Emergency health care professionals' experiences of factors that influence care quality and safety

www.sciedu.ca/cns Clinical Nu sing S udies 2015, Vol. 3, No. 3 ORIGINAL ARTICLE Eme gency heal h ca e p o essionals’ expe iences o ac o s ha in luence ca e quali y and sa e y Ma i Salminen-Tuomaala ∗1, Päi i Leikkola2, Eija Paa ilainen3 1School o Heal h Ca e and Social Wo k, Seinäjoki Uni e si y o Applied Sciences, Finland 2Seinäjoki Cen al Hospi al, Finland 3School o Heal h Sciences, Uni e si y o Tampe e, Sou h Os obo hnia Hospi al Dis ic , Finland Recei ed: Decembe 28, 2014 Accep ed: Ma ch 30, 2015 Online Published: Ap il 20, 2015 DOI: 10.5430/cns. 3n3p60 URL: h p://dx.doi.o g/10.5430/cns. 3n3p60 ABSTRACT In oduc ion: Mo e esea ch is equi ed on ca e quali y and pa ien sa e y, especially om he ca e p o ide pe spec i e. Aims and objec i es: The s udy desc ibes ac o s ha a ec he quali y o eme gency ca e as expe ienced by nu ses, pa amedics, hospi al and ambulance a endan s and p ac ical nu ses in ou -o -hospi al eme gency medical se ices. Me hods: Da a we e collec ed in Oc obe 2013 by semi-s uc u ed in e iews (n= 15) in Finland and analysed using induc i e con en analysis. Resul s: High quali y eme gency ca e is pa ien -cen ed, equal, p o essional, indi idualized and holis ic. I encompasses he ollowing a eas: p omp eme gency ca e on si e; p e en ion o pa ien de e io a ion; indi idualized holis ic ca e; a anging sa e ollow-up ca e; suppo ing he coping o pa ien s and amilies and; secu ing he sa e y o pa ien s and s a on si e and in ambulance. The ca e quali y ca e is a ec ed by p o essionals’ heo e ical and p ac ical compe ence and pe sonal quali ies, by he a ailabili y o equipmen , co-ope a ion, con ex ual ac o s, pe sonnel policy and by he ou come o consul a ion wi h a doc o . Conclusions: Eme gency ca e s a will be expec ed o p o ide inc easingly ex ensi e, holis ic ca e on si e. All s ages o he ca e pa hway should be e alua ed and compa a i e in e na ional s udies conduc ed o de ec de elopmen needs. Rele ance o clinical p ac ice: Consis en p ac ices and ins uc ions a e indica ed. Managemen needs o p omo e s a coping and mo i a ion by means o educa ion, ocusing on he ca e o olde pa ien s and clien s a ec ed by mul iple diseases, and on psychosocial and social p oblems o people a ec ed by alcoholism o social exclusion. Key Wo ds: Eme gency ca e, Quali y o ca e, Eme gency heal h ca e p o essional, Ou -o -hospi al eme gency ca e 1. INTRODUCTION Eme gency medical se ices (EMS) and ou -o hospi al ca e a e key a eas in heal h se ices, p o iding u gen ca e o acu ely ill o inju ed pa ien s and anspo ing hem o de ini- i e ca e uni s. De eloping he quali y o eme gency ca e is a cu en conce n, bo h in e na ionally and na ionally. In Fin- land, he ocus is on p omo ing pa ien sa e y, bu ew s udies ha e so a been conduc ed on eme gency ca e speci ically. [1] In Finnish legisla ion, [2] eme gency medical se ices a e de- ined as a combina ion o ou -o hospi al se ices p o ided unde he adminis a ion o hospi al dis ic s, mainly o as- sess pa ien s’ need o acu e ca e and ans e o hospi al. The Minis y o Social A ai s and Heal h Dec ee [3] u he s a es ha all isk managemen and sa e y planning in heal h and social se ice o ganiza ions mus s a wi h pa ien s and wi h ensu ing ha hey ecei e sa e, high quali y ca e. ∗Co espondence: Ma i Salminen-Tuomaala; Email: [email p o ec ed]; Add ess: School o Heal h Ca e and Social Wo k, Seinäjoki Uni e si y o Applied Sciences, Finland. 60 ISSN 2324-7940 E-ISSN 2324-7959 www.sciedu.ca/cns Clinical Nu sing S udies 2015, Vol. 3, No. 3 A g ea numbe o ecommenda ions exis , di ec ed a im- p o ing he quali y o heal h ca e. A na ional example is p esen ed he e: A Quali y Manual published by he As- socia ion o Finnish Local and Regional Au ho i ies lis s ou ac o s ha a e essen ial o he quali y o heal h se - ices; (1) quali y o se ing clien s (pa ien -cen edness and imeliness), (2) clinical quali y (compe ence, pa ien sa e y), (3) quali y o p ocesses (smoo h ope a ion o se ices) and (4) e ec i eness.[4] O hese, pa ien sa e y is a c i ical componen o quali y in EMS. [4] P o ision o pa ien -cen ed, indi idualized ca e can be seen as ano he cen al aspec o quali y. Fo pa ien s, indi idualized ca e has been shown o in ol e an expe ience o ecei ing suppo du ing ca e p ocedu es. [5–7] Op imally, pa ien -cen ed, indi idualized ca e combines a en ion gi en o a numbe o ac o s; he clinical ca e si ua ion, he pa ien ’s eac ions, his o he indi idual li e si ua ion and po en ial and willingness o pa icipa e in decision-making conce ning ca e. [6] I has also been poin ed ou ha besides a ending o he pa ien ’s unique needs a he igh ime, ca e p o essionals need o pay a en ion o he po en ial o he ca e con ex in seeking o help he pa ien .[8] High quali y eme gency ca e is also equa ed wi h expe se ices, which mee pa ien needs while also aking in o conside a ion he a ious s akeholde s. Quali y is seen o esul om he ca e p o essionals’ join commi men o e e y- hing hey unde ake in o de o help pa ien s. [9] As in o he coun ies, Finnish law equi es ha heal h ca e o ganiza ions ollow e idence-based p ac ices o ensu e high quali y ou - comes. [10] In u u e, he de elopmen o clinical eme gency se ices will ely on eal- ime elec onic in o ma ion abou he pa ien ’s medical his o y. [11] Finally, one mus also bea in mind ha as pa o hei e o o p omo e pa ien sa e y as an impo an quali y ac o , [12–15] ca e p o ide s need o look beyond he physical aspec o ca e. To be able o eel sa e, pa ien s also need suppo , p o ided by means o a com- munica i e con ac , in e aining hei iden i y and egaining equilib ium a e he acu e inciden .[16] The quali y o ou -o hospi al eme gency ca e canno be dis- cussed wi hou some idea abou he challenges u u e is likely o b ing. As in many o he coun ies, Finland’s popula ion is ageing apidly. An inc easing numbe o eme gency ca e pa ien s will be olde people wi h mul iple illnesses. Addi- ionally, ewe people a e nowadays ca ed o in ins i u ions, bu con inue li ing in hei own homes. Mo e o en han be- o e, eme gency ca e p o essionals will encoun e people in poo heal h. Guidelines on wha kind o ea men s o unde - ake will be equi ed. Ca e p o essionals may occasionally need o conside whe he o no o e ain om hea y ea - men s, bu also, mo e commonly han ea lie , hey will be expec ed o adminis e holis ic ca e on si e. Compe ence in ge ia ic acu e ca e will be e y much sough a e in u u e. Mo eo e , eme gency ca e se ices may be he only con ac ha people a ec ed by alcoholism, social exclusion o men- al heal h p oblems ha e wi h heal h se ices. I is c ucial ha well- unc ioning co-ope a ion ne wo ks a e de eloped and main ained be ween p ima y heal h ca e, eme gency so- cial se ices, home nu sing, subs ance abuse se ices and EMS.[1,17–19] Besides he challenges b ough on by a skewed age py amid, p o essionals wo king in eme gency heal h ca e se ices will ha e o ake on a numbe o o he complex asks. Thei wo k will ake place in an inc easingly in e na ional en i onmen , in which s uc u al changes a e common in heal h and social ca e o ganiza ions. C ea ing ne wo ks o se ices will be necessa y, al hough in Finland he e is also a co-exis ing endency o cen alize eme gency ca e se ices. Finally and impo an ly, in oday’s socie y, pa ien s and hei amilies ha e lea n o expec and demand indi idualized se ices. [11] The exis ing esea ch on EMS in Finland, conduc ed ei he om pa ien o ca e p o ide pe spec i e, mainly discusses nea -misses and ad e se e en s as ac o s ha a ec he qual- i y in eme gency medicine. [7,20–23] Mo e s udies a e needed om he pe spec i e o eme gency ca e p o essionals, o explo e hei concep ions and expe iences o ac o s ha con- ibu e o he quali y o ou -o -hospi al ca e ha hey p o ide. Thei expe iences will be aluable when seeking o de ec isks and p e en human e o s. [24,25] S udying ca e p o es- sionals’ expe iences o he wo k en i onmen , equipmen and ac o s ha a ec pa ien sa e y can also help o de elop he quali y o eme gency ca e.[26] Aims The pape discusses ac o s ha in luence ca e quali y and pa- ien sa e y in ou -o -hospi al eme gency ca e as expe ienced by eme gency ca e p o essionals. The same ac o s a e wo h conside ing in e na ionally. The s udy e eals de elopmen needs in he eme gency ca e pa hways ha a e in e es ing bo h na ionally and in e na ionally. 2. METHODS 2.1 Design The pu pose o he esea ch was o desc ibe ac o s ha in luence he quali y and sa e y o pa ien ca e as expe i- enced by eme gency heal h ca e p o essionals, ha is nu ses, pa amedics, hospi al and ambulance a endan s and p ac ical nu ses wo king in ou -o -hospi al eme gency medical se - ices. The e ms eme gency heal h ca e p o essional and eme gency heal h ca e p o ide will be used h oughou he Published by Sciedu P ess 61 www.sciedu.ca/cns Clinical Nu sing S udies 2015, Vol. 3, No. 3 s udy o e e o his g oup o p o essionals. The esea ch aims a p oducing new knowledge o be used in de eloping sa e, high quali y eme gency ca e o pa ien s u he . This s udy is a pa o a la ge p ojec on he quali y and sa e y o eme gency medical se ices in one hospi al dis ic se ing 200,000 inhabi an s. The p ojec aims a p oducing quan i a i e and quali a i e esea ch knowledge o ac o s ha a e associa ed wi h quali y and pa ien sa e y in ou -o - hospi al eme gency ca e. This a icle ocuses on he ca e p o ide pe spec i e. E en ually, he pe spec i es o pa ien s, amilies and ca e p o ide s will be inco po a ed. The o e all quali y p ojec sp ings om a s uc u al change in Finland in 2013, when he du y o o ganizing eme gency medical se ices was ans e ed om indi idual municipali ies o hospi al dis ic s un by join municipal au ho i ies. A quali a i e app oach based on semi-s uc u ed in e iews was selec ed o his s udy, because li le ea lie esea ch ex- is s on he quali y o eme gency medical se ices in Finland, especially om he ca e p o ide pe spec i e. The esea ch asks we e: (1) Wha is high quali y eme gency ca e like as expe ienced by hospi al eme gency heal h ca e p o essionals? (2) Wha ac o s a ec he quali y o pa ien ’s eme gency ca e as expe ienced by eme gency heal h ca e p o essionals? 2.2 Da a collec ion Da a we e collec ed by semi-s uc u ed in e iews (n= 15) in Oc obe 2013 wi hin a single hospi al dis ic in Finland. The hemes add essed in he in e iews in ol ed he quali y o ou -o hospi al eme gency ca e and sa e y, as expe ienced by he eme gency heal h ca e p o essionals. All he in e iewees we e asked he same ques ions. They we e eques ed o de- sc ibe (1) wha good quali y is in ou -o hospi al eme gency ca e, (2) wha i consis s o , and (3) wha ac o s in luence i . The olun a y pa icipan s, selec ed by disc e iona y sam- pling ou o a o al o 200 employees wo king in ou -o - hospi al eme gency se ices o he hospi al dis ic , consis ed o i e pa amedics, i e nu ses, h ee hospi al and ambulance a endan s and wo p ac ical nu ses. In Finland, nu ses hold a Bachelo ’s deg ee o equi alen , whe eas p ac ical nu ses and hospi al and ambulance a endan s (phased ou as a ce - i ica e bu s ill used in job desc ip ions) ha e comple ed a oca ional uppe seconda y quali ica ion. Pa amedics a e ei he nu ses o p ac ical nu ses specialised in eme gency ca e. Ten ou o hese p o essionals wo k in he so-called ad anced and i e in he basic le el o eme gency ca e. In Finland, eme gency ca e p o essionals can each he ad anced le el by aking a es o demons a e hei abili y o anspo pa ien s while main aining pa ien s’ i al unc ions and o ini ia e ad- anced ca e ( o example eme gency medica ion, 12 channel ECG, managemen o esusci a ion, in uba ion using ligh anaes he ic, ex e nal de ib illa ion). Ad anced le el eme - gency ca e p o essionals a e compe en in eaching a wo king diagnosis o choose app op ia e ac ion based on examina ions and in e iew. They mus also be able o manage medical escue ope a ions in ol ing mul iple pa ien s. Basic le el eme gency ca e p o essionals, on he o he hand, a e compe- en in ini ia ing basic li e-sa ing p ocedu es and in ensu ing ha he pa ien is no de e io a ed du ing anspo a ion. Eligible pa icipan s had a minimum o wo yea s’ wo k expe- ience in ou -o -hospi al eme gency se ices. The in e iews we e conduc ed indi idually in a peace ul se ing and aped wi h he pa icipan s’ consen . The leng h o he in e iews a ied om 60 o 80 minu es. 2.3 Da a analysis The da a we e analysed using induc i e con en analysis. [27] The ansc ibed ma e ial amoun ed o 124 pages using Times New Roman, on size 12 and single spacing. Fi s , he ma- e ial was ead h ough se e al imes. All he sen ences and uni s o hough ha seemed o ep esen an answe o he esea ch asks we e picked ou and w i en down as educed exp essions, e aining he o iginal o m as a as possible. Exp essions wi h he same o simila con en s we e g ouped unde he same sub-ca ego y. Sub-ca ego ies wi h simila con en s we e hen combined in o gene ic ca ego ies, which we e u he combined o o m main ca ego ies. Du ing he analysis, he in es iga o e u ned o he o iginal da a se e al imes o ensu e plausible in e p e a ion.[28] 2.4 T us wo hiness and e hical conside a ions The us wo hiness o he s udy will be discussed in e ms o he ollowing c i e ia sugges ed o he e alua ion o qual- i a i e esea ch: c edibili y, ans e abili y, dependabili y and con i mabili y. [29] Fi s , he c edibili y o he esul s is ensu ed by ample, ecen ly acqui ed in e iew ma e ial. C edibili y is u he inc eased by he ac ha in o man s ep- esen ed ou p o essions; nu ses, pa amedics, hospi al and ambulance a endan s and p ac ical nu ses, who had a g ea deal o expe ience o eme gency se ices and who could be ega ded as expe s in hei ield. Second, he ans e abili y o he esul s is enhanced by he desc ip ion o he in o man s’ p o essional backg ound and by a s ep-by-s ep desc ip ion o he induc i e con en analysis. Thi d, o s eng hen he de- pendabili y o he s udy, wo o he in es iga o s we e asked o e alua e he p og ess o he analysis om sub o gene ic o main ca ego ies. Fou h, he con i mabili y o he esul s is based on he illus a ion o con en s by means o o iginal 62 ISSN 2324-7940 E-ISSN 2324-7959 www.sciedu.ca/cns Clinical Nu sing S udies 2015, Vol. 3, No. 3 exp essions. The exce p s p o ide a conc e e illus a ion o he plausibili y o he esul s. Finally, s udy us wo hiness is enhanced by he in es iga o ’s expe ience o wo king in acu e nu sing ca e, e en hough he p econcep ions may also ha e a ec ed us wo hiness nega i ely. Le i also be added ha ecen legal e o ms and o ganiza ional change in eme - gency heal h ca e se ices may ha e shaped he eme gency ca e p o essionals’ expe iences. Resea ch e hical guidelines we e obse ed h oughou he s udy. [30] Pa icipa ion was olun a y and in o man s we e asked o hei consen , including he use o eco de . Be- o e he onse o he s udy, pa icipan s we e in o med bo h o ally and in w i ing abou he pu pose o he s udy, s o - age o apes, ansc ip ion and he app op ia e elimina ion o apes and w i en ma e ial. Pa icipan s we e awa e ha hei anonymi y was ensu ed and ha hey could wi hd aw a any ime. 3. RESULTS 3.1 High quali y eme gency ca e Eme gency heal h ca e p o essionals wo king in ou -o - hospi al se ices desc ibe high quali y eme gency ca e in he ollowing e ms: I is pa ien -cen ed, equal, p o essional and indi idualized; i means encoun e ing pa ien s holis i- cally and esponding o hei ca e needs; i p ese es li es, p o ec s pa ien s and seeks o p omo e he sa e y and con i- nui y o he pa ien s’ ca e. 3.2 Cons i uen s o high quali y eme gency ca e Acco ding o eme gency heal h ca e p o essionals, high qual- i y eme gency ca e encompasses he ollowing a eas o con- s i uen s: p o iding p omp eme gency ca e on si e; p e en - ing pa ien de e io a ion; p o iding indi idualized holis ic ca e; a anging sa e ollow-up ca e; suppo ing he coping o pa ien s and amilies and secu ing he sa e y o pa ien s and s a on si e as well as in he ambulance. The i s a ea, p omp eme gency ca e on si e en ails apid assessmen using he ABCDE P o ocol and unde aking app op ia e li e-sa ing measu es. “Good eme gency ca e esponds o he pa ien ’s needs, so ha he pa ien ge s he igh kind o help a he igh ime.” The second cons i uen o high quali y ca e, p e en ing pa- ien de e io a ion, equi es in ensi e pa ien obse a ion o de ec signs and symp oms o de e io a ing s a us. The aim is o p e en complica ions and u he b eakdown o i al unc ions. “Good eme gency ca e ensu es ha he pa ien ’s condi ion ne e , in any ci cums ances, de e io- a es.” Thi d, indi idualized holis ic ca e means encoun e ing peo- ple in a pa ien -cen ed and p o essional manne . Acco ding o he in e iewees, he essen ial ask is o assess he pa ien ’s li e si ua ion and o espond o he o his physical, psycholog- ical and social ca e needs. Physical illness may no always be he p oblem; he pa ien may need com o and help in acing loneliness o in dealing wi h ea s. The in e iewees s ess ha social and inancial p oblems seem o be on he inc ease. Especially aged people, immig an s and people a - ec ed by alcoholism and social exclusion may ha e special psychosocial needs ha need o be add essed u gen ly. The ou h a ea men ioned by in e iewees in his s udy is a anging sa e ollow-up ca e. This ques ion needs o be add essed al eady on si e, since no all pa ien s need o be anspo ed o hospi al. In his con ex , eme gency heal h ca e p o essionals ind i necessa y o assess isks o pa ien ’s coping and wellbeing and o examine he pa ien ’s and am- ily’s social si ua ion. The isks may be connec ed ei he wi h he pa ien ’s physical o psychological heal h o wi h his o he li ing en i onmen . Bo h psychosocial ac o s and he conc e e en i onmen need o be conside ed be o e i is possible o decide whe he o no he pa ien can be sa ely le a home. “Some g anny o example, i he e is a decline in he gene al condi ion, when she is aken away o u he ca e, she does no need o be alone a home and po en ial alls o wo se hings a e a oided.” The i h a ea b ough up by eme gency heal h ca e p o es- sionals is suppo ing he coping o pa ien s and amilies. This in ol es app op ia e counselling and suppo , based on he ca e p o essional’s assessmen o he si ua ion. Besides counselling, emo ional and conc e e suppo a e equen ly equi ed. O al counselling is no always su icien . I he pa ien and amily membe s a e e y dis essed, i becomes necessa y o w i e down ins uc ions on he app op ia e ca e o m o ensu e sa e y o ca e. “You should be able o ake in o conside a ion he whole si ua ion, i is no jus abou he po- en ial auma o symp om o illness, i is he whole li ing en i onmen and social si ua ion o he pa ien and o he hings ha a ec his abili y o deal wi h i and manage a home, be o e you can e en conside i he will cope a home.” Published by Sciedu P ess 63 www.sciedu.ca/cns Clinical Nu sing S udies 2015, Vol. 3, No. 3 The las cons i uen o high quali y eme gency ca e ha eme ged in his s udy is secu ing he sa e y o pa ien s and ca e p o essionals, bo h on si e and in he ambulance. When- e e possible, po en ial isks and h ea s o sa e y need o be an icipa ed. Ca e p o essionals may also need o eques assis ance om he police o ensu e bo h pa ien s’ and hei own sa e y. Occasionally, he pa ien ’s ca e may be delayed due o denied access o si e be o e he a i al o police, i e o escue uni s. Si ua ional sensi i i y and logical, consequen decision-making a e hus impo an quali ies in p o essionals p o iding high quali y eme gency ca e. These skills can be de eloped h ough expe ience and hey ha e a majo impac on he sa e y o pa ien ca e. “One has o wai , ha also a ec s he quali y o eme gency ca e in a way, how soon you ge he e, he e may be some he oin use , who has ches pain, and he e may be weapons o some- hing, and you canno jus go and s a helping immedia ely.” Table 1 depic s he cons i uen s o high quali y eme gency ca e as expe ienced by eme gency heal h ca e p o essionals wo king in ou -o -hospi al eme gency se ices. Table 1. Cons i uen s o high quali y eme gency ca e Sub-ca ego y Gene ic ca ego y Main ca ego y Unde aking li e-sa ing measu es P omp eme gency ca e on si e Cons i uen s o high quali y eme gency ca e P omp assessmen o he pa ien ’s condi ion E ec i e use o he ABCDE P o ocol De ec ing signs o de e io a ion P e en ing b eakdown o i al unc ions P e en ing he de e io a ion o pa ien s P e en ing complica ions Encoun e ing pa ien s in a p o essional, pa ien -cen ed manne P o iding indi idualized holis ic ca e Mee ing he pa ien ’s indi idual needs Assessing he pa ien ’s li e si ua ion De ec ing isks o pa ien ’s heal h and wellbeing Taking he pa ien ’s and amily’s social si ua ion in o conside a ion A anging sa e ollow-up ca e Assessing and suppo ing coping a home P o iding su icien counselling o pa ien s and amily membe s Suppo ing he coping o pa ien s and amilies P o iding emo ional and conc e e suppo o pa ien s and amily membe s De ec ing po en ial isks and h ea s on si e Secu ing he sa e y o pa ien s and ca e p o essionals on si e and in he ambulance Op imum use o assis ance om o he au ho i ies Consequen and logical decision-making 3.3 Fac o s ha a ec he quali y o eme gency ca e The analysis o he in e iews u he e ealed ha acco d- ing o eme gency heal h ca e p o essionals, he quali y o eme gency ca e is a ec ed by he ollowing ac o s: he eme gency ca e p o essional’s knowledge and skills; he p o- essional’s pe sonal quali ies; he a ailabili y o eme gency ca e equipmen ; he e ec i eness o co-ope a ion; con ex- ual ac o s; pe sonnel policy and he deg ee o success in consul ing a doc o . Eme gency ca e p o essionals’ knowledge and skills depend on hei educa ion and amoun o wo k expe ience. Skilled use o he eme gency ca e equipmen and applica ion o nu s- ing knowledge o p ac ice a e men ioned by he in e iewees as impo an componen s o he ca e p o essionals’ compe- ence. E ec i e o ien a ion o new employees is emphasized in his con ex . Second, ca e p o essionals’ pe sonal quali ies a e also seen o a ec ca e quali y and pa ien sa is ac ion. Ca e p o essionals’ cha ac e and pe sonali y in luence pa- ien s’ expe ience o he ca e. Thei wo k mo i a ion and ale ness le el also di ec ly a ec he quali y o ca e. Oc- casionally, a ious human ac o s and ca e p o essionals’ pe sonal p oblems may de e io a e he quali y o ca e. The hi d ac o ha eme ged om he analysis, he a ailabil- i y o eme gency ca e equipmen , depends on esponsible ca e and main enance o he equipmen . I is essen ial ha a e i s use, he equipmen is e u ned o i s place as com- monly ag eed upon. This p ac ice p omo es he quali y o ca e by sa ing ime. “We now ha e uni o m equipmen , which makes i easie o people, who mo e om one eme - 64 ISSN 2324-7940 E-ISSN 2324-7959 www.sciedu.ca/cns Clinical Nu sing S udies 2015, Vol. 3, No. 3 gency ca e uni o ano he , some imes in he middle o a p ocedu e. You jump in o ano he ambulance o help ou . I is an impo an pa ien sa e y issue, no only ha he equipmen is o high quali y, bu also ha hey a e simila , and each bag and cabine is equipped he same way, so you know whe e o ind hings.” In his s udy, he ou h ac o ound o con ibu e o high quali y eme gency ca e was he e ec i eness o co-ope a ion be ween eme gency heal h ca e p o essionals, pa ien s, ami- lies and o he pa ne s. When wo king wi h pa ien s and hei amilies, success ul co-ope a ion is especially buil on he ca e p o essional’s communica ion skills. Good co-ope a ion in ol es encoun e ing and counselling pa ien s and amilies on si e in a manne ha c ea es sa e y and encou ages amily membe s’ pa icipa ion in pa ien ’s ca e a home. The ca e p o essional’s abili y o communica e e ec i ely wi h he pa ne a wo k as well as wi h police and escue au ho i ies a e also c ucial o lexible and e ec i e ca e. Si ua ional sensi i i y is equi ed o smoo h co-ope a ion. “The e a e so many mo ing pa s because he e a e a lo o people in ol ed. E e y si ua ion is di e en .” Fi h, ac o s associa ed wi h he eme gency ca e con ex and si e may ha e a g ea in luence on he quali y o he ca e p o- ided. The e a e always si ua ion-speci ic ac o s ha equi e a en ion. Con ex ual ac o s, o example da kness, slippe y oads o o he wise haza dous en i onmen may jeopa dize he sa e y o he si ua ion. Mul iple people may be a isk and in dis ess. “When you hink o ca ing o an indi idual pa- ien , some imes ac o s in he en i onmen a - ec he quali y, o example he e is an anxious amily membe who in e enes, so i is mo e di icul o concen a e on he si ua ion and you ha e o spend some ime on i be o e you ha e space o ca e o he pa ien , so some imes a well-meaning amily membe may complica e he si ua ion a li le.” “When you go o a la whe e he e a e a lo o in oxica ed people, he e a e g ea occupa ional sa e y isks and you mus concen a e on e e y- body, so ha no hing happens, so he e a e g ea isks in he en i onmen and ha a ec s how well you can ake ca e o an indi idual pa ien .” Acco ding o he eme gency heal h ca e p o essionals in- e iewed o his s udy, pe sonnel policy is an especially signi ican ac o ha a ec s he quali y o eme gency ca e. The ca e p o essionals eel ha suppo and encou agemen om he managemen enhances he wo k a mosphe e and p omo es hei wo k mo i a ion and coping a wo k. They also ind i impo an ha employe s main ain su icien hu- man esou ces and encou age con inuing educa ion. The managemen ’s in e es in ge ing o know he s a and in looking a e hei wellbeing and coping a wo k a e app eci- a ed. In con as , ca e p o essionals’ coping a wo k is ound o be unde mined by ans e s o o he posi ions and by o he o ganiza ional changes, which c ea e insecu i y, diminish he s a ’s coping esou ces and impai he unc ion o he whole uni . In Finland, he mos ecen challenge esul s om he ac ha eme gency ca e uni s, ea lie un by p i a e companies o by municipal escue au ho i ies, we e aken o e by hospi al dis ic s. Finally, one mo e ac o ha a ec s he quali y o eme gency ca e is consul a ion wi h a doc o . Eme gency heal h ca e p o essionals ind he consul a ion challenging, i he doc o on call is no amilia wi h eme gency ca e, does no know wha medicines and equipmen ambulances ca y o is no awa e o wha possibili ies he e a e o ea pa ien s on si e o in he ambulance. Consul ing a doc o who is no a na- i e speake o he Finnish language occasionally p esen s a isk o misunde s anding. On he o he hand, consul a ion is ound o succeed especially well i he ca e p o essional has ca e ully assessed he pa ien ’s condi ion be o e calling and i ins uc ions a e p o ided by an expe ienced expe eme - gency ca e physician. The quali y o ca e is also p omo ed by s anda dized ca e models and clea ins uc ions p o ided by physicians o long- e m use. Table 2 summa izes he ac o s ha a ec he quali y o eme gency ca e as expe ienced by he ca e p o essionals in e iewed o his s udy. 4. DISCUSSION This s udy accesses expe iences o nu ses, pa amedics, hospi- al and ambulance a endan s and p ac ical nu ses wo king in ou -o -hospi al eme gency medical se ices. Lea ning abou eme gency heal h ca e p o essionals’ expe iences is aluable, because hei desc ip ions o high quali y eme gency ca e and ac o s ha in luence he quali y o he ca e depic a pic u e o he eme gency medical se ices cu en ly p o ided in Finland. In his s udy, he quali y o eme gency ca e was ound o be associa ed wi h he ca e p o essional’s heo e i- cal and p ac ical compe ence, co-ope a ion, pe sonnel policy and con ex ual ac o s. Pa o he ac o s ha a ec he quali y o eme gency ca e a e si ua ion-speci ic and canno be con olled. Pe sonnel policy, howe e , is an a ea wi h po en ial o con ibu e o he quali y and sa e y o eme gency ca e. In o de o p o- Published by Sciedu P ess 65 www.sciedu.ca/cns Clinical Nu sing S udies 2015, Vol. 3, No. 3 mo e s a coping and wo k mo i a ion, pe sonnel policy mus be encou aging and suppo i e o con inuing educa ion. Knox, e al. [31] oo, emphasize he impo ance o con inu- ing educa ion in eme gency ca e. This s udy con i ms ha good communica ion be ween eme gency ca e p o essionals, pa ien s and amilies essen ially imp o es he quali y and sa e y o he ca e deli e ed. Fo example, consul a ion wi h non-specialis doc o s o immig an doc o s is po en ially challenging, as he ounda ion o common unde s anding is lacking. Close co-ope a ion be ween eme gency ca e p o es- sionals and doc o s p omo es pa ien sa is ac ion and quali y o ca e. [21] Mo ey, e al. [32] and Kilne and Sheppa d [33] sugges aining and p ac ising eam wo k o enhance com- munica ion and o minimize e o s in ou -o -hospi al eme - gency ca e. Fu he mo e, heal h ca e manage s can p omo e eme gency heal h ca e p o essionals’ wo k mo i a ion by inc easing oppo uni ies o pa icipa e in decision-making and in de eloping ca e quali y. Imp o ed mo i a ion is con- nec ed o highe quali y o ca e.[34] Wo king wi h a amilia pa ne in a wo k a mosphe e ha p omo es coping c ea es u he sa e y and dec eases he isk o aul y assessmen . I is also essen ial ha all eam membe s become commi ed o e alua ing and de eloping he quali y o hei wo k and ha he managemen demons a e an encou aging a i ude o p omo e he pe manency o s a .[35] Table 2. Fac o s ha a ec he quali y o eme gency ca e as expe ienced by/acco ding o eme gency heal h ca e p o essionals Sub-ca ego y Gene ic ca ego y Main ca ego y The ca e p o essional’s educa ion Fac o s ha a ec he quali y o eme gency ca e Skilled use o he eme gency ca e equipmen The ca e p o essional’s knowledge and skills The ca e p o essional’s wo k expe ience The ca e p o essional’s wo k mo i a ion The ca e p o essional’s pe sonal quali ies The ca e p o essional’s pe sonali y The ca e p o essional’s ale ness le el Human ac o s The condi ion o he eme gency ca e equipmen The a ailabili y o eme gency ca e equipmen Easy- o- ind eme gency ca e equipmen The ca e p o essional’s communica ion skills wi h pa ien s and amilies The e ec i eness o co-ope a ion The ca e p o essional’s communica ion skills wi h he pa ne a wo k Co-ope a ion wi h o he au ho i ies Eme gency ca e en i onmen Con ex ual ac o s The dis ess o people in ol ed in he si ua ion The numbe o people in ol ed in he si ua ion Suppo om managemen Pe sonnel managemen Su icien esou ces Pe sonnel policy Encou aging aining and educa ion Wo k a mosphe e The consul ing doc o ’s expe ise and expe ience The deg ee o success in consul ing a doc o The consul ing doc o ’s Finnish language skills S anda dized ca e models and ins uc ions p o ided by an eme gency ca e physician The a ailabili y o high quali y equipmen is ano he c i ical cons i uen o quali y in eme gency ca e. The pa icipan s o his s udy gene ally ind he quali y o he equipmen sa is- ac o y bu hey would app ecia e mo e aining on how o use i . Ca e p o essionals also indica e ha clea pe manen ins uc ions om expe ienced doc o s specialised in eme - gency ca e would inc ease pa ien sa e y. Simila ly, ea lie s udies ha e shown ha ca e p o essionals’ wo k expe ience 66 ISSN 2324-7940 E-ISSN 2324-7959 www.sciedu.ca/cns Clinical Nu sing S udies 2015, Vol. 3, No. 3 combined wi h clea ins uc ions con ibu e o high quali y eme gency ca e. [13,15,25] Ins uc ions signi ican ly in luence he success o he ini ial assessmen and o he en i e eme - gency ca e pa hway. [36] They can also help in he e o o each e idence-based, good p ac ices. [37] The wo k in eme - gency ca e, wi h i s cons an ly changing ca e si ua ions and encoun e s na u ally en ails s ess and s ain, which makes i all he mo e impo an ha ca e con inui y is ensu ed and sa e ins uc ions p o ided.[35] The inc easing sha e o olde popula ion and he g owing numbe o people a isk o social exclusion pose special challenges o pa ien sa e y in ou -o -hospi al eme gency ca e. P o essionals wo king in eme gency se ices will e- qui e mo e p o ound heo e cal and p ac ical compe ence in iden i ying he co e p oblem in olde pa ien s, who a e o en a ec ed by mul iple diseases and memo y impai men . Eme gency ca e p o ide s will also need o add ess a ious psychosocial and social p oblems ha indi iduals a ec ed by alcoholism o a isk o social exclusion su e om. 5. CONCLUSION The esul s o his s udy conduc ed in Finland highligh he need o pay a en ion o eme gency ca e p o essionals’ con- inuing educa ion needs. I is ad isable ha se e al p o- essionals sha e he esponsibili y o de eloping p ac ical o ien a ion p og ammes and o o ien ing new s a o he use o equipmen . The mo e expe ienced ca e p o essionals, oo, would bene i om a new app oach o con inuing educa- ion; as an inc easing numbe o pa ien s will be ea ed on si e, mo e ex ensi e and holis ic compe ence will be equi ed. Speci ic con en s o educa ion will mos p obably in ol e he acu e ca e o ge ia ic pa ien s, encoun e ing social p ob- lems and on-si e ca e o pa ien s a ec ed by men al heal h p oblems and in oxican abuse. Special a en ion should be paid o he de elopmen o si ua ional sensi i i y, commu- nica ion and consul a ion skills, which ha e a majo impac on ca e quali y and sa e y. Desc ibing all s ages o he ca e pa hway - he ca e on si e, in he ambulance and in hospi al eme gency depa men – would make all ac ion isible and help de ec needs o u he de elopmen . Rele ance o clinical p ac ice The ole o con inuing educa ion is essen ial in ensu ing ha ca e p o essionals possess he inc easingly holis ic and ex ensi e heo e ical and p ac ical compe ences equi ed as he sha e o pa ien s ea ed on si e only g ows. I seems ha p o essionals migh bene i om psychological aining, case s udies and simula ion educa ion, designed o p ac ice in e ac ion and communica ion skills. A na ional, e en in- e na ional consul a ion p o ocol migh p e en p oblems in communica ion wi h doc o s. Consul ing doc o s also need o be in o med o wha ac ion eme gency p o essionals wo king on si e a e able and allowed o unde ake. Secondly, he ocus o u u e con inuing educa ion should be on he acu e ca e o ge ia ic pa ien s, on encoun e ing social p oblems and on he ca e o pa ien s a ec ed by men- al heal h p oblems and in oxican abuse. An inc easingly indi idualized, holis ic app oach o he pa ien ’s si ua ion will be equi ed. REFERENCES [1] Kuisma M. 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The e ec o quali y ci cles on job sa is ac ion and quali y o wo k-li e o s a in eme gency medical se ices. In e na ional Eme g Nu s. 2013; 21(4): 264-270. h p://dx.doi.o g/10.1016/j.ienj.2012.10.002 [35] Kelly S, Fa aone. Imp o ing he ED Expe ience wi h Se ice Excel- lence Focused on Teamwo k and Accoun abili y. J Eme g Nu s. 2013; 39(1): 33-36. PMID:22513189. h p://dx.doi.o g/10.1016/j .jen.2011.12.015 [36] Fos e D, Goe zen B, Nolle e C, e al. Eme gency se ices leade - ship: a con empo a y app oach. Jones & Ba le Lea ning. 2012. [37] Shapi o SE. E idence-based p ac ice o ad anced p ac ice eme - gency nu ses. Ad Eme g Nu s J. 2007; 29(4): 331-338. h p: //dx.doi.o g/10.1097/01.TME.0000300115.09572. 8 68 ISSN 2324-7940 E-ISSN 2324-7959