A Delphi Study to Ascertain
Future Educational Requirements
of Accident and Emergency
Nurses and Paramedics
Gary Morgan, Project Manager
Dr Matthew Cooke, University of Warwick
Part of the Shared Learning Opportunities Project, a
partnership between the acute hospitals of Coventry
and Warwickshire and Warwickshire Ambulance
Service NHS Trust
Supported by the Coventry and Warwickshire
Workforce Development Confederation
Introduction
This work formed part of a six- month research project on shared learning
opportunities between accident and emergency nurses and paramedics. The project
took place between April and October 2001 and required definitions of the future
skills, experience and professional attitudes of these two groups (in the five to ten year
time frame).
The Delphi study was initiated with the aim of determining the appropriate attributes
of each group as envisaged by experts in the appropriate field. The paramedic side of
the study was targeted towards the idea of a “practitioner” in order to accommodate
the changing role.
Further information on this work can be obtained from the project manager on:
nhsproject@supanet.com
Delphi Study
This type of study is a proven way of achieving reliable consensus from a group of
experts. It uses a technique of three rounds of questions to the experts in order to
achieve consensus.
In round one of this study, the experts are asked open questions so as to obtain their
views, unbiased by either the other experts or by the investigators. For round two all
the responses achieved in round one are collated into appropriate groups. The experts
are then asked to give their opinion of the importance of each of these factors. They
are asked to score this on a five point Likeart scale where one represents not required
and five represents essential requirement.
In round three all the results are collated and the same questions are sent out again.
The difference with the third round is that each person is able to see how many people
scored each point on the scale and is reminded of their own scale. In this way they are
given the opportunity to revise their score with knowledge of the other experts
opinion. The results of this third round then form the consensus opinion. Analysis is
then undertaken by creating a total score for each of the factors.
Progress
Initially the majority of work was in identifying appropriate participants. To make the
study valid, each group of participants had to contain a minimum of ten people.
Therefore a total of 26 people were identified on both the nursing and paramedic side
to allow for any reduction in responses as the study progressed.
On the nursing side the two groups were defined as:
• NAE: Accident and Emergency Nurse Managers. Sample taken from
hospitals offering acute Accident and Emergency services in the local area
(e.g. West Midlands, Trent regions).
• NHE: Nurse involved in Higher Education (e.g. senior lecturers). Sample
taken from list of institutions providing ENB approved courses relating to
acute care.
On the paramedic side the two groups were defined as:
• POM: Senior Operational Managers of Ambulance Services (e.g. Director of
Operations). Sample taken from West Midlands and Trent regions, with
additio nal from other regions to make up required numbers.
• PMA: Medical Advisors to Ambulance Services & Course leaders involved in
Paramedic Related Higher Education. Due to the very limited number of
institutions involved in paramedic related higher education, this group was
enhanced by medical directors of ambulance services. Sample was again
mainly taken from the West Midlands and Trent regions.
The initial round of questions are illustrated in figure 1.
Figure 1: Round One Questions
Paramedic Groups
1. What do you see as the skills required by a paramedic practitioner *?
2. What do you see as the experience required for someone to take up the post as a
paramedic practitioner (please be as specific as possible)?
3. What specific training do you believe a paramedic practitioner should have
achieved since their initial qualification?
* We envisage the role of a paramedic practitioner of the future as being in dealing with the
seriously ill and injured, treating minor conditions at the scene, deciding on the further health
care needs of the patient to a variety of health care sources and the ability to discharge patients
from the scene.
Nursing Groups
1. What do you see as the skills required by an experienced nurse working in an
accident and emergency department?
2. What do you see as the experience required for someone to take up the post as this
nurse in the accident and emergenc y department (please be as specific as
possible)?
3. What specific training do you believe an experienced nurse in accident and
emergency should have achieved since qualification?
These questions were sent out by email on the 9th May. Participants were asked to
return the study by 23rd May with the collation date set at 31st May. Reminders were
sent out on the 24th May to those participants who had not replied. The main initial
problem identified was the non-delivery of some emails (particularly to those using an
older system via the NHSnet). This was compounded by the fact that the sender was
not aware of this as non-delivery messages were not returned. To counter this, a web-
based address was then used (already set up in case of problems developing).
Collation of round 1 took place on the 21st May. The main problem initially apparent
was the overlap of answer areas over the three questions. This was in part due to the
general nature of the questions. This was resolved in round 2 following the
categorisation of the answers into each question area. The results from Round 2 were
collated and Round 3 sent out on the 13th August.
Results
The results from Round 3 are shown in Appendix 1. They are shown in question
order, with the columns representing the results from each participant group. A mean
score is given for each answer, together with the standard deviation (sdev) and the
number of replies for that answer (n=). A high level of agreement with the statement
is indicated where the mean score is 4 or above. A score of 2 or below indicates a high
level of disagreement with the stated answer. In question 2, the participants were also
asked to grade the time required where they thought the item was essential.
Accident and Emergency Nurses
Question one illustrates the wide range of skills that the participants expected the
experienced accident and emergency nurse to possess. As would be expected, many of
the current skills utilised are reinforced by the study. The essentials of patient
assessment are highlighted, particularly in the areas of history taking, questioning,
observation and triage. Consensus was found in the areas of using underpinning
theoretical knowledge in clinical decision making across all categories.
In the area of management, important skills were considered to be leading teams, risk
assessment and managing of disaster. It is possible that a more autonomous role is
being proposed, as organising and managing caseloads achieved a high consensus.
Finally, managing your own stress scored highly, a factor often given a high priority.
A relatively high consensus was found in all areas of teaching/evidence based
practice. Communication skills (written and verbal) scored highly, with an emphasis
also on good communication with other professionals and patients. A very high
consensus was found in the areas of care of the bereaved and defusing violent
situations.
As would be expected, many clinical skills (for example basic life support, vital signs,
wound care, splinting and plastering) were found to be essential. The study again
showed in this section a move towards more autonomous practice, for example in 12-
lead ECG interpretation. In terms of advanced life support, there was consensus in the
areas of defibrillation and drug administration. Opinion was divided over the more
advanced skills in trauma and paediatrics. Infection control, hygiene/continence care
and moving/handling were considered essential. Consensus was also found in the
areas of venepuncture, cannulation, catheterisation and spinal immobilisation.
The autonomous practice section revealed areas (often beyond current scope of
practice without additional qualifications) that the participants believed to be
important. There was consensus towards the decision to initiate treatment and
administration of:
• Activated charcoal
• Anti-emetic (e.g. Metoclopramide)
• Aspirin
• Atropine (3mg in cardiac arrest)
• Atropine (for bradycardia)
• Entonox
• Epinephrine (1:10,000)
• Glucagon
• Glyceryl Trinitrate (GTN)
• Hartmanns
• Lidocaine (local anaesthesia)
• Naloxone Hydrochloride
• Oral antibiotics (selected)
• Oral painkillers (selected)
• Oxygen
• Paracetamol Elixir (Calpol)
• Salbutamol (Ventolin)
• Sodium Chloride (0.9%)
• Tetanus Toxoid
The degree of consensus was varied (differences can be seen in the mean and standard
deviations), indicating that the role of the nurse is probably undecided and may be
likely to change in the future. This was reinforced by the consensus towards other
autonomous practice areas.
Question 2 revealed the previous experience the participant’s thought the experienced
nurse should possess. As can be seen from the results, the only factor that gained
positive agreement was that the nurse should have previous experience in an accident
and emergency department. General comments alongside the answers were that no
one route was definable, and that many areas would be useful as an addition.
Question 3 indicated the level of theoretical training required. The minimum previous
academic qualification was at GCSE (or O- level). Opinions were divided over exactly
what further education qualification would be appropriate. However, 75% of
respondents thought a minimum of diploma level was appropriate.
There was consensus towards additional specific courses that would be beneficial (e.g.
ATNC/TNCC, PALS/APLS and ALS). Teaching/assessing, Manchester triage and the
ENB 199 courses also scored highly (although with variations in opinion).
Paramedics
As would be expected, many of the currently practised skills were identified as still
being relevant. The high scores in current patient assessment skills implied the
continued importance of this area in the future. Palpation (probably currently
underused) and mobility assessment were also considered important.
The high scores attributed to decision- making based on underpinning theoretical
knowledge would indicate that future training needs will need to be reassessed. This
appears particularly important in the areas of minor illness, injury and mental health,
which are not currently covered. Furthermore enhanced education may also be
required in anatomy and physiology, obstetrics and management of the sick child.
The management section produced different opinions within and between the groups.
Areas of risk assessment and awareness of the scope of other agencies were
considered important. No consensus was reached on teaching and assessment skills,
and the importance of critical appraisal of research was divided.
Communication skills were found to be important in all areas. Care of the bereaved
and defusing violent/aggressive situations were interesting additions to the current
portfolio of training.
Again, the current range of clinical skills was emphasised. In addition consensus was
reached in 12- lead ECG interpretation and the use of temperature in diagnosis. As
well as the underpinning knowledge in minor injuries mentioned previously, there
was also high consensus in the field of wound care skills. This encompassed aseptic,
dressing and wound closure techniques (including suturing and glueing) and
infiltration of local anaesthetic. Infection control was also deemed to be important.
Additional areas (that are currently being introduced) in advanced life support were
highlighted, including needle cricothyroidotomy and thoracocentesis. Other skills
where there was consensus, but to a lesser degree were intubation with rapid sequence
induction and male catheterisation.
The current* range of drug administration was supported with additional consensus
in:
• Benzyl Penicillin
• Chlorpheniramine (for anaphylaxis)
• Hydrocortisone
• Lidocaine (in local anaesthesia)
• Morphine Sulphate
• Oral antibiotics (selected)
• Oral painkillers (selected)
• Paracetamol Elixir (Calpol)
• Prednisolone
• Tetanus toxoid
• Tenectaplase
• Thrombolytics (other than streptokinase)
* Some examples are already in use in ambulance services. Those illustrated in bold
are already part of JRCALC guidelines.
Again the consensus varied according to group. Other drugs only reaching consensus
with one group included:
• Activated charcoal
• Amiodarone
• Ketamine
• Lorazepam
• Propofol
Finally, other areas of autonomous practice were agreed to be important, with again
wound management and minor trauma scoring highly. Discharge of patients requiring
advice and resolved emergencies were other areas of increased autonomy. Additional
skills proposed included the ability to refer directly to other agencies and the initiation
of blood tests.
In question 2, consensus was reached on the experience required for this role in the
following areas:
• Accident and emergency departments
• Anaesthetics/theatres
• Coronary care units
• Mental Health
• Minor injury units
• Obstetrics and gynaecology
• Orthopaedics
• Paediatrics
• Primary care
The degree of consensus was varied between groups. There are significant additional
areas above the current paramedic training.
The analysis of results to question three indicates variation in the academic level
required (other than the IHCD paramedic award). 75% of respondents agreed that a
minimum diploma le vel was appropriate. This implies that the actual requirement
above this level is at present undecided. Aside from this, additional specific courses
highlighted PHTLS and PALS as a very high consensus. MIMMS was also
considered important. Interestingly the A33 (Developing Autonomous Practice), a
nursing qualification, was highlighted by the operational managers.
Summary
Accident and Emergency Nurses
The results from the nursing study indicated that currently practised skills are
generally in line with future expectations. The exceptions were found to be in the
areas of autonomous practice, where in many areas an increase in current scope and
role was apparent.
Paramedics
The results from the paramedic study indicate that both underpinning knowledge and
skills will increase as the role develops. The study particularly highlighted the areas
of:
• Minor illness
• Minor injury (particularly wound management)
• Mental health
• Additional drug administration
• Discharge of patients and resolved emergencies
• Direct referral routes
Additional areas of training to enable the appropriate experience to be gained were
also highlighted.