Flight nurse’s and Flight Paramedics perform as members of an aeromedical crew on helicopters (rotor wing), and airplanes (fixed wing) aircraft, providing for in-flight management and care for all types and ages of patients. Responsibilities of this job include the planning and preparation of each flight, to include such things as; safety, evaluation of an individual patient’s in-flight needs and request of appropriate medications, supplies, and equipment to provide continuing care from origination to the destination facility. They act as liaisons between facilities during an interfacility transport and from scene location to trauma center during medical and trauma related emergencies. They also initiate emergency treatment in the absence of a physician during in-flight medical emergencies. Flight nurses and flight paramedics have training in mechanical ventilation, hemodynamic support, vasoactive medications, airway, and other intensive care skills.
Most air medical businesses expect nurses to have at least 2 to 5 years of experience in emergency or critical care units, and the more trauma experience, the better (flightnursetraining.com). This means nurses that have a proven ability to manage multiple patients with vastly different conditions, as well as being able to make split-second decisions about patient care with maximum attention to patient care and safety. Flight paramedics are expected to have a minimum of three years current experience as a paramedic on an advanced life support team and/or critical care transport team. Both of these roles may have to tend to multiple critical cases all at once, so it is important that he or she have the skills to cope with high stress situations. Even though those hired into the role of a flight nurse and flight paramedic come into the role with a core background in critical care and expected level of baseline knowledge, higher level of autonomous critical thinking and rapid decision making is a new skill encountered for many coming into this role.
A well-structured training program is an integral part of laying a strong foundation to build the necessary knowledge base needed to assure both a flight nurse and flight paramedic are prepared to perform in their role as a crew chief. Approximately six years ago a well-structured crew chief training program was in place that allowed for consistent and structured learning that allowed all crew member 2 (CM2) to obtain the necessary skills and knowledge expected to hold a position of crew chief. These modules covered areas of navigation, communications, safety, aviation, critical thinking; and incorporated reading material, practical exercises, quizzes and tests which the CM2 worked through in a systematic process. At the completion of the training module; the crew member then went through a question answer board (QAB) process. In the QAB, the crew member was asked a series of questions by a board consisting of a crew chief, clinical manager, pilot, medical director and given multiple scenarios. If the QAB was completed successfully the CM2 then advanced to status of a crew chief. Current State of Problem
Currently a structured training program that assures all flight nurses and flight paramedics obtain this baseline level of knowledge that is expected of those in the crew chief role does not exist. The current practice is the assumption that all CM2’s obtain the skills and knowledge necessary by reaching their seventy fifth patient transport. This training plan does not allow for the structured delivery of expected skills and knowledge nor does it allow for a baseline competency to be demonstrated before being promoted from CM2 to crew chief. The current process was put into place to meet the increased demand for staffing experience by the company during a rapid growth period where eight bases turned into sixteen in four years. This current process put into place at this time did allow for rapid streamlined training of new staff; but it failed to take into account quality over quantity. This new process has resulted in CM2’s being promoted to the level of a crew chief without the necessary knowledge that is expected of this role as determined by the management. Goal State
All crew members at CM2 status go through a structured crew chief training program. This training will allow for the delivery of consistent, well-structured necessary skills and knowledge. A well-structured training program will assure that all flight crew who obtain crew chief status will have obtained the same base of knowledge and will have all demonstrated the same level of desired competence. Learner Analysis
The instructional setting is primarily on the job training; information gained through the live patient care transport environment via ground, rotor or fixed wing aircraft. Nurses and paramedics work as partners in patient transport. This team configuration can be two nurses, or one nurse and one paramedic; but at all times one team member must be a nurse. The third person at the base is the pilot in command, who does not provide any patient care but does and can assist in aviation and safety training. These teams are on shift; stationed at their assigned base for a 24 hour period of time; where training through simulations, reading, and discussions will occur during non-patient transport times. There are 16 bases in the company; located in California, Texas and Oregon. There are 8 full time medical crew assigned to each base and an additional 2-3 part time staff at each base.
Age of paramedics and nurses range from 27-61. English is native language spoken by all medical crew members. Educational levels in addition to holding an accredited paramedic license or registered nurse license are ranging from associate degree to doctorate. All Registered nurses in the capacity have received specialized training in critical care, trauma and hold specialized certificates in these areas. All paramedics in this capacity have also obtained additional critical care related training and certificates. Both the nurses and the paramedics receiving the crew chief training have been employed with this company in the flight role for a minimum of 1 year and have obtained the CM2 status. The content area is focused on five areas; to include aviation, safety, communications, navigation, and critical thinking. All medical crew have obtained the basic level of training in these areas have been deemed CM2 which puts them at “novice” status which deems them competent to safely complete patient transports. The crew chief level of training is aimed at bringing crew members from novice to expert level. Prior Knowledge
Prior knowledge of all who will receive the crew chief training are those who are at the current CM2 level. They have been working in the capacity as flight nurses or flight paramedics at this company for a minimum of 1 year and have been on at least 75 patient transports. 25% of the total crew members have prior experience working as Flight Nurses or Flight Paramedics at another company; 10% of the flight paramedics have prior flight crew experience through the military prior to coming to this company. Those crew members who achieved crew chief status per the current model will be given a baseline written assessment and go through a crew chief QAB. Those who pass these two items will remain at the status of crew chief; and those who do not pass these assessments will complete a bridge crew chief training program, focusing on those areas of the training they did not pass during their assessments. A written assessment and QAB will be repeated at the conclusion of the bridge training. All crew members surveyed have positive feedback regarding this proposed process. Entry Skills Required
Entry level skills required to the crew chief training is to be a CM2 and to have successfully passed the CM2 questions answer board. Successful completion of CM2 training demonstrates successful objectives completed as stated in the CM2 training. In addition to CM2 status; all crew members must have obtained a national certification. National certifications the nurses may obtain are critical care registered nurse (CCRN), care flight critical nurse (CFRN), or certified emergency nurse (CEN). These are each a 100-150 questions tests that are scheduled to be taken at independent test centers as determined by the certifying agencies. The CM2 must also be in good standing with the company; meaning no disciplinary actions in the crew members personal file in the previous six months. Attitudes and Motivation
The majority of the flight nurses and flight paramedics are very driven; intense people with a high desire to obtain the crew chief status. Primary motivation comes from the desire to obtain the title status of “crew chief” and the increased pay rate of 5% per hour. Secondary motivation is the drive that comes from internal motivation to achieve additional training to reach expert level knowledge in this field. Current attitudes towards training are positive with an overwhelmingly stated desire to have a more structured training program; with higher standards and rigor needed to become a crew chief. Based on the annual employee survey; one of the indicators as stated by employees to improve morale is for a more structured and rigorous crew chief training program. Unique Characteristics and Learning Styles
The majority (70%) of the learners described themselves as learning best through “doing.” Those who stated they learn better through hands-on and learning state reading, watching or hearing the learning material is helpful if they can then have additional hands-on training through simulations or live on-the-job situational experiences. Another 40% of learners said they were not sure how they learned best; but felt having access to the material in writing or reading to be studied was very helpful. All learners wanted tangible resources available such as protocols, standard operating procedures, drug calculators, and other tools that could be obtained through electronic means such as their phones or IPADS; to be accessed as needed during simulated training and live patient transports. According to Kolbs Adult Learning Styles; adults have four distinct ways of preferred ways for examining, analyzing and integrating new knowledge. Converging (doing and thinking), diverging (feeling and watching), Assimilating (watching and thinking) and Accommodating (doing and feeling).
In the VARK model; Neil D Fleming described the primary ways adults acquire new knowledge; the preferred learning styles. In this VARK model; 41% are kinesthetic learners, 16% visual, 25% auditory and 18% readers. Crew member feedback of preferred learning styles and research based evidence regarding preferred adult learning styles appear to correlate. This will allow support from management to build a new crew chief training program that will be based in the delivery methods that will allow consumption of material to be presented through the desired learning styles of adult learners. Unique characteristics of this group of learners is their collective attitudes and internal drive to desire a more rigorous and structured training program with an extreme minority of the crew members desiring to hold title of crew chief without demonstration of knowledge and skills required. It will be important to build a training program that accommodates all of the stated learning styles so as to use the crew member’s desire for the training to have a product that matches in quality and desired outcome of trainees. Accommodations
According to Gregg, Talbert and Lentz (1999),”An appropriately selected instructional accommodations not only provides equal awareness to learning opportunities but also minimizes the learner’s likelihood of failure. Appropriate educational accommodations are determined by taking into account the adult’s unique leaning needs.” All crew members have demonstrated a prerequisite knowledge required to begin this training through successful completion of the CM2 training. All learners are primary English language learners without physical disabilities; as this is a requirement to obtain the role of flight nurse or flight paramedic in this company. The accommodations that should be considered for this training program is one that utilizes all learning styles to ensure the best possible success by all those beginning the training program. Performance Context
Learners can expect full organizational support in the training process. One of the top goals of the organization as identified in their “Strengthen from Within Plan” is to re-build and strengthen a training strategy that will allow for employees to have a structured, well planned out, standardized training program. Employees have overwhelmingly voiced concern in the area of clinical training with regards to the crew chief training in the annual employee survey and through the Best of Practice Suggestion Forum. Management has acknowledged the priority of a structured crew chief training process lost priority in recent years; stating it has been likely to the rapid growth experienced by the company in the last 5 years and with this comes a need to recruit employees bring them to novice status in order to staff new bases.
This has caused an oversight in strengthening crew chief training which brings employees to that of expert level in the field. Management has also acknowledged that current process that was put into place approximately 6 years ago; which brings a CM2 to crew chief status via a CM2 completing 75 patient transports and obtaining a national certification has fallen short of hopes and expectations for this modality of crew chief training. All management are in agreement a more structured training program is needed. All would agree that the skills learned through a structured crew chief training program bring medical flight crew members from a novice to an expert level which translates to superior patient care, superior customer service, which lead to strengthening of the company as a whole. Physical Aspects of the Site
The crew chief training takes skills learned by flight crew members during their CM2 training program and adds depth, strengthens critical thinking and problem solving processes and brings a CM2 at novice level up to crew chief which is considered expert level. This training will take place while the crew member is on shift. Training will occur via reading material, videos, discussion with preceptor, clinical manager and base manager, scenarios through case studies and live demonstration during patient transport. The CM2 will be required to complete a written test and sit on a QAB at the end of the crew chief training Process. All required training materials and equipment will be available at each of the 16 bases in the company. Base managers and clinical managers will work with the preceptors to assure all materials and equipment will be kept at each base, kept current with what is being used in live environment and kept in working order. Social Aspects of the Site
In the performance setting, medical crew members work in teams. The teams always consist of two nurses, or one nurse and one paramedic. The third team member is the pilot; who are not involved directly in the patient care. Medical crew member’s work in team’s independent of direct supervision of a supervisor. Supervisors such as clinical managers, base managers and a medical director are always available by phone 24 hours a day 7 days a week as needed by the medical crews. The skills obtained in the Crew Chief training will not be being utilized by the medical crews for the first time. Many of these skills learned will have already been used by the crew members in the crew chief training; as much of the training had already been presented to some degree during the CM2 training.
It is possible that some patient care skills learned by CM2 and again as crew chiefs will have only been completed on mannequins in simulations and not on live patients until that patient condition presents itself. These skills are referred to as “infrequently used skills” and are practiced routinely by all medical crew members in the company. Those receiving initial first time skills and knowledge in their role are the crew member 1 (CM1) team members who are gaining the on-the-job training needed to achieve CM2 status. In these instances; a CM1 is always assigned into a work partnership with another crew member who is at least at the CM2 status. Relevance of Skills to Workplace
All skills learned in the training will relate directly to all skills utilized in the actual workplace. There are not current perceived physical, social or motivational constraints. Crew members are highly motivated to have structured crew chief training due to the relationship between skills learned and skills used in work environment. High motivation also exists due to the desired status achievement of crew chief and due to the increased monetary stipend received.
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