddenly damaged; therefore, such people require fast, essential, and appropriate actions. To protect human health, many organizations have been established, each of them has taken a part of responsibility to conduct these important actions. In all countries across the world, these centers are considered as the most important part of health-care services, and the main purpose of this system is to provide satisfactory services in the shortest possible time and according to scientific standards on the world. Statistics show that given the current situations, more than 950,000 ground emergency medical missions are annually carried out in Iran by emergency ambulances and motorcycles, of which majority are cardiovascular diseases and accidents. In Isfahan Province, more than 145,941 emergency missions, including 49,498 accident missions and 96,443 nonaccident mission, were carried in 2014. This represents a huge volume of activities and services to patients and injured. Today, prehospital care is a fundamental and decisive component in the treatment of emergency patients. If treatment of patients is done more accurate and faster resulting in reduced mortality and disability caused by diseases and public confidence in the system will be increased. Saving patient in the shortest time is in the priority of health measures and care. One of the first and most important measures and most basic component of emergency care performed by emergency personnel is to supply and maintain open airway, ensuring effective ventilation and providing oxygen for the patient. Proper airway management can lead to saving patients' lives, and its great and undeniable value is evident, so airway management is of the most important aspects of treatment  aims to ensure ventilation and sufficient supply of oxygen to the patient. Emergency medical service system consists of a comprehensive network of personnel, equipment, and resources. The most important component of prehospital emergency system is efficient human resources to deal with a variety of incidents and illnesses, and with them, the goals of organization are achieved, improvement in knowledge and skills of this group of health system, as one of the most important inputs of health system, can have a significant impact on performance indicators.
In accidents, the first contact of emergency patients is prehospital emergency staff, so they must have sufficient knowledge and skills in all fields of nursing and urgent care. One key factor affecting how prehospital emergency personnel make a decision is having adequate facilities and equipment as well as knowledge and skills required to use these devices and equipment. Other factors such as experience, education degree, academic field, and participation in educational programs are involved in knowledge and skills of emergency personnel whereas some real experiences and observations show that the performance of clinical staff is not desirable. Furthermore, they highlight the inadequacy of the clinical capabilities of staff. In Iran, currently, only one specialized level of emergency is trained which is known as emergency medical technician, and alongside the graduates in this discipline, the graduates in other disciplines such as nurses, technicians, anesthetists, operating room experts, and nurse aide are employed. They are trained differently meaning the absence of the same education system for training the same experts for emergency, and this uniform composition and different teachings can potentially cause problems in providing in-service training and reduce the quality of services to patients.
To understand how much the goals and standards in the field of emergency care can be achieved and what effective factors are available in achieving it and to identify the strengths and weaknesses of learners in terms of different aspects to provide strategies to strengthen or fix them, one of the important components of teaching–learning process, i.e., evaluation, is used. Evaluating knowledge, skills, and capabilities of personnel and identifying existing gaps between their knowledge and skills before their participation in critical situations can minimize the risks associated with the response to the crisis. One of the major issues in evaluation in medical sciences disciplines is to enhance knowledge, attitudes, and skills needed by them. Evaluation should be designed in a way, in which students and staff can apply their learned knowledge and skills in real-working environments and adopt themselves with their working environment. To evaluate staffs, behaviors are compared with job description and the standards which reflect their expectations, evaluation the quality of staff 's performance in not vary practical so using reliable and repeatable simulation methods seems desirables. Finding a clinical evaluation method with high objectivity and the ability to measure practical skills in an environment which is very similar to real environment is considered as a challenge, so the objective structured clinical examination has become very important and its validity and reliability in precise and objective evaluation of clinical skills have been proven in many studies. Objective Structured Clinical Examination (OSCE) test is appropriate to evaluate all clinical capabilities including patient care, clinical examination, history taking, interpersonal communication, procedures, data interpretation, and results of the clinical and laboratory tests, the knowledge, ability to solve problems and clinical judgment, and even to evaluate the level of students' attitude and their professional behavior. This examination is a performance-based evaluation, in which practical knowledge and behavioral and decision-making skills are comprehensively and objectively investigated under conditions similar to reality. For this reason, it has been widely used as a standard test.
The studies showed that a significant percentage of mortality and disability happen before reaching the hospital. The existence of human forces with sufficient knowledge and skills and doing correct and timely prehospital emergency care can play a role in reducing mortality and disabilities caused by accidents and diseases. Considering the fact that one of the most important actions in saving the lives of patients and injured in prehospital emergency is airway management and given that the researcher saw the differences between the personnel's knowledge and skills in airway management. This study aimed to investigate emergency medical technicians' cognitive and practical skills in airway management and its relationship with some related factors.
| Materials and Methods|| |
This study is descriptive and analytical. Its population includes all emergency medical technicians in Isfahan Province. Inclusion criteria are being interested in participating in the study, graduating in one of the disciplines of nursing, medical emergency, anesthesia, or operating room, and occupation in one of the prehospital emergency operating stations in Isfahan Province.
Based on the inclusion criteria and the formula of estimation of sample size, 68 persons were selected. Simple convenience sampling method was used and 18 nurses, 20 medical emergency technicians, 14 anesthetists, and 11 operating room technicians were randomly selected by simple convenience sampling method. The tools used for data collection were personal and demographic characteristics form, cognitive skills inventory, and clinical skills checklist, including five skills in airway management. Personal and demographic characteristics form includes the information on age, gender, marital status, education, working experience in prehospital emergency, academic field, elapsed time of graduation, time elapsed since the last resuscitation, university (public or private), workplace (urban or road), the number of missions per month, the number of shifts per month, working experience in other health centers including hospitals, clinics, employment status in prehospital emergency care, participation in educational programs related to airway management, and time elapsed since participation in training classes related to airway management. Cognitive skill inventory includes thirty four-option questions that involve the areas of cognitive skills including knowledge, understanding, application, and analysis in airway management. Choosing correct option as 1 score and choosing a wrong option or no option has no score. In cognitive skill inventory, the minimum and maximum scores are 0 and 30, respectively. According to obtained scores, personnel were classified at three levels of poor with 0–10 score, moderate with 11–20 score, and good with 21–30 score. This is self-made inventory. To confirm its validity, it was offered to ten experts in the fields of medical emergencies and education. Then, it was revised based on their comments and applied on twenty emergency medical personnel, and the results were investigated after estimating Cronbach's alpha of reliability. Cronbach's alpha was estimated to 83%.
The practical skill checklist used to investigate the emergency medical technicians' practical skills in airway management was self-made, and it was set and developed using standard skill sheets and reference books on prehospital emergency. It includes five skills of insertion of oral airway and nasal airway and suction of airway secretions (22 points), insertion of endotracheal tube (endotracheal intubation) (13 points), maneuvers of opening airway and ventilation with bag-valve (20 points), intubation of airway with Combitube (15 points), and insertion of laryngeal mask (11 points).
To evaluate practical skills, OSCE test was used. Test was designed at five stations. To increase the test validity, designed stations were revised according to the views and suggestions of several professors who had experiences in holding OSCE test and test validity was confirmed. To measure the reliability of checklist, interobserver reliability was used, and the correlation was estimated 87%. The levels of practical skills were classified as follows: poor (0–27 score), moderate (28–54 score), and good (55–81 score). All skills were in accordance with standard protocols, and they were same for all research units. After receiving a letter of introduction from Isfahan University of Medical Sciences and offering it to the Center for Disaster Management and Emergency Response and describing the purpose of research and observing ethical rules and getting consents from participants, required data were collected. Personal and demographic information forms and cognitive skill inventory were filled out by samples, and practical skills were observed and scored by observers. Descriptive and inferential statistics (t-test, ANOVA, and Pearson's correlation coefficient) and SPSS Version 20 (SPSS Inc, Armonk, NY: IBM Corp.) software were used to analyze the data.
| Results|| |
The number of participants was 63 who were in 23–50 age group. Their mean age was 33.8 years old. The majority of participants were married (69.8%). Their mean working experience in prehospital emergency centers and other health-care centers was 8.5 and 3.6 years, respectively, and their mean elapsed time of graduation was 8.2 years. Their mean time elapsed since the last resuscitation was 34.5 days, their mean number of missions per month was 101.2, and their mean number of shifts per month was 12.9. In terms of employment status in prehospital emergency care, the majority of them were in regular employment (38.1%). Almost 47.6% and 47.6% of them had associate degree and bachelor, respectively, whereas only 4.8% of them had master degree. Majority of them were graduated from public university (93.7%), and in the academic field, 28.6%, 17.5%, 22.2%, and 31.7% were nursing, operating room, anesthesia, and medical emergency, respectively. Most of them worked in urban centers (66.7%), whereas most of them had the experience of participation in training classes related to airway management (90.5%). Most of the participants' time elapsed since participation in training courses related to airway management was 1 month to 1 year (44.4%).
The results of this study show that there was no significant relationships between emergency medical technicians' scores of cognitive and practical skills in airway management and age, marital status, education, working experience in prehospital emergency, academic field, university (public or private), workplace (urban or road), working experience in other health centers including hospitals, clinics, participation in educational programs related to airway management, and time elapsed since participation in training classes related to airway management. Mean score cognitive skills of participants with contractual employment were significantly less than others, but there was no significant relationship between participants' score of practical skills and their employment status. There was no significant relationship between participants' score of practical skills and their academic field. The participants' total score of cognitive skills was 20 ± 3.8 (of 30) and their total score of practical skills was 58.9 ± 5.04 (of 81).
Almost 50.8% (32 persons) of participants were at the moderate level in terms of cognitive skills and 19% (12 persons) of participants were at the moderate level in terms of practical skills. Nearly 49.2% (31 persons) of participants were at the good level in terms of cognitive skills and 81% (51 persons) were good in terms of practical skills [Table 1]. Furthermore, Pearson's correlation coefficient showed that there was a direct relationship between the score of cognitive skills and the score practical skills (P < 0.001, r = 0.556) [Table 2].
|Table 1: Frequency of participants in terms of the levels of cognitive and practical skills|
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|Table 2: Pearson's correlation coefficient between the score of cognitive skills and the scores of practical skills|
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| Discussion and Conclusion|| |
The results showed that participants' total score for cognitive skills was 20 ± 3.8 (of 30) and their total score for practical skills was 58.9 ± 5.04 (of 81), 50.8% (32 persons) of participants were at moderate level in terms of cognitive skills, and 49.2% (31 persons) in terms of cognitive skills while the majority of participants (81%) were at the good level in terms of practical skills. Dadashzadeh et al. in their study reported that enhancing the knowledge and skills of the health system group may facilitate the provision of emergency care. Panahi et al. (2008) showed that one of the reasons for the increased mortality rate of infant who requires prehospital emergency in Iran compared to other countries is emergency inadequate skills of medical staff. Obby in his study noted that one of the reasons for poor performance by emergency medical staff in providing prehospital trauma care is lack of knowledge and skills related to trauma. According to researcher who also served as a member of the health-care system in the studied centers, high level of staff's cognitive and practical skills facilitates the provision of emergency care for patient. Furthermore, the results showed that, in estimation of total score of practical skills, the mean scores of skills of ventilation with bag-valve and maneuvers of opening airway, insertion of oral and nasal airway and suction of airway secretions, insertion of endotracheal tube (endotracheal intubation), intubation of airway with Combitube, and insertion of laryngeal mask were 16.1, 15.7, 9.8, 10.8, and 6.4, respectively. The lowest mean score was related to the skill of insertion of laryngeal mask. Wiese et al. in their study noted that laryngeal airway is more effective than ventilation with a bag-valve in airway management. Furthermore, Guyette et al. in their study noted that poor knowledge in resuscitation protocol compared to proper performance in inserting aggressive airway in the field of medical emergencies. Imanipour and Peyrovi in their descriptive study entitled “evaluation of performance of master of science students in critical care nursing in terms of skills of cardiopulmonary resuscitation process using OSCE test” showed that airway management skill is one of five important clinical skills in resuscitation process which was placed third with 35.5%. Furthermore, the results showed that there was a direct relationship between the score of cognitive skills and the score practical skills (P < 0.001; r = 0.556). In other words with an increase in the score of cognitive skills, the score of practical skill also increased. Furthermore, in [Table 3], Pearson's correlation coefficient showed that there was a direct relationship between the score of cognitive skills and the scores of all stations of practical skills (P < 0.05). In a study by Imanipour and Peyrovi, it was shown that the performance of students was generally at a moderate level in the field of cardiopulmonary resuscitation (CPR) process and the level of cognitive skills related to this process was lower than the level of related practical skills. Furthermore, they stated that experiences and observations showed that performance of clinical staff is not sometimes that desirable and this represents inadequate clinical capabilities of staff. This is not consistent with the results of our study. The difference between the results of our study and that of Imanipour and Peyrovi might be due to different studied groups. In our study, the participants were staff who are the first medical care forces encountering cardiac or respiratory arrest patients and are forced to react quickly and take some measures for the patient while, in Imanipour and Peyrovi's study, the participants were students who were not yet working practically and also had no skills. The results showed that there were no significant relationships between the scores of cognitive and practical skills and quantitative variables listed in the table (P < 0.05). A descriptive-analytical study by Pourmirza Kalhori et al. (2012), entitled “a study of emergency medical staff's knowledge of last CPR guidelines 2010, Kermanshah Province” showed that, with the increase in age, the knowledge of staff reduces and there was no significant relationship between knowledge and working experience. In a study by Borimnejad et al., they showed that working experience had no positive impact on nurses' knowledge of CPR, whereas, in a study by Mohsenpour et al. (2010), they showed the positive and significant relationship between employment status and working experience and nurses' knowledge. The results showed that there was no significant relationship between the scores of cognitive and practical skills and education and time elapsed since participation in training courses related to airway management (P < 0.05).
|Table 3: Pearson's correlation coefficient between the score of cognitive skills and the scores of practical skill stations|
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The results of this study are consistent with the results of study of Pourmirza Kalhori et al. (2013). According to their study, there was no significant relationship between knowledge of CPR and education and academic degree. However, specifically in airway management station, the knowledge of people who had nurse-aid degree was less than the knowledge of other people with other degrees. Furthermore, in terms of time elapsed since participation in the last training classes related to airway management, in airway management station, there were significant differences between the knowledge of people who participated in such courses and people who did not participate (27, P = 0.02).
According to the results of t-test listed showed in [Table 3], there was no significant relationship between the mean scores of cognitive (P = 0.87) and practical (P = 0.82) skills and marital status, there was no significant relationship between the mean scores of cognitive (P = 0.17) and practical (P = 0.20) skills and type of university, there was no significant relationship between the mean scores of cognitive (P = 0.81) and practical (P = 0.83) skills and workplace, and there was no significant relationship between the mean scores of cognitive (P = 0.92) and practical (P = 0.30) skills and participation or nonparticipation in training classes related to airway management.
The results of this study are consistent with the study by Borimnejad et al. (2007). They showed that participation in training classes has no impact on individuals' knowledge. Furthermore, in a study by Pourmirza Kalhori et al. (2013), there was no significant relationship between knowledge of CPR and workplace, but in advanced resuscitation station that includes airway management skills, the staff who worked on road had more knowledge compared to staff who worked in urban centers. This can be due to more samples at urban stations and new graduated forces at road stations. Furthermore, they emphasized on positive impact of participation in training classes on staff's knowledge and suggested to hold CPR training courses every 6 months. According to the results, mean score cognitive skills of participants with contractual employment was significantly less than others (P = 0.006), but there was no significant relationship between participants' score of practical skills and their employment status (P = 0.12), but there was no significant relationship between participants' scores of cognitive (P = 0.80) and practical (P = 0.51) skills and their academic field. These results are consistent with the results of a study by Pourmirza Kalhori et al. (2013), in which they reported that there was no significant relationship between knowledge and academic field. Despite the results of this study, the study by Mohsenpour et al. (2009) showed that employment status has a direct relationship with the knowledge of nurses. Furthermore, the results showed that there was no significant relationship between participants' scores of cognitive (P = 0.80) and practical (P = 0.51) skills and their academic field. Chandrasekaran et al. in their study in India showed that the doctors' and nurses' knowledge of BLS is essential  whereas Zautcke et al. also reported that it is necessary to evaluate competency of emergency medical staff.
| Conclusion|| |
The results of this study showed that 50.8% of participants were at the moderate level in terms of cognitive skills and 81% of participants were at the good level in terms of practical skills. According to the results, there was a direct relationship between the emergency medical technicians' scores of cognitive skills and practical skills in airway management. This means if cognitive skills are increased, practical skills will be enhanced. Hence, it is recommended to find strategies to increase emergency medical technicians' cognitive skills. According to the results of the present study, participants had a low score in the insertion of aggressive airway including laryngeal mask, so it is recommended that holding practical workshops and training classes to improve the level of emergency medical technicians in terms of this skill.
The present study was extracted from master's thesis approved by Isfahan University of Medical Sciences with No. 395229. We thank supervisors, Deputy of Research, Faculty members of the School of Nursing and Midwifery, participants, and all those who cooperate in the conduction of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Nursing and Midwifery Care Research Center, Department of Adult Nursing, School of Nursing and Midwifery, IsfahanUniversity of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]
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