Plan de implementación

As the speciality of emergency preparedness develops, there is an increased emphasis on developing and providing credible, beneficial and affordable

training in order to equip healthcare workers with the knowledge and skills necessary to deal with an unexpected major incident (Ingrassia et al, 2014. Hammad et al, 2011. Heinrichs et al, 2010. Hynes, 2006. Markenson et al, 2005).

Guidance on the frequency of emergency preparedness training suggests that “as a minimum requirement, NHS organisations will be required to

undertake a live exercise every three years; a table-top exercise every year and a test of communication strategy every six months” (DH, 2005; p5). A

resulting limitation is that not all staff will be on duty (for example, annual leave, sick leave, maternity leave, study leave) during these organisational training events. Consequently, a proportion of staff may not be exposed to any emergency preparedness training (Baack & Alfred, 2013. Boyd et al, 2012. Conlon & Wiechula, 2011). No formal examination of knowledge gained or retention is required, therefore the effectiveness of this training is not known (Boyd et al, 2012. Hammad et al, 2011. Powers, 2007). These studies appear audit based, confirming the proportion of staff who have undertaken mandatory training, with little awareness of how these individuals experienced this training.

A range of standard emergency preparedness mandatory training packages exist, resulting in potential variations of non-standardised content and the possibility of a non-coherent approach, limiting the possible effectiveness of this training (Boyd et al, 2012. Kollek, 2009. Hammad et al, 2012. Powers, 2007). Whilst it could be argued that different geographic regions have

specific preparedness requirements (urban cities versus rural locations), the lack of an agreed mandatory approach may result in certain localities focusing on, for example, leadership and communication skillsand

organisational provision, rather than the individual workers requirements, whereas another Trust may focus purely on clinical skills. This potentially results in staff with differing knowledge bases and different deficits of knowledge. In addition, a non-standardised approach is problematic when staff move between regions or are required to work together during major events or large incidents. There is no national teaching framework or accreditation process, therefore any individual who deems themselves as suitable, can teach emergency preparedness to their staff. This potentially impacts on the quality, content and credibility of the education provision (Boyd et al, 2012. Daily & Birnbaum, 2010. Chaput et al, 2007).

Training and education appears to focus on organisational response (Djalali, 2014, Whetzel et al, 2013), core knowledge (Worrall, 2012. Veenema, 2007. Weiner, 2005a), equipment use (Arbon et al, 2013. Worrall, 2012) and clinical skills development (Franc-Law et al, 2010. Heinrichs et al, 2010). There is not evidence that this preparation considers the individual workers requirements, personal context or their experience within this area or builds this into other aspects of response. Further information on this area is required to ascertain the impact of the lack of knowledge of the individual workers experience within their emergency preparedness work.

An additional training implication of emergency preparedness is financial, time and resource costs (DH, 2005). Emergency preparedness training occurs alongside mandatory training, including basic life support and manual handling. However, justifying the allocation of limited resources for planning of low probability incidents can be challenging (Cohen, 2013b. Willis, 2007). Releasing clinical staff to attend mandatory training sessions can have a detrimental impact on staffing levels and a negative financial impact on the Trusts finances. However, training is thought to be an essential component of preparedness (Worrall, 2012. Conlon & Wiechula, 2011. Fung et al, 2009. Wong et al, 2006, NAO, 2002. Haywood, 2003). The current economic climate in the UK has resulted in hospitals cancelling mandatory study days (Jones, et al, 2014.Boyd et al, 2012. Haywood et al, 2006), favouring in-house training (as opposed to national standardised courses), which has a potential impact on staff preparedness and variation in clinical practice between regions.

With a lack of guidance on training content and the pressure on time and money, innovative methods of training for staff are required. Various teaching methods, including table-top exercises, DVDs, live drills and

computer simulation are used in clinical practice (Araz & Jehn, 2012. Cohen et al, 2012. Hammad et al, 2012. Boyle et al, 2007. Powers, 2007). These different educational modes each have their own impact on time, financial resources as well as educational efficiency and credibility. It is recognised that limited frameworks for training exist, resulting in generic training being delivered (Cohen et al, 2013a. Franc-Law et al, 2010. Douglas, 2007,

Jennings-Sanders, 2003). The generic nature of this delivery does not appear to recognise the individual worker, their learning style and other personal characteristics that may impact on their motivation to learn and the efficiency of their learning.

Published audits of health-care workers knowledge of major incident plans, aims to determine knowledge recall of Trusts unique plans (normally delivered via in-house training). The literature describes how these plans are poorly remembered (Baack & Alfred, 2013. Milkhu et al, 2008, Wong et al, 2006 & Madge, 2004), which potentially results in an inadequate clinical response. The link between knowledge attainment and clinical practice is unclear through a small-scale audit, due to the static checking of knowledge, with limited consideration of application. In addition, these studies utilise medics as their sample population who by nature of their role, often move from Trust to Trust. The data from these studies concludes that knowledge retention is poor (Baack & Alfred, 2013. Milkhu et al, 2008, Wong et al, 2006 & Madge, 2004), but no study could be found replicating this audit within a pre-hospital care environment. Importantly for this thesis, current studies provide a poor insight into how practitioners absorb information, although they do identify some challenges in delivery.

Paramedic training has traditionally been skill-based. However the move from vocational training to a recognised profession has resulted in an increase in evidence-base to ensure that their training supports their evolving role as paramedic (Simpson et al, 2012. Shields & Flin, 2012.

Donaghy, 2008), with a move away from skills based training to a comprehensive higher education approach. Traditionally in the UK,

vocational training has been based on occupational standards that staff are expected to meet (Williams et al, 2010. Clements & MacKenzie, 2005). This competence-based training is popular in healthcare professions, but does not reflect the non-technical aspect of the paramedics role (Shields & Flin, 2012. Williams, 2010a).

The competency, practice led training traditionally found in pre-hospital care is often not evidence-based, rather it is practically based with minimal, underlying academic knowledge (Clements & MacKenzie, 2005).

Competency training encourages a minimum standard (Talbot, 2004. Rees, 2004), often viewed as a safe operational standard, and does not promote the idea of the evidence-based autonomous practitioner (DH, 2008). For competencies to be effective, knowledge evaluation must be evaluated and measured. The available literature does not demonstrate these points and no validated and standardised competencies exist.

Within this study, it is proposed that practitioner experience is a recognised form of evidence. This knowledge, gained from clinical experience, is

important to consider in practice-based professions. The literature recognises ‘professional craft knowledge’ and ‘practical know-how’ as an important form of knowledge, when used in conjunction with other forms of evidence (Powers, 2009. Rycroft-Malone et al, 2004. McCormack et al, 2002) and within the area of emergency preparedness this intuitive, practice-

based experience could be an important component of a developing evidence base (Boyd et al, 2012. Challen et al, 2012). This reflects the

concept of evidence as expressed by Staniszewska et al, 2014, as being made up on clinical, economic and practice-based evidence. The latter includes experiences as a focus of evidence.

Additionally, evidence suggests that preparedness education needs to be standardised and content needs to evolve from a defined evidence-base. This development requires recognition of core terminology and

consideration of the role that paramedics undertake (Daily & Birnbaum, 2010).

Preparation and education is important to paramedics, to prepare them for potential clinical experience. This clinical experience is discussed within the next section.