Emergency medicine is a field of practice based on knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury. These affect patients of all age groups with a full spectrum of episodic, undifferentiated, physical and behavioural disorders. It also encompasses an understanding of the development of prehospital and in-hospital emergency medical systems and the skills necessary for this development (International Federation of Emergency Medicine, 2019). Over the last two decades, emergency medical services (EMS) have come to play an increasingly important role in the Danish healthcare system. EMS have traditionally been used as a hospital support function, focusing on ensuring safe and reliable transport from the scene of an emergency to the nearest hospital. Today, it offers high-quality prehospital care by specialised professionals, and is tightly integrated with other healthcare services (Healthcare Denmark, 2019). To be successful in prehospital emergency care, a qualified and competent prehospital team with sufficient training regarding quick decision-making, resuscitation, invasive techniques, airway and trauma management is necessary (Carhart, 2014).
Traditionally, a standardised continuous medical education (CME) programme has been used, which, in Denmark, includes up to 5 days of supervised annual training. In addition, the emergency medical technicians (EMTs) and paramedics have the option to carry out self-directed training at their local ambulance stations, to maintain a high level of performance and skill.
Motivation is vital for the ability to learn, but is highly dependent on the individual trainee (Gostlow et al, 2017). It requires attention, self-awareness, honest self-assessment and genuine self-discipline, to develop self-regulated learners (Zimmerman, 1990). Motivation is acknowledged as one of the most significant psychological concepts in education, because of its well-established relationship to learning and performance outcome (Vallerand et al, 1992). EMS personnel want to carry out self-directed learning (Williams et al, 2013), but the work environment, pressure, and training facilities can impact their motivation (Tagawa, 2014; Li et al, 2010). Previous studies have suggested that local access to training facilities is beneficial for the learning environment (Bannon, 2000; Gostlow et al, 2017).
The aim of this study was to evaluate whether easy access to local training facilities would improve EMS personnel motivation for self-directed training.
The Zealand Region
The Zealand Region in Denmark has around 832 500 inhabitants (Statistics Denmark, 2017). Even though healthcare is a public responsibility, the politicians in the Region have hired the private company (Falck) to operate the ambulances. The region is divided into four sections, the north, south, east and west. The eastern section consists of five ambulance stations, with 118 full-time EMTs and paramedics (referred to here collectively as EMS personnel). Stations 1 and 3 are the largest stations in the area, with the highest number of EMS personnel employed.
EMS personnel in Denmark are divided into three levels. Level 1 EMTs have completed basic Danish EMT education and assist level 2 EMTs and paramedics. Level 2 EMTs have at least 18 months of experience as level 1 EMTs and are able to perform patient treatment and assessment. Paramedics have at least 3 years of experience as level 2 EMTs and have more responsibility regarding medication and patient handling (University College of Northern Denmark, 2016; Fag og Arbejde, 2020; Retsinformation, 2020a).
Throughout many years, the CME programme in the Zealand Region has consisted of 2–5 annual supervised training days, according to educational level. Level 1 EMTs have two annual days of training, level 2 EMTs have three, and paramedics have five. There are also two to three senior paramedics or supervisors per section (north, south, east, west), who can conduct supervised education and professional assistance, and are primarily used to perform the standardised annual CME (Retsinformation, 2020b).
Methods
Design and population
This was a pilot study with a before-and-after design method, conducted over 8 months. The primary purpose was to explore if easy access to training facilities, with training equipment and facilities would improve EMS personnel motivation to carry out self-directed training.
The population of this pilot study was 118 EMS personnel located on the five ambulance stations in the eastern section of the Zealand Region. Of the five stations, two were manned by the same personnel on rotation and so were counted as one station in the results (Station 1).
Data collection
Two questionnaires were used as research instruments; an initial questionnaire to establish a baseline and an identical follow-up questionnaire to measure the effects of interventions. The questionnaires were self-administered and accessible via a web-link to an online survey. They were distributed through local newsletters, emails and printed posters at the ambulance stations.
The questions were developed by the author of the study. As the study originally began as a local improvement project and was not anticipated to become a study at the time of questionnaire development, the questions have not been subject to further validation. The questionnaires explored each individual's rating of their own level of motivation, training effort, professional level, and the standard of the local training facilities, on a scale from 1–10, with 10 being the best. The initial questionnaire was distributed between 30 April and 4 June 2018 and the follow-up questionnaire was distributed between 19 November 2018 and 31 December, 2018. The intervention period between the initial and follow-up questionnaires was 5 months.
Training interventions
The interventions were initiated from June 4th, 2018. Several initiatives were introduced:
No additional or extra training time was given. Training time was therefore only available in between callouts.
Ethical considerations
Though this study did not need ethical approval (according to the Danish National Committee on Health Research Ethics j.nr. 19089087), several ethical considerations were made.
As described in the Helsinki declaration and according to the General Data Protection Regulation, the author is bound to protect the identity and personal information of participants. The study was therefore conducted anonymously online, so that no specific identity was known to the author. The names of the ambulance stations were known by the author, but have been anonymised in this publication in order to prevent any form of identification.
Because of the anonymous data collection, no approval from the Danish Data Protection Agency was needed. The collected data was kept secure and was only accessible to the author.
To obtain personal consent in accordance with the Helsinki declaration, the participants were informed of the purpose of the study, that participation was voluntary and that they could choose to withdraw their participation at any time, before completing the questionnaire. Furthermore, they were informed that the questionnaire was anonymous and that their identity was unknown in the results at all times, including at publication. Completing the questionnaire was regarded as personal consent to participate in the study and to allow the data to be published.
In the study period, the author was working in the study area, but was excluded from the study. The author did not intervene, or actively encourage training, so as not to affect the results of the study. There was no economic gain for the involved participants, which could affect the results. The private ambulance company was informed, and they approved the research being conducted in their facilities.
Data analysis
Data were expressed as the average of individual ratings and standard deviation (SD). Frequencies were reported as absolute values and the developments described as both a numeric and a percentage value. As this was a pilot study, and because of the author's limited experience in statistical procedures, no further statistical analysis was performed.
Results
The results are presented in Table 1. Response rates were 58.5% (n=69) for the baseline questionnaire and 65.25% (n=77) for the follow-up. The increase in response rates was only seen at stations 1 (+3.23%) and 3 (+25.0%). No change in response rates was seen at stations 2 and 4.
| Initial | SD | Follow-up | SD | +/- | +/- (%) | |||
|---|---|---|---|---|---|---|---|---|
| Q1 | Where is your primary workplace? | |||||||
| Station 1 | 31 | 32 | +1 | +3.23 | ||||
| Station 2 | 8 | 8 | 0 | - | ||||
| Station 3 | 28 | 35 | +7 | +25.00 | ||||
| Station 4 | 2 | 2 | 0 | - | ||||
| Total | 69 | 77 | +8 | +11.59 | ||||
| Q2 | How would you rate your current professional level? (0–Could be better / 10–Really good) | 6.6 | 2.0 | 6.9 | 1.8 | +0.3 | +4.55 | |
| Q3 | How would you rate your current effort in carrying out self-directed training? (0–Could be better / 10–Really good) | 4.8 | 2.2 | 5.9 | 2.5 | +1.1 | +22.92 | |
| Q4 | How often have you been carrying out self-directed training within the last month? | |||||||
| Every shift | 6 | 12 | +6 | +100.00 | ||||
| Every second to third shift | 29 | 37 | +8 | +27.59 | ||||
| More infrequently | 34 | 28 | -6 | -17.65 | ||||
| Q5 | How would you rate your potential for professional development? (0–I have reached my full potential / 10–I have great potential for development) | 7.8 | 2.3 | 7.4 | 2.5 | -0.4 | -5.13 | |
| Q6 | How would you rate your current motivation for professional learning? (0–Could be better / 10–Really good) | 7.0 | 2.4 | 7.6 | 2.5 | +0.6 | +8.57 | |
| Q7 | How would you rate your current level of motivation for self-directed training? (0–Could be better / 10–Really good) | 5.6 | 2.5 | 6.7 | 2.8 | +1.1 | +19.64 | |
| Q8 | How would you rate the possibility of carrying out self-directed training (according to time, workload or facilities)? (0–Bad / 10–Really good) | 4.1 | 2.7 | 5.9 | 2.8 | +1.8 | +43.90 | |
| Q9 | Which parameters do you feel are the most important factors for your motivation to carry out self-directed training? (More answers possible*) | |||||||
| Accessibility of training equipment | 55 | 61 | +6 | +10.90 | ||||
| Payment for training | 19 | 13 | -6 | -31.58 | ||||
| Coaching from an instructor | 39 | 30 | -9 | -23.08 | ||||
| Collegial coaching | 50 | 50 | 0 | - | ||||
| Other | 10 | 8 | -2 | -20.00 | ||||
| Q10 | How would you rate the training facilities on your ambulance station? (0–Inadequade / 10–Really good) | 3.7 | 2.5 | 6.3 | 3.0 | +2.6 | +70.27 | |
Regarding current level of training effort, on a scale from 1–10, the rating increased from 4.8 to 5.9. The frequency of training sessions completed increased, with six carrying out training every shift in the initial questionnaire to 12 in the follow-up, and 29 carrying out training every second to third shift in the initial questionnaire to 37 in the follow-up. The rating of the possibility of carrying out self-directed training increased from 4.1 to 5.9 and the rating of the training facilities increased from 3.7 to 6.3.
When asked about current motivation for self-directed training, the rating increased from 5.6 to 6.7. The motivation for professional learning increased from 7.0 to 7.6.
When assessing current professional level, the rating increased from 6.6 to 6.9, but the rating of potential for professional development decreased from 7.8 to 7.4.
The results also revealed that accessibility (n=61), collegial coaching (n=50) and coaching from an instructor (n=30) are the most important factors for motivation. Other reported factors for motivation were payment for training, training in warm areas, monthly themes, designated training time, mandatory training, quality training mannequins, available textbooks, coaching via e-learning, and training opportunities targeted at students.
Discussion
This study investigated whether motivation for self-directed training could be improved by easy access to training facilities.
The results showed a general increase in motivation for both learning and training. The frequency of training sessions completed also increased. Furthermore, after intervention participants reported a higher rating of the possibility of carrying out self-directed training.
Motivation is a subjective feeling and is highly dependent on the individual trainee, because it requires openness to change, genuine self-discipline and acceptance for one's learning (Zimmerman, 1990; Gostlow et al, 2014). Therefore, the training facilities were also evaluated via applied questionnaires. If EMS personnel were not open to change and did not see the initiatives as positive, there was no reason to think it might improve their motivation. However, in assessing the results, there was an increase in the rating of the local training facilities in the follow-up questionnaire. This gives the impression that EMS personnel saw the initiatives as positive, and it can therefore be assumed, that their motivation might be improved by them.
Furthermore, the results showed an almost 12% increase in respondents, which suggests a link between motivation to participate and motivation to carry out self-directed training. An increase in response rate was only seen on the two largest stations. On the two smaller stations, no change in response rate occurred. In future studies it may be of interest to explore possible explanations.
Both the initial and follow-up questionnaires showed that accessibility of training equipment was the most important factor influencing motivation to carry out self-directed training, followed by collegial coaching. This fits well with the assumption that EMS personnel value local training facilities (Bannon et al, 2000). In the follow-up questionnaire, there was a decrease in the reported rating of the need for coaching by an instructor and payment for training, which suggests that, if training equipment is easily accessible, these two parameters are perceived as being less important. This is in contrast to other studies, which found that learners need support and facilitation for them to be motivated to perform self-directed training (Regan, 2003; Tagawa, 2008).
Time is also an important factor in motivation, according to the participants. This is in line with another study, which recommends mandatory time for training (Martin, 2006). With an increase in ratings of both self-directed training effort and the frequency of training sessions completed, the results in this study suggest that when time to prepare training sessions is minimised, EMS personnel find time to carry out self-directed training, even without extra designated time for training.
Furthermore, the results show an increase in participants' rating of their current professional level following intervention, which fits well with the more frequently completed training sessions. However, there was a minor decrease in the rating of the potential for professional development. This result does not match the increase in motivation, which should have a positive effect on future development, according to Martin (2006).
Because this was a pilot study conducted without a fixed participant group, it was impossible to measure specific changes in motivation. Therefore, the findings in this study only suggest that the interventions had a positive effect. In future studies, it would be beneficial to include a fixed controlled participant group and the use of further statistical analysis of the results. Furthermore, a validated research instrument should be used.
Limitations
There are some limitations to this study. The study was conducted without a fixed participant group, which makes it impossible to say whether the respondents in the questionnaires were those who were most motivated, or if it was a representative selection of EMS personnel in the area.
The study was conducted over a period of 8 months, without a fixed participant group, therefore there is a possibility that some of the initial respondents changed job and were unable to complete the follow-up questionnaire. Some of the respondents in the follow-up questionnaire may also have been new employees.
The questionnaire was developed by the author of the article. However, no validation instrument was used.
No power calculation was made, due to the author's limited experience with statistical procedures. Therefore, no calculation of the statistical significance of the results has been conducted.
Furthermore, the study was conducted in the aftermath of union negotiations regarding pay and work conditions in the private ambulance contractor. The resulting general negative attitude towards the results of these negotiations may have influenced the results of this study, as some EMS personnel may not have desired to participate in the study or carry out self-directed training without payment.
Finally, the physical facilities, regarding buildings and space, turned out to be a challenge as three stations had only limited space for training areas. One station had the training area placed in a non-heated garage.
Conclusion
Many factors were found to impact the motivation of EMS personnel to carry out self-directed training. The most frequently reported factor was accessibility of training equipment and this was supported by individual ratings. With an increase in ratings regarding motivation and effort for carrying out self-directed training, this study suggests that initiatives to make training facilities more easily accessible improve motivation for self-directed training in EMS personnel.
Due to the lack of a fixed participant group, this pilot study only suggests an improvement. In future studies it would therefore be beneficial to include a fixed group of participants and further statistical analysis, in order to evaluate the possible effects of interventions to improve motivation.