What an ambulance nurse needs to know : from educational content to critical incidents

Sammanfattning: Ambulance personnel today are highly trained and perform specialized care. There are high expectations with respect to knowledge and competence of the Registered Nurses, RNs, in ambulance care, as they possess a medical responsibility for patient care in this setting. The overall aim of this thesis was to explore the training for RNs in ambulance care in Sweden and Europe, and to study the alignment between education and the need for training in clinical reality as reflected by critical incidents. The thesis builds on four studies: Study I aimed to assess recommendations in Clinical Practice Guidelines, CPGs, for management of traumatic brain injury in the prehospital setting with respect to level of evidence. A systematic review was performed. Twelve CPGs were identified, including 21 prehospital recommendations for prehospital care. The number, as well as the content, of prehospital recommendations varied considerably and there was insufficient evidence for several topics relating to the care of patients with TBI, in a prehospital setting. Study II aimed to describe the educational content concerning professional practice as presented in the curricula for the specialist nursing program in prehospital emergency care in Sweden. Eleven universities were included. In total, 49 curricula were analyzed with summative content analysis, resulting in three categories: medical-, nursing- and contextual knowledge. There was largest focus on medical knowledge and least focus on nursing, the registered nurses’ main profession. Study III, a case study with the aim to identify core content in Swedish, Finnish and Belgian university curricula in education on advanced level for RNs in ambulance care, showed the same results with respect of distribution of core content. Study III also aimed to describe teachers’ perception of the content that is required for the profession as a nurse in ambulance care. The teachers intended for the students´ to acquire broad competence in clinical reasoning by implementing theory into practice, as well as developing the students’ personal aptitude and instilling a scientific awareness. Study IV aimed to explore critical incidents as perceived by ambulance nurses and to relate them to their perceived preparedness. Interviews with eleven ambulance nurses, using critical incident technique, showed that critical incidents were mainly related to experiential knowledge. The ambulance nurses emphasized decision-making in situations where both time and information were limited and that they were not able to prepare themselves mentally as the most common reasons why critical incidents occurred. Clinical rotations were considered to be the factor that was most important for managing the critical incidents that arose. Conclusions and implications: CPGs for management of traumatic brain injury are incomplete and not always tailored for the prehospital setting. CPGs should be developed with high level of evidence to ensure that prehospital recommendations in guidelines are consistent, evidence-based, comprehensive, and thus promote better prehospital outcomes and avoid harm to patients. The course content in specialist training for RNs in ambulance care were similar for Sweden, Finland and Belgium with a focus on medical knowledge. The teachers in these countries aimed for the students´ to acquire broad competence in clinical reasoning. The ambulance nurses from Stockholm perceived that the clinical rotations were considered to be the factor that was most important in avoiding and managing the critical incidents that arise. These results suggest that it is possible to create a common core curriculum for training for RNs to work in ambulance care. Moreover, a continuous development of the content of the training program based on the demands from the evolving health care sector is desirable.