International Emergency Nursing 51 (2020) 100890

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International Emergency Nursing

journal homepage: www.elsevier.com/locate/aaen

Prehospital emergency nurses’ experiences of care in critical incidents T

a,b,⁎ e,f b,e c d
Helena Sjölin , Veronica Lindström , Veronica Vicente , Håkan Hult , Charlotte Ringsted ,
Lisa Kurlandg
a
Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Orebro, Sweden
b
Department of Clinical Science and Education Södersjukhuset, Karolinska Institute, Sweden
c
Department of CLINTEC, Karolinska Institute, Stockholm, Sweden
d
Centre for Health Science Education, Faculty of Health, Aarhus University, Aarhus, Denmark
e
Academic EMS in Stockholm, Sweden
f
Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institute, Stockholm, Sweden
g
Örebro University, Dept. of Medical Sciences, Örebro University Hospital, Dept. of Emergency Medicine, Sweden

A R T I C LE I N FO A B S T R A C T

Keywords: Introduction: The ambulance care setting is complex and unpredictable and the personnel must prepare for
Ambulance upcoming assignments. Prehospital emergency care nurses (PENs), are frequently exposed to critical incidents
Critical incident (CIs). There are, to our knowledge, no prior studies describing experiences of requirements for management of
Experiential knowledge caring for a patient during a CI in the ambulance care context. Therefore, the aim of the study was to explore
Nurse
PENs’ experiences of care in CIs.
Prehospital emergency care
Method: A qualitative research design with content analysis has been used, based on semi-structured interviews
with eleven PENs in Sweden.
Results: PENs’ experiences can be described as: “In a critical incident, personal ability based on experiential
knowledge is central to patient care”. Three generic categories underpinned the main category: “Clinical ex-
pertise”, “Professional approach” and “Broad knowledge base”.
Conclusions: The care given during a CI in the ambulance care setting depends on PENs’ personal ability based on
experiential knowledge. Employers need to build an organization providing prerequisites and support during an
CI. Suggested activities are to create forums for PENs to share experiences with each other, possibility to get
feedback on completed assignments and continued training to develop new knowledge and be prepared for the
unpredictable environment that characterizes CI.

1. Introduction uncertain environments increasing stress levels [5,6]. A PEN needs to

The ambulance care setting is complex and the working environ-
ment is unpredictable [1]. Ambulance personnel are exposed to critical
incidents (CIs), potentially involving medical errors with risk to pa-
tients’ safety and affects the staff emotionally [2,3]. In the current
study, a CI was defined as an experienced, decisive event, dilemma or
episode during an ambulance mission that has affected prehospital
emergency care nurses’ (PENs’) in its work situation. The event, which
could be positive or negative, would include something “out of the
ordinary” that set it apart from everyday work [4]. This means that the
event itself has a minor role; it is the experience of performing care in
the situation, which is the studied phenomenon. Previous studies have
described PENs’ experience of emergency calls as stressful with
prepare for upcoming tasks, often with limited information, without
knowing or understanding what awaits. Hence, PENs must constantly
be ready for changes in the care situation [1]. This means that the PENs
need to have broad competencies such as professional skills, leadership
skills, communication- and collaborative skills and situational judge-
ment skills [7]. A previous study showed that the content of curricula in
the specialist nursing programme in prehospital emergency care in
Sweden predominantly focused on medical knowledge, particularly
medical science, clinical judgement, medical care and treatment. Nur-
sing and contextual knowledge were described to a lesser extent in the
curricula [8]. There are, to our knowledge, no prior studies describing
experiences of requirements for management of caring for a patient
during a CI in the ambulance care context. The new knowledge that this

⁎
Corresponding author at: Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Orebro, Sweden.
E-mail addresses: helena.sjolin@oru.se (H. Sjölin), Veronica.Lindstrom@ki.se (V. Lindström), Veronica.vicente@sll.se (V. Vicente), Hakan.hult@ki.se (H. Hult),
Charlotte.Ringsted@au.dk (C. Ringsted), Lisa.Kurland@oru.se (L. Kurland).

https://doi.org/10.1016/j.ienj.2020.100890
Received 2 July 2019; Received in revised form 6 May 2020; Accepted 12 May 2020
1755-599X/ © 2020 Elsevier Ltd. All rights reserved.
H. Sjölin, et al.
Fig. 1. Result, categorisation.
study can provide is expected to identify the ambulance nurse's need for
support in their professional practice and in this way create further
opportunities for safer patient care in an unpredictable environment.
Therefore, the aim of the study has been to explore PENs’ experiences of
care during CIs.
2. Methods
2.1. Study design
The study had a qualitative in-depth interview design. An empiri-
cally inductive approach was used to describe experiences of the phe-
nomenon studied [9]. The chosen design aims to gain a deeper un-
derstanding of PENs’ experiences of performing care during a CI.
2.2. Setting and participants
The study was carried out in Stockholm’s ambulance service in
Sweden. Recruitment of PEN’s took place after approval from the head
of the ambulance service. At least one Registered Nurse (RN) must staff
ambulances in Sweden [10]. Each county council then decides whether
there is a requirement for staffing with specialist nurses or not. In
Stockholm, one specialist nurse and one RN or Emergency Medical
Technician (EMT) staff ambulances. PENs have a specialist nurse edu-
cation in prehospital emergency care, involving courses totalling 60
credits including at least 30 credits for in-depth studies in Caring Sci-
ences [11]. In addition to specialist nursing programs for prehospital
emergency care, there also are ten other programs with different or-
ientations, such as anesthesia, intensive care and district nurse. Se-
venteen PENs from five different ambulance stations were purposefully
selected among Stockholm County Council employees. Inclusion cri-
teria were graduation from the specialist nursing programme in pre-
hospital emergency care and at least one-year full-time work in am-
bulance care and that they had experiences of CIs. PENs on leave of
absence or those with additional specialist nursing education were ex-
cluded. The informants received a letter with information and the op-
portunity to consent or refuse participation in the current study. They
also received information about the study aim and the current defini-
tion of a CI.
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International Emergency Nursing 51 (2020) 100890
2.3. Data collection
Eleven interviews were carried out between February and April
2015 with open-ended, semi-structured questions. The interviews
started with an open question: “Can you express your experiences of
caring in a CI”. After the main question, the interviews proceeded with
follow-up questions such as: “Can you elaborate more? and “How did you
feel?”. This was to help the PENs to stay focused on their experiences
and on the aim of the study. Data collection continued until no new
information was obtained during the interviews [12,13]. After the first
eight interviews, data saturation was experienced and then three fur-
ther interviews were conducted to ensure that nothing new about the
phenomenon emerged. Each interview lasted between 25 and 60 min
and was transcribed verbatim.
2.4. Data analysis
Data analysis was carried out using inductive content analysis ac-
cording to Elo and Kyngäs (2008) [14]. The analysis consisted of three
phases: preparation, organisation and reporting, a process of under-
standing the shift between different abstract levels of meaning [14].
The preparation phase began by reading all transcribed interviews
several times, to acquire an initial understanding of the whole tran-
script. During the organisation phase, the transcribed interviews were
divided into meaningful units, condensed to codes: single words or
short phrases, to uncover similarities and discrepancies in the data. By
relating the codes to each other, a pattern of meanings emerged that
generated a structure of subcategories, generic categories and a main
category. During the process of coding, sorting and categorisation, re-
curring discussions and reflections were undertaken by the research
group to ensure reaching mutual consensus in interpretation and to
avoid research bias [12]. In the reporting phase, subcategories, generic
categories and phenomenon: a main category, presented in a figure (see
Fig. 1) [14]. Quotations from the informants are included as explicit
examples, described here under “Results”. A certified English translator
has edited the quotations to ensure that nothing of importance has been
omitted or misinterpreted.
H. Sjölin, et al.
2.5. Ethical considerations
According to the World Medical Association’s Declaration of
Helsinki, the four ethical principles were considered [15]. This has
meant that the requirements have been met regarding information,
written consent, confidentiality and use when publishing. When there
was a risk that some CIs could tear down memories that could cause
psychological impact, follow-up support calls were offered if needed.
However, none of the informants expressed such a need. The study was
approved by the Regional Ethics Committee in Stockholm, Sweden
(Diary number 2013/1164-31/5).
3. Findings
Eleven interviews were conducted. Four women and seven men
participated, on average 34.8 years old with 4.5 years of experience as
PENs. They had completed their training as PENs at seven different
universities. The main category was expressed thus: “In a critical in-
cident, personal ability based on experiential knowledge is essential to pa-
tient care”. Three generic categories were found to underpin the main
category: “Clinical expertise”, “Professional approach” and “Broad
knowledge base”. The categories are presented in Fig. 1 by their sub-
categories and illustrated by quotations.
3.1. Clinical expertise
The result showed that the PENs experienced working in the am-
bulance service in unpredictable environments as requiring clinical
skills in critical incident management. Apart from a standard action
plan, they also needed alternative strategies based on previous experi-
ence and ingenuity for upcoming problems regarding patient care and
practical malfunctions. This generic category is illustrated by the three
subcategories: “Challenging decision-making”, “Action plans and strate-
gies” and “Unpredictable environment”.
3.1.1. Challenging decision-making
PENs experienced decision-making as challenging in several ways.
Knowing and understanding how to make correct decisions both in
critical- and non-critical situations was essential. The challenge lay in
limited time and limited information coupled with an action imperative
and the need to decide the order of actions in the management of the
situation:
“And in what order do I do this now? He is cold and wet and it is
snowing, and the environment is inappropriate […] – You want to
do everything at the same time… (no. 1)”
3.2. Action plans and strategies
Several PENs mentioned different types of decision tools as an ad-
vantage in CIs to facilitate decision-making and teamwork. They had to
have a ready action plan and alternative strategies for solving upcoming
problems, both practical and logistical. They experienced standard ac-
tion plans and emergency medical guidelines, for example resuscitation
in cardiac arrest, as helpful. However, sometimes PENs also experi-
enced the need to be able to solve upcoming problems by being in-
novative with creative solutions, which sometimes failed:
“Suddenly there is a new problem that you have to deal with, so
your thoughts are interrupted by something so unexpected […] and
then you have to change strategy, fast. It is not that easy.” (no. 4)
Solving problems with alternative strategies is not always about
patient care in a critical incident situation, it may also be related to
different types of devices. Dealing with malfunctions in healthcare
equipment and radio communication systems or problems with the
ambulance, might be one reason for not being able to accomplish a task
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International Emergency Nursing 51 (2020) 100890
or implement the necessary assessment or care:
“When we got into the ambulance, the side door had frozen and it
was 20 degrees below zero and I couldn’t close it.” (no. 3)
When PENs experienced not being able to solve the problem, they
fulfilled their care assignment anyway, and in the case above, they
drove the patient to the hospital with an open door, with the patient
strapped to the stretcher, wrapped in extra blankets to prevent hy-
pothermia.
3.2.1. Unpredictable environment
The ambulance care setting is an unpredictable environment, which
challenged PENs’ ability to prepare themselves mentally beforehand.
PENs prepared for the unprepared situation by creating a mental image
of the upcoming situation before meeting the patient but also in the
actual meeting with the patient. At the same time, strategies for pro-
blem-solving and care were also continuously created during CIs. In CIs
with suddenly changing situations, PENs experienced not being able to
think through the situation or not managing to change pace quickly.
PENs were aware of and used to not being prepared, and they expressed
the need to be able to adapt to unpredictable environments:
“We weren’t really mentally prepared when we got up (to the pa-
tient’s apartment) but at the same time you had to… it is one of our
strengths to be able to change focus when things change in the
patient’s condition.” (no. 4)
Another special circumstance included being prepared for working
in unsafe environments and the need for – and lack of – assistance.
Several PENs described different types of events in which they wanted
assistance but there was none available:
“So, we called for assistance […] but there were no other units
available to help us, either other ambulances, other emergency
service units, fire department or police, so we had to manage the
situation on our own.” (no. 4)
3.3. Professional approach
The results showed that the PENs experienced their professional
approach as essential in care situations. They had to bridle their own
emotional reactions despite the sense of chaos that a critical incident
could generate. They also needed the personal ability to create possi-
bilities for giving nursing care to patients despite communication bar-
riers and ethical conflicts. This generic category is illustrated by the
three subcategories: “Confident appearance”, “Managing communication
barriers” and “Awareness of ethical concerns”.
3.3.1. Confident appearance
PENs felt that they had to prove themselves calm and confident in
front of patients and relatives even though they felt insecure during CIs.
It also emerged that it was not until after the CI has ended that PENs
released their chaotic feelings:
“I know now, afterwards, that when I was in the situation, I seemed
to be quite calm and stable, but then later on I thought of what could
have happened. Then I was not calm and stable…” (no. 2)
3.4. Managing communication barriers
PENs experienced that one of the challenges was communication in
patient care. Communication barriers arose both due the medical si-
tuation and to language problems. Often, relatives had to help in
communication. Language difficulties and problems with interpreters in
communication with patients were raised:
“There were some language barriers. We had to let his relatives
H. Sjölin, et al.
interpret, and (how do we) know that they are interpreting cor-
rectly, i.e. Interpreting what I’m saying.” (no. 9).
Another problem was communication with patients with mental
illness who were also drug-addicted, violent or threatening. In order to
deal with such a situation, the ability to understand and predict a
possible development of the event based on environment and visual
impressions was needed. PENs used different strategies for handling
these situations:
“Many people who have mental health problems are also intoxicated
at the same time, or affected in some other way and it makes it even
more difficult […] When you enter (in to the apartment) […] you
quickly get an insight into the patient's everyday life. Just quickly
taking in what is in the apartment […] it also makes it possible to
talk to the patient” (no. 6).
3.4.1. Awareness of ethical concerns
Types of ethical concerns expressed in the interviews concerned
assignments involving child abuse and neglect, death, and cessation of
resuscitation in Out-of-hospital cardiac arrest, (OHCA). Encountering
children who might have suffered harm affected PENs:
“There were two severely intoxicated parents. One of them was
hardly breathing at all and the other just… and there were two small
babies in the apartment.” (no. 6)
PENs often experienced the desire to do more. There were also si-
tuations in which nothing more could be done and they had to deal with
and accept the situation as it was:
“When you look at the child and see that there is nothing more you
can do […] and the feeling of being powerless when you know right
from the beginning that you’re fighting against something that you,
like, see is impossible.” (no. 2)
PENs experienced how facing death, watching a person die, ceasing
resuscitation and notifying relatives that saving him was impossible,
was an ethically and emotionally challenging duty, especially the first
time:
“[…] this task, informing about death… We don’t declare someone
dead, but we sometimes terminate cardiac arrest resuscitation. But
we can’t just do it and walk away; it’s up to us to talk to the relatives
then.” (no. 2)
3.5. Broad knowledge base
PENs experienced working in the field of ambulance care as re-
quiring a broad knowledge base and, with increased experience, it in-
creases professional certainty in handling patients in CIs. PENs related
that professional expertise increases over the years and that assessments
and decisions taken around patients and their needs are based on in-
depth knowledge and a more reflective patient-ethical approach. This
generic category is illustrated by the two sub-categories: “Levels of
professional competence” and “Sufficient training”.
3.5.1. Levels of professional experience
In CIs, PENs are more vulnerable and in need of a broad knowledge
base. PENs experienced being novice in their profession or having an
inexperienced colleague as a challenge:
“I didn’t get any support from my colleague, because he was as
much of a novice as me, and he relied on me.” (no. 8)
Another informant related how collaboration with more experi-
enced personnel in the team was important for novices:
“My colleague was an emergency medical technician with extensive
experience; he and I took over the situation on scene and made
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International Emergency Nursing 51 (2020) 100890
things happen.” (no. 7)
The lack of specific experience, especially concerning children, was
mentioned. PENs expressed that they did not handle enough assign-
ments concerning seriously ill children which led to a sense of in-
security and lack of in-depth knowledge:
“I find critically ill children really tough, of course. That’s because I
haven’t worked with children earlier.” (no. 9)
3.5.2. Sufficient training
Perception varied concerning the content of the education that PENs
had undergone, but overall, they wished that they had had more
training in how to prepare themselves mentally and how to deal with
the unexpected. The subjects of severely injured patients, death, and
knowledge of transcultural differences were mentioned but everyone
stated explicitly that more knowledge was needed about the severely ill
children. PENs also experienced not receiving enough training in pre-
paring themselves mentally and dealing with the unexpected. An im-
portant aspect of the training, often mentioned, was that CIs did not
always turn out to be what they seemed from the beginning. Several
PENs said that their training consisted mainly of the theoretical
knowledge needed for decision-making in relation to the events de-
scribed. Specialist training varied widely but an overall comment was
that a broad knowledge base is essential and that the education is too
short:
“The ambulance nurse should be trained in such a broad knowledge
base and we only have one single year of education” and “when you
only have a little experience of being a RN before the specialist
training, there is so much to focus on.” (no. 1),
Some PENs described having lectures and discussions on ethical
dilemmas in CIs concerning death, for example ceasing resuscitation in
OHCA and dealing with relatives after unexpected death, but also re-
ported concerns for children suffering harm. Other PENs felt that they
did have training and discussions about seriously ill children, death,
severely injured patients and knowledge of transcultural differences.
The informants experienced the importance of discussing potential CIs
and how they might react. Lack of training concerning being prepared
to see “the worst-case scenarios”, was described:
“Actually, we did not discuss this aspect, how it feels to see a mu-
tilated body for example […], and that is something that would have
been pretty relevant to discuss, I think.” (no. 11)
3.6. In a critical incident, personal ability based on experiential knowledge
is essential to patient care
PEN experienced a requirement for personal ability based on ex-
perience knowledge to be able to provide care in a CI. This means that
they need clinical expertise when working in an unpredictable en-
vironment, and explicit strategies and decision-making skills in sudden
changing situations. They considered that their professional approach
was fundamental in care situations and that they must create possibi-
lities for giving nursing care to patients. PENs understood ambulance
care as being an experience-based profession and that with increased
experience, their professional certainty in handling patients in CIs in-
creased.
4. Discussion
The overall findings in this study shows that experience-based
knowledge is the most important factor in being able to provide good
care in a CI. Qualitative research seeks to understand the world from
PEN's perspective [13]. This study provides the opportunity to discover
new meanings in prehospital emergency care by using a qualitative care
H. Sjölin, et al.
science strategy. In this way, PEN's descriptions of their experiences
have contributed to a deeper and more nuanced understanding of care
in a CI.
The result shows that the PENs experienced a need of clinical ex-
pertise to be able to perform good care in a CI. Many of the CIs de-
scribed in the current study concerned multifaceted and complex in-
cidents which could arise in any situation, and PENs always had to keep
an open mind and be creative and adaptable. Most commonly, CIs in-
volved challenges of lack of time and information, inappropriate en-
vironment and sudden changes in the situation or being interrupting by
something unexpected. It is previously described how PENs’ worries in
CIs are related to specific nursing situations and environmental factors
[6]. Human factors were also shown to be the most important causes for
reporting incidents [2].
PENs experienced unpredictable environments and suddenly chan-
ging situations as necessitating the ability to make urgent decisions in
order to treat patients. Earlier studies add that the extent and severity of
the situation also play pivotal roles in making the best decision in the
given situation [16,17]. PENs face the challenge of being prepared for
the unprepared in every patient meeting. Previous clinical experience is
important in understanding the entire patient situation and managing
complex situations [1,18]. PENs also described needing to bridle their
emotions and simultaneously have a supportive approach to patients,
which means that they must maintain a professional approach in un-
predictable situations.
PENs must make their own decisions in uncertain conditions,
usually without any support from authorities. No one else can take over
that responsibility as in other healthcare professions, and not all com-
plex situations have a specified protocol [17,19]. Prehospital decision
tools may assist in reducing “time to definite care” and facilitate a
correct assessment of the patient's condition [20]. However, earlier
studies indicate that adherence to prehospital guidelines differs and
that content and evidence in existing guidelines vary [21,22,23]. Sev-
eral informants mentioned that limited or incorrect information af-
fected opportunities to make quick and correct decisions. This means
that the assessments and dialogue with patients may be inaccurate and
affect patient safety. It is important to be prepared and understand the
issue with this limitation and deal with the difficulties [1]. PENs need
therefore to be open-minded, having a professional approach and re-
main uninfluenced by preconceptions. It is necessary to create pre-
requisites for holistic patient care, including medical care and technical
skills [19]. Rantala et al. also argue that the quality of prehospital care
is “in the eye of the beholder” but it often relies on the relationship
between patient and PEN [24]. One of the barriers to getting and giving
information was difficulties due to communication, language and
comprehension. Several studies confirm that communication skills and
interpersonal relations together with experiential knowledge are key
abilities in CIs, and that PENs must be prepared for these situations to
avoid unequal care [25,26,27,28].
The PENs in this study felt that they need to maintain a professional
approach and be able to control their own emotions even though the
situation could be chaotic and contain aggravating circumstances.
PENs’ daily work contained ethical dilemmas to solve, many dealing
with child abuse or neglect and death. In such situations, ethical
competence is required, and these situations need to be trained in
practical and contextual situations [29,30]. One study showed that
prehospital providers perceive experiencing distress as a “regular part
of the job” and that there was a culture not to talk about it with other
colleagues [31]. However, knowledge and experience gained from
other colleagues or from working in the profession make situations
requiring complex ethical decisions easier and may also reduce negative
reactions to mental stress [17]. Reflection may also be a strategy to
identify attitudes towards emotional challenges in the ambulance care
setting [32]. Feedback on completed assignments (e.g. in OHCA) and
implemented nursing measures improve care for future patients [33]
and recurrent training may be a prerequisite for making appropriate
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International Emergency Nursing 51 (2020) 100890
care decisions.
The result also shows that PEN experienced a need to have a broad
knowledge base as they meet patients of all types and with every
conceivable disease state. Through increased knowledge and formal
competence, PENs’ clinical expertise is strengthened. Earlier studies
describe many ambulance nurses as feeling pressured, for example
when nursing critically ill children, often related to insufficient ex-
perience and knowledge [5,34]. This confirms that a broad knowledge
base is needed and that formal university education for PENs is only the
basic level of the education needed. Therefore, continued education is
essential for the development of prehospital emergency care. This re-
sponsibility should lie with employers in the ambulance service.
4.1. Limitations
The participants had similar educational background; all PENs had
graduated from the specialist nursing programme in prehospital
emergency care but from seven different universities. In Sweden, the
specialist nurse education is governed by “The Swedish higher educa-
tion act” which describes common learning objectives for each field
[35]. The university is responsible for ensuring that the student
achieves the common learning objectives in relation to the context but
formulates syllabuses independently. This means that the content may
differ between different universities, which can explain differences in
the PENs perception of preparedness for CIs.
The PENs also had varying degrees of experience as a PEN
(1–8 years) and consequently different years of graduation, which
means that the educational content and set up varied over time. The
sample should be representative but when time has passed, there is a
risk that participants will have forgotten precisely how events went and
their descriptions may be affected [36,4,37]. However, the definition of
a CI states that it is a retrospective, individual perception. Conversely, if
the incident is specific or extreme, the memory of it may be more vivid
[4].
PENs were selected among Stockholm County Council employees. It
may constitute a limitation that some PENs had only experienced
working in a metropolitan area, and their experience is not re-
presentative of working in a rural environment. However, most PENs
worked in the suburbs with proximity to both urban and rural areas.
Seeking PENs, the sampling strove for gender balance like that the
ambulance organisation. There were four women and seven men, a
proportion reflecting the gender balance in the ambulance service in
Stockholm at the time of the study and thus representative for the or-
ganisation.
A weakness with qualitative interview studies may be a low number
of people interviewed. However, the number of interviews is not con-
sidered decisive to achieve a credible result, but it is the content rich-
ness that determines [12]. In this study, eleven PENs, who told us in
detail about their experiences were interviewed, which was perceived
as sufficient. The trustworthiness of the study is reinforced by the fact
that authors (HS, VV) read the interviews independently of each other.
The authors then clustered the meanings into a valid structure and the
whole research team reflected on them. This multi-professional (HS, VL,
VV, HH, CR, LK) team is a further guarantee for the analysis that has
been carried out. Three of the authors (HS, VV, VL) have clinical ex-
perience of working as a PEN which strengthens their credibility;
however, this could affect the analysis, which has been counteracted by
the awareness of having to rein in their understanding.
5. Conclusion
The results show that PENs relied on personal ability based on ex-
periential knowledge in care when managing a CI. Based on our find-
ings, it is evident that employers and stakeholders need to build a
knowledge-based organization that both provides appropriate pre-
requisites and support to PENs during an ongoing CI, but also creates
H. Sjölin, et al.
opportunities for feedback and reflection afterwards. The experience
generated during professional practice is important, but it needs to be
enriched by the experience of others to be confirmed and developed.
This means that the staff must be able to share knowledge between each
other. Important prerequisites are: 1/create forums that enable PEN to
share experiences with each other to gain additional knowledge about
care during a CI in ambulance care. 2/feedback on completed assign-
ments and nursing measures implemented to gain understanding and
new knowledge from the experience. Furthermore, it is important with
continued training and simulation of CIs to enable PENs to manage
their strategies for meeting the unprepared.
CRediT authorship contribution statement
Helena Sjölin: Conceptualization, Methodology, Formal analysis,
Writing - original draft. Veronica Lindström: Conceptualization,
Methodology, Formal analysis, Writing - review & editing. Veronica
Vicente: Conceptualization, Methodology, Formal analysis, Writing -
original draft. Håkan Hult: Conceptualization, Methodology, Writing -
review & editing. Charlotte Ringsted: Conceptualization,
Methodology, Writing - review & editing. Lisa Kurland:
Conceptualization, Methodology, Formal analysis, Writing - review &
editing.
Declaration of Interests
We declare no competing interests. BAP, LAM and PvD acknowledge
that the intellectual property related to the miniPIERS prediction model
used in the CLIP trials was transferred in its entirety from the University
of British Columbia to them, among other inventors, prior to the trial.
They have no financial benefit from the use of the model based on the
transfer.
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