Yesterday I pointed out some of the things that I think the LAS are doing wrong with respect to the post-qualification training of ambulance crews.
Today I hope to be a lot more positive and provide some solutions.
The one solution that I'm not going to discuss is the need to provide many more formal, multi-day and single day, training courses as I think that goes largely without saying.
The first problem is that we are still intent on chasing the pointless ORCON target, with too many calls, calls that are inappropriately triaged and not enough staff and ambulances training takes a back seat to pleasing the government.
One thing that has been mentioned a lot internally of late is that there are 400 new staff joining the service. If this is true then there should be enough staff to enable in-service training to really take off – if not then how have we managed to cope with the current number of staff?
Increased numbers of staff means that perhaps we might be able to take crews off the road for protected training days – days where Control won't be ringing constantly to see if the training is finished.
One day a month should be a protected training day. Lets assume twenty weekdays in a month – that means that 1/20th of staff could be trained every day. Surely we have enough capacity for 1/20th of staff to be off the road at once – with 400 people joining the service and plenty of people wanting to do overtime to pay their mortgage there shouldn't be a reduction in active road staff.
We should employ people who have a background in education to come up with a syllabus or framework for training. The syllabus should be reviewed every few months to take in new research and practice methods.
How much could you fit into twelve days of training throughout a year? Make them twelve-hour training days and you are looking at 144 hours of training a year. That should be enough to keep us up to date as well as reinforcing skills that we don't practice that often.
How would we pay for this? If we removed a few assistant to the assistant of the assistant director of operations (East London) and returned them to the road we would not only save money, but also get a few more road staff back.
The officers who provide this training should be educated outside of the service – they should be put on education courses that aren't connected to the NHS. This is how you bring in new ideas on educational theory.
Why, for instance, aren't the current training department investing in e-learning that staff can do on their own time? Why aren't they doing a podcast for crews to listen to as they commute into work? Why aren't they building a library of texts and research that we can use? Why aren't we all given an ATHENS account so that we can look up things ourselves?
Our service phones are capable of playing MP3 files – why aren't we using that to deliver training?
Should I really have to resort to looking up things on Wikipedia on my iPhone during my shift?
We need fresh new ideas that stretch the method of learning from the current 'Powerpoint slides being read out in a classroom' into something more engaging.
Why aren't we spending time in hospital to learn more from our colleagues there? I know that my experience of working in a hospital all those years ago makes me a better EMS.
An example of how this works really well are the heart attacks that we take into the angioplasty labs. When you take in your first one the staff ask if we would like to stay and watch – then they would talk us through what they were doing – and crews enthusiastically embraced this. It was interesting, useful knowledge presented in a really good way.
Then the crews, normally a cynical bunch, return to station and talk about how 'cool' it is and share their expanded knowledge with enthusiasm.
I've often called for the ORCON target to be scrapped – but for that to happen I think I'd need to kidnap the minister for health and demand it before I start sending him back in small pieces.
We should set up an internal standard for educating our staff – all staff should have X amount of hours training every year. That no more than 2% of training days can be cancelled. That staff should expect professional tuition. Standards that show everyone that the service is serious about training and maintaining it's staff.
It's not enough to throw education at people and expect it to stick. At least once every year staff should be assessed on their skills and knowledge and (with no risk of disciplinary action) should then, if they are found to be below standard, go for further training.
Currently if you have poor practice it is not recognised until a patient complains or dies. Then the person is disciplined and is either sacked or given 'advice and guidance' which means re-training. By assessing people regularly you can prevent these adverse outcomes and the need to 'punish' staff.
I've seen people with their hand position in the wrong place for CPR, I've seen people placing the leads for an ECG on the patient incorrectly – by assessing people we would be able to pick this poor practice up and correct it, hopefully before it becomes a problem.
I emphasise that this mustn't be a disciplinary procedure – instead it should be a way to re-train people before they end up being disciplined for poor practice.
By reaching out to other parts of the NHS we should get better at getting feedback to ambulance crews – was that patient I brought in getting the right care from me or did the doctors and nurses at the hospital just roll their eyes at my treatment of them and say nothing?
It is part of the job that I have only a limited time of patient contact and no real way of knowing if what I did for them was the right thing to do. The patient vanishes into the hospital and unless I make a real effort (and probably breach data protection legislation) I have no idea if my treatment of them was correct.
We should build a pathway from the hospital back to us road staff so that we can gain confidence in our treatment of patients and also so that any training issues can be flagged up.
It shouldn't just be restricted to hospitals – we should be sent out with social carers, district nurses and community psychiatric teams. We should be entering GP surgeries and learning about their jobs. Why aren't we going into medical education institutions to share our knowledge with the students there? The learning could go both ways there.
At present some of our patient report forms are audited – the last time I looked I'd had three report forms audited over the last two and a half years. The only feedback that I got was in a meaningless 'compliance' percentage, which if you look at it closely is incredibly statistically flawed.
(For example – for someone with a diabetic problem you get marked down if you don't treat for hypo- and hyperglycaemia at the same time. Which is impossible as they are mutually exclusive conditions. Also the marking criteria is out of date as the treatment has changed).
What we need is more regular feedback on our report forms by not forcing the team leaders who are supposed to do this onto the road to make ORCON targets.
We have an internal magazine – mostly it concerns itself with ambulance crews who have delivered a baby, or the survivor of a cardiac arrest meeting the crew who saved their life. Lots of little pieces about a crew treating someone for smoke inhalation following a house fire. Only a small part of it's content is concerned with training issues.
I would suggest that this balance needs to be flipped around. It's true that it's nice to celebrate our successes, but once you've read that type of story once or twice it gets old fast. Instead the training department should have a larger say in what goes into the magazine. New policies should be highlighted and case studies and foundations for home study should be more available. Isn't that more important?
We get a printed bulletin every week, but we don't always get it delivered to the station, nor do we always get the time to read it, there is only one printed copy per station (although it is also on the internal website) – meanwhile the internal magazine is sent individually to each member of staff. Which of these two approaches is more likely to reach the road staff? And which one is filled with 'feel good' stories instead of more important clinical updates?
Touching once more on communication – how can I learn about best practice, or even just simple little tricks from my fellow road colleagues? Currently there is no way to communicate our knowledge between us.
As an example I met an FRU from our of area on a recent job and he tied a head bandage in a new way that I'd never seen before and it worked really well. Without that chance meeting how else could he have shared that knowledge?
Our communication at the moment is very 'top down', what we need to have is some way of communicating around our own level and an easier way to communicate back up the management structure.
The easy way of doing this would be via an internal forum – we are many staff spread over a large geographical area – isn't that what internet communication was designed for?
Where is the internal training blog that allows comments? Where is the wiki of best practice? Where is the forum where ideas can be shared?
I can tell you from experience that blogs, wikis and forums are incredibly easy to set up and with the proper community rules are also easy to maintain.
So, in summation, what we need is protected training times that can't be cancelled, a and high standard for our education. We should use all the methods that modern teaching uses, including learning at a distance, e-learning and podcasts or videocasts that can be viewed on station or at home.
We should partner with hospitals, GP surgeries and medical education establishments to expand our experience beyond the back of our ambulance as this is something where knowledge could flow both ways. We should make feedback, both internally and externally, much simpler and encourage this discussion as much as possible.
We should use our existing communication pathways to better educate staff – there are huge problems at the moment due to the large area that we cover although by setting up the communication tools we can pretty much guarantee education.
Finally we should put education as a much higher priority than it is at the moment – without education all we road staff feel that we are doing is 'stopping the ORCON clock'. With education you will be able to get a highly motivated workforce that will result in improved performance, and more importantly, improved care.