Table 2 Overview of reviewed articles

Campeau 2009 [31]

Canada

To generate a substantive theory of paramedic scene management practice.

Qualitative: interviews

Paramedics (n = 24)

The space-control theory of paramedic scene management describes that paramedics coordinate key specific social processes (reducing uncertainty through social relations, controlling the trajectory of the scene, temporality at the scene, collateral monitoring) to establish “space control” at the scene. The space (or environment) is interpreted broadly to include both human and physical (non-human) elements.

Campeau 2011 [32]

Canada

To develop a theory about an important aspect of practice by exploring expertise in scene-management among paramedics.

Qualitative: interviews

Paramedics (n = 24)

The main category of paramedic expertise in scene management called paramedic kairotope means knowing when and where to act and acting at the right time and place. It is based on two subcategories: substantial use of subtleties in interpersonal communication, and innovative problem solving.

Chang 2018 [33]

Taiwan

To identify the perceived most desirable core competencies for all levels of emergency medical technicians.

Quantitative: statistical analysis of questionnaires

Emergency medical technician instructors (n = 84), emergency medical technician medical directors (n = 9)

Identified core competencies were related to assessing scene safety; conducting ongoing assessment; an accurate understanding of the patient from the medical and psychological point of view; proving appropriate care for each patient group and considering moral, social, and religious aspects of care; acting in accordance with ethics and health and safety policies.

Crowe 2017 [34]

United States

To describe the components of team leadership and team membership on a single patient call where multiple EMS providers are present.

Qualitative: focus groups

Paramedics (n = 9)

Key components of team leadership were: creating an appropriate action plan; receiving, processing, verifying and prioritizing information gained from team members; reconciling incongruent information; assessing situation and modifying plan. Key components of team membership were: being situationally aware, demonstrating appreciative inquiry; being safety conscious/advocating for safety.

Gurňáková 2013 [35]

Slovakia

To assess the frequency and the nature of deviations from recommended guidelines in paramedic teams in the selected competition task.

Mixed: videos, interviews, ratings of performance, statistical methods

Paramedics (n = 56)

Processing of initial information from the dispatch center of the most successful paramedic teams were characterized by paying full attention to initial information and forming an appropriate image of the situation. After arriving on the scene, they made more examinations recommended by guidelines and took more medical history data. They also verified verbal information by examinations and summarized gathered information after some intervals.

Gurňáková 2017 [36]

Slovakia

To test the relationship between performance confidence and actual performance in EMS crew leaders in the selected competition task.

Mixed: videos, interviews, ratings of performance, statistical methods

EMS physicians (n = 24), paramedics (n = 27)

The most successful EMS leaders’ performance confidence was as high as their actual performance. Their approach to gathering and interpreting information was characterized by collecting as much information as possible, making an initial hypothesis about the patient’s health problems, but verifying it by doing all necessary examinations, following medical guidelines properly.

Henderson 2013 [37]

United States

To examine difficult and complex service interactions between EMS providers and front-line patients.

Qualitative: interviews

Paramedics (n = 30)

Communication with the patient and information provided from bystanders’ behavior and communication, and assessment of the patient’s identity (a combination of race, gender, socioeconomic status, and potentially other variables) serve to shape street-level interaction between EMS and the patient.

Holly 2017 [38]

United Kingdom

To identify non-technical skills for use within a behavior rating system relevant to the provision of pre-hospital emergency care within rural/remote settings, and to develop and pilot the behavior rating system.

Mixed: literature review, observation of existing training course, expert advice, questionnaire

Development phase: experts in pre-hospital care or emergency medicine (n = 4), BASICS Scotland Course directors (n = 3), health psychologist (n = 2)

Evaluation phase: general practitioners (n = 67), practice nurses (n = 9), paramedics (n = 2), participant who did not state their profession (n = 4)

The behavioral rating system includes one relevant category - gathering information. It is comprised of three elements and associated markers: conducting a risk assessment of the scene and ensuring it is safe to approach the patient before proceeding (e.g., noting any environmental hazards to self and the patient, stating the decision to approach the patient or not), reviewing decisions to ensure they are still appropriate requesting a second opinion from others (e.g., discussing alternative suggestions, stating the final decision), and trying alternative options when a certain approach is not working (e.g., stating alternative approach/intervention to be tried, beginning to use new approach/intervention).

Holmberg 2010 [39]

Sweden

To describe the registered nurses’ experience of being responsible for the care of the patient in the ambulance care setting.

Qualitative: interviews

Registered nurses (n = 5)

Important parts of the care for patients in ambulance services were encountering the patient unprejudiced and with no pre-made assumptions, but at the same time to have a plan; being open-minded and have a broader outlook at the situation; medical assessment and assessment of the patient’s and significant others’ psycho-social situation and needs; making medical and nursing decisions.

Holmberg 2017 [40]

Sweden

To identify the types of knowledge that EMS managers considered desirable in their ambulance clinicians.

Modified Delphi

Registered nurses and emergency medical technicians working as EMS managers:

1st round (n = 30)

2nd round (n = 27)

3rd round (n = 24)

The desired knowledge was related to following categories and sub-categories: knowledge to handle the specific ambulance care (e.g., knowledge to assess risks in a dangerous environment, knowledge to manage personal safety), knowledge to assess and care for patients’ medical needs (e.g., knowledge to assess and care for different medical conditions, knowledge of treatment guidelines), knowledge to holistically assess and care for patients (e.g., knowledge to assess the patient’s situation from a holistic perspective, knowledge to support persons in crisis).

Jensen 2011 [41]

Canada

To establish consensus on the most important clinical decisions paramedics make during high-acuity emergency calls and to visualize these decisions on a process map of an emergency call.

Delphi

Medical directors and paramedics, the latter of whom work a variety of roles (ground ambulance paramedic, supervisor or

manager, quality assurance, clinical development, and

educator):

1st round (n = 23)

2nd round (n = 22)

3rd round (n = 20)

4th round (n = 23)

Identified important decisions during high-acuity calls were related to scene management (e.g., recognize potential hazards and scene safety, decide when to leave the scene and when to treat o scene), assessment (e.g., initial assessments of the patient’ medical condition, decide if the patient has the capacity to refuse or content), and treatment (e.g., decide on appropriate treatment, reassess the patient after giving a treatment, decide to change care plan based on patient changes).

Kilner 2004 [42]

United Kingdom

To identify desirable attributes of the ambulance technician, paramedic, and clinical supervisor to inform future curriculum development.

Delphi

Chief executives and medical directors or advisors of ambulance trusts:

1st round (n = 34)

2nd round (n = 42)

Desirable attributes were identified: abilities to take a history and conduct patient assessment and examination of both adults and children; intellectual skills to enable the interpretation of clinical data, the implementation of clinical judgment and decision making and the formulation of a diagnosis; aware of and adherence to national and local guidelines and policies.

King 2010 [43]

United States

To identify attributes that distinguish effective from ineffective responders and leaders in a disaster.

Qualitative: focus groups

Medical directors for the 9-1-1 EMS systems (n = 24)

Attributes of effective disaster responders were grouped in following categories: disaster training and experience (e.g., can assess or “size up” the disaster situation), cognition (e.g., can weight or balance options, can focus and concentrate, can think quickly, think or plan ahead, sees the broader picture), problem solving/decision making (e.g., can make difficult decisions, considers all available information, can decide and act based in incomplete information), adaptable/flexible (e.g., able to change one’s way of doing things, considers alternatives, open-mindedness).

Myers 2016 [44]

New Zealand

To adapt and evaluate a non-technical skills rating framework for the air ambulance clinical environment.

Mixed: adaptation phase – expert working group, scoping review, focus groups, clinician survey, filed testing data; evaluation phase –assessments of video-recorded performance, assessments of performance immediately after simulations

Survey: clinicians (n = 38), flight nurses (n = 20), specialist transport physicians (n = 12), paramedics (n = 6)

Simulation study: physicians from specialty training programs in intensive care and anesthesia (n = 3), anesthetics (n = 3), critical and intensive care medicine (n = 3), emergency medicine (n = 5), general medicine (n = 2)

Non-technical skills rating framework includes the following relevant categories, associated elements and examples of positive behaviors. Situation awareness referred to gathering information (e.g., conducting a frequent scan of the environment, cross-checking information to increase reliability), recognizing and understanding (e.g., increasing frequency of monitoring in response to a patient condition, verbalizing observed trends and their meaning to other team members), and anticipating (e.g., continually preparing for the next phase of the mission, setting and communicating intervention thresholds). Decision making referred to identifying options (e.g., recognizing alternative options for decisions, discussing clinical and other relevant considerations), balancing risks and selecting options (e.g. considering risks of different options, weighing up factors with respect to a patient’s condition), and re-evaluating (e.g., assessing a patient after key stages or regularly, reviewing a situation if the decision was to wait and see).

Nordby 2015 [45]

Norway

To present a case where the consequences of following a rule formulation “do not resuscitate” could have been fatal.

Qualitative: a case study

One case with two paramedics involved

To be able to interpret the validity of written guidelines, paramedics need to develop personal skills that transcend the ability simply to follow written instructions. Virtue ethical analyses, decision-making abilities, and communication skills are important as conceptual tools in making difficult clinical decisions.

Prytz 2018 [46]

Sweden

To investigate whether expert-novice differences in visual search behavior found in other domains also apply to accident scenes and the emergency response domain.

Quantitative:

eye-tracking measurements, a task based on images presented on a computer screen

Students (n = 20), ambulance service staff (n = 9), rescue service staff (n = 8)

Expert emergency responders spent more time looking at task-relevant information (areas of the accident images), and were more accurate in the assessment of the accident scene than novices. The longer time was due to a longer fixation duration rather than a large fixation count.

Reay 2018 [47]

Canada

To understand how paramedics conduct decision-making in the field, and to develop a grounded theory of paramedic decision-making in the prehospital setting.

Qualitative:

interviews, observations

Paramedics (n = 13)

Paramedic decision making was described as adaptive (flexible and creative) to the specific context and consisted of three categories: constructing a malleable model of the situation (based on information supplied by the dispatcher and gathered from the scene before reaching the patient), continuously revising the model (based on patient and scene conditions and available resources), and situation-specific action (based on reasoning about treatment decisions, working with protocols, seeking medical advice initiating treatment). Two additional components, considering patient and personal safety, and considering extrication are associated with each category.

Salminen-Tuomaala 2015 [48]

Finland

To identify factors that influence care quality and patient safety in out-of-hospital emergency care as experienced by emergency care professionals.

Qualitative: interviews

Paramedics (n = 5), nurses (n = 3), hospital and ambulance attendants (n = 3), practical nurses (n = 2)

High-quality emergency care is patient-centered, equal, professional, individualized and holistic. It encompasses the following areas: prompt emergency care on the scene; prevention of patient deterioration; individualized holistic care; arranging safe follow-up care; supporting the coping of patients and families; securing the safety of patients and staff on the scene and in the ambulance.

Sedlár 2017 [49]

Slovakia

To identify situation assessment and decision making strategies of EMS physicians in routine and non-routine situations.

Qualitative: interviews

EMS physicians (n = 15)

Critical assessments and decisions were related to the patient’s medical condition, patient’s behavioral and psychological characteristics, physical environment, and other people’s behavioral and psychological characteristics.

Schultz 2012 [50]

United States

To identify a set of all-hazard disaster core competencies and performance objectives required by the specific target audience (emergency department nurses, emergency physicians, and out-of-hospital emergency medical services personnel).

Modified Delphi

Participants representing multiple academic and provider organizations (n = 22)

All-hazard disaster core competencies were organized into domains: recognition, notification, initiation and data collection (recognize a disaster is in progress, assess the situation, initiate the disaster plan, notify the appropriate persons); public health and safety (prevent and mitigate risks to self and others); clinical considerations (manage patients with presentations that commonly occur during specific types of disasters); special-needs populations (manage patients according to their specific psychosocial, medical, cultural, age, and logistic needs); critical thinking/situation awareness (synthesize information and formulate new plans).

Smith 2013 [51]

United States

To study the cognitive strategies used by expert paramedics to contribute to understanding how paramedics and the EMS system can adapt to new challenges.

Qualitative:

audio-video recordings of 2 simulation scenarios

Paramedics (n = 10)

The more experienced paramedics made more patient assessments, explored a wider variety of presumptive diagnoses, and identified the medical problem earlier. They switched attention more between two patients and used their team partner more, and provided more advanced level care for both patients. Their patients arrived at the emergency department more prepared for specialized emergency care.

Suserud 2003 [52]

Sweden

To describe the scope and method of ambulance nurse assessment in pre-hospital emergency care.

Qualitative: interviews

Ambulance nurses (n = 6)

Before meeting patients, experienced nurses plan less for routine calls and consciously plan for unusually serious calls. But in planning and initial assessment, they emphasized the importance of an open approach. It means to be prepared, but not committed to any particular courses of action. In the initial assessment, they emphasized the importance of capturing situations at a glance and doing on-the-spot primary assessments to give a comprehensive picture of the scene.

Suserud 2003 [53]

Sweden

To describe the scope of ambulance nurse assessment in pre-hospital emergency care and show how it is made.

Qualitative: interviews

Ambulance nurses (n = 6)

According to nurses, balancing the demands of medicine and nursing care are the essential ingredients in pre-hospital emergency care. They emphasized the importance of a detailed assessment of the patient’s medical condition, needs, social and cultural background, and on that basis, to make appropriate medical and nursing decisions/actions.

Tavares 2013 [54]

Canada

To develop and critically appraise a global rating scale for the assessment of individual paramedic clinical competence at the entry-to-practice level.

Mixed:

Development phase – a task analysis using multiple simulation-based performances and actual clinical cases, a focus group, a modified Delphi process.

Appraisal phase – video-recorded simulations and assessments of performance using the developed rating scale

Task analysis: experts from a paramedic program (the number not stated)

Focus group: practicing paramedic clinicians (n = 17)

Modified Delphi process: experts in paramedicine (n = 9)

Simulations: novice paramedic students (n = 25), entry-to-practice students (n = 36), active paramedics (n = 24)

The global rating scale has four relevant categories that are described through their required attributes: situation awareness (e.g., observing the whole environment, avoiding tunnel vision), history gathering (e.g. interpreting and evaluating findings while discriminating between relevant and irrelevant findings, a consideration for differential diagnosis), patient assessment (e.g., the ability to continue appropriate reassessment/detailed assessment as needed, a consideration for differential diagnosis), decision making (e.g., selecting an appropriate management plan and/or decision strategy, avoiding premature closure).

Torabi 2017 [55]

Iran

To describe the experiences of Iranian prehospital emergency personnel in the field of ethical decision-making.

Qualitative: interviews

EMS personnel (n = 15)

Ethical decision making is based on the assessment of the scene atmosphere (local cultural beliefs and values, characteristics of the mission, the patient’s or bystander’s expectations), assessment of patients’ condition and their family (patient and disease characteristics, family preferences and perspectives), and predicting outcomes of decision-making (determination of medical futility, detecting potential risks and threats, forecasting legal consequences).

Von Wyl 2009 [56]

Switzerland

To test whether technical skills and non-technical skills are assessable with satisfactory interrater reliability during a regular paramedic training.

Quantitative: statistical analysis of observer-based ratings, simulation

Paramedics (n = 30)

The checklist for the rating of non-technical skills contained team components. Leadership components were making decisions and talking about considerations, decisions, and results. Membership components were making verbal or non-verbal decisions and talking about consideration, decisions, and results.

Wihlborg 2014 [57]

Sweden

To elucidate the desired professional competence of the specialist ambulance nurse, according to the professionals.

Modified Delphi

Specialist ambulance nurses, ambulance services managers, medical managers, clinical teachers, university teachers, scientists, union representatives:

1st round (n = 38)

2nd round (n = 37)

3rd round (n = 37)

The desired competencies were related to following areas: generic abilities (e.g. being flexible and adaptive, performing work in a problem-solving and thoughtful way), professional judgment (e.g. assessing the patient’s situation in a holistic manner, considering ethical principles), and professional skills (e.g., performing medical treatment and nursing care, working according to guidelines and for enhanced patient safety).

Wireklint Sundström 2011 [58]

Sweden

To describe and analyze assessment in pre-hospital emergency care provided by professional carers in the ambulance services, both for critical and non-critical conditions.

Qualitative: observations, field notes, interviews

Paramedics (n = 6), registered nurses (n = 3), specialist ambulance nurses (n = 2)

It was found that openness to the situation and recognition of the patient’s lifeworld is an essential part of assessments. Assessments focused solely on a patient’s medical condition can be an obstacle to a full understanding of the individual. A caring assessment focused on the patient’s suffering and needs adds further dimensions to the objective data. Therefore, the inclusion of the patient perspective relieves suffering and enables more safe decisions.

Wireklint Sundström 2012 [59]

Sweden

To study how ambulance personnel prepare themselves for their everyday assignments and avoid making premature decisions.

Qualitative: observations, interviews

Paramedics (n = 6), registered nurses (n = 3), specialist ambulance nurses (n = 2)

EMS requires the personnel to expect the particular event, but to avoid being governed by predetermined statements, to switch focus with respect to actual situational priorities, to adapt to a changing situation, to make immediate decisions/actions, to assess the situation continuously, to anticipate what might happen, to act systematically and in a structured way.

Wyatt 2003 [60]

Australia

To examine the utilization of tacit knowledge by experienced paramedics made explicit through their application of professional judgment.

Qualitative: observations, interviews

Mobile intensive care paramedics (n = 3)

Experienced paramedics are open to a variety of causes for the patient’s clinical problem, prepared not to have to arrive at a specific diagnosis, able to absorb a variety of information sources concurrently, direct attention to the problem at hand, make quick and sound judgments, choose whether to act or not, recognize multiple means and ends to clinical problems, discuss issues to arrive at a suitable course of action, and tend to rely less on established rules and guidelines.