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BMC Med Educ
BMC Med Educ
BMC Medical Education
1472-6920
BioMed Central London

39267028
5856
10.1186/s12909-024-05856-7
Research
Workshop-based training of pre-hospital emergency technicians for acute psychiatric patients: benefits and drawbacks
Shirzad Fatemeh shirzad.f@iums.ac.ir

1
Shariat Seyed Vahid 2
Masjedi Neda 3
Ghadirivasfi Mohammad 4
Ghalichi Leila 5
Fakhrian Arghavan 6
Hadi Fatemeh 7
1 https://ror.org/03w04rv71 grid.411746.1 0000 0004 4911 7066 Spiritual Health Research Center, Department of Psychiatry, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
2 Mental Health Research Center, School of Behavioral Sciences and Mental Health, Department of Psychiatry, School of Medicine, Tehran Institute of Psychiatry), Tehran, Iran
3 https://ror.org/01c4pz451 grid.411705.6 0000 0001 0166 0922 Department of psychiatry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
4 https://ror.org/03w04rv71 grid.411746.1 0000 0004 4911 7066 Medical faculty, Research Center for Addiction and Risky Behaviors (ReCARB), Iran University of Medical Sciences, Tehran, Iran
5 grid.411746.1 0000 0004 4911 7066 Mental Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Science, Tehran, Iran
6 grid.411705.6 0000 0001 0166 0922 Fellowship of Psychosexual Medicine, Department of Psychosexual Medicine, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
7 https://ror.org/034m2b326 grid.411600.2 Department of Psychiatry, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
12 9 2024
12 9 2024
2024
24 9968 11 2023
1 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Pre-hospital emergency technicians are crucial in managing patients with acute psychiatric symptoms. They must quickly assess the condition, make a primary diagnosis, and refer the patient to the appropriate treatment center. Insufficient skills in these situations can cause serious harm. Educating technicians on dealing with these patients may enhance their knowledge and skills; however, we do not know the extent and longevity of this improvement and which areas are affected. This study investigates the impact of training on pre-hospital emergency technicians’ knowledge and skills.

Methods

This quasi-experimental study involved pre-hospital emergency technicians in Robat Karim and Nasim Shahr counties from December 2022 to January 2022. The technicians received workshops on interacting with psychiatric patients. The training topics included the basic principles of coping with a psychiatric patient. They also covered a step-by-step approach to dealing with an aggressive patient, dealing with a patient threatening suicide, managing agitation, managing a patient suffering from panic attacks, and finally dealing with a delirious patient. A pre-test assessed their baseline knowledge and skills, followed by a post-test after training and another test three months later. The test results were analyzed.

Results

This study involved forty male participants ranging in age from 25 to 44 and with work experience ranging from five to twenty years. As a result of training in dealing with acute psychiatric patients, technicians developed significant skills and knowledge immediately after training, and these improvements remained significant three months after training. Nevertheless, the correct answers decreased during the three-month follow-up compared to the pre-test. Education was less effective at managing panic, delirium, and agitation.

Conclusion

In conclusion, technicians’ knowledge and skills can be effectively enhanced through training; however, the impact diminishes with time. Theories and practical methods, periodic repetition, and real-world internships are the best ways to maximize training effectiveness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-024-05856-7.

Keywords

Pre-hospital emergency
Technician
Acute psychiatric patient
Vice President of Health, Iran University of Medical Sciences,Tehran,Iran.98-3-8-4868 98-3-8-4868 98-3-8-4868 98-3-8-4868 98-3-8-4868 98-3-8-4868 98-3-8-4868 issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

Initially responding to a crisis when a patient has acute psychiatric symptoms, pre-hospital emergency technicians are the first healthcare providers to arrive. They rapidly assess the situation, diagnose the nature of the disorder, and, while managing the crisis, refer the patient to the appropriate treatment center [1, 2].

The emergency technician’s lack of skill and sufficient proficiency in the conditions mentioned above may lead to confusion in making decisions in critical situations. This may lead to an elevated psychological burden [3] and serious injury to the patient. As a result, this can negatively affect patients’ attitudes towards treatment and motivation to follow treatment.

Therefore, training courses are held and periodically repeated for emergency technicians to improve their knowledge and skills and keep them current [4, 5].

In a 2018 study in the Kuwait Emergency Medical Service (KEMS), researchers concluded that pre-hospital emergency technicians who attended a training course gained more knowledge and skills in dealing with psychiatric patients, their performance was significantly more effective three months later, and they also reported higher competency and confidence during three months after the training [6].

In a 2019 South African study, pre-hospital emergency providers’ ability to perceive, assess and manage psychiatric emergencies was reported to be poor due to limited knowledge and insufficient training. So, only 2.5% felt confident about the pre-hospital management of psychiatric emergencies [7].

In 2020, a study applied both quantitative and qualitative methods to gain an adequate understanding of pre-hospital technicians’ knowledge and skill levels in how to approach and manage patients with psychiatric symptoms. In the quantitative section, they were asked questions about the technician’s proficiency in the primary skills needed in dealing with psychiatric patients (empathy skills, aggression management, ability to assess suicide, etc.). In the qualitative section, in-depth qualitative interviews were arranged with them. The results of their analysis were divided into three general categories: encountering psychiatric patients, awareness of the lack of information about psychiatric disorders, and the expectations technicians have of future psychiatric patient management training. However, their basic knowledge of psychiatric disorders was low, which led to inadequate patient care. Technicians believed that psychiatric patient management training should be combined with pre-hospital training [8].

In Iran, few studies have been conducted on pre-hospital emergency personnel training [9]. These studies have not been very successful in their training results and emphasize the necessity to design additional specialized courses for this group [10]. Finally, we found no study targeting acute psychiatric patient management for pre-hospital emergency technicians in Iran.

This research determined the effect of training on dealing skills with patients with acute psychiatric symptoms. It also examined the knowledge and skills of pre-hospital emergency technicians in two central suburban counties near Tehran. We also want to design a practical and feasible model for training emergency technicians in the country.

Methods

Study design

This was a quasi-experimental study in which the participants were selected from among the emergency technicians of Rabat Karim and Nasim Shahr counties via convenient sampling. It aims to investigate the impact of training on pre-hospital emergency technicians’ knowledge and skills.

Selection of subjects and settings

All pre-hospital emergency technicians or technical assistants of the emergency center in Rabat Karim and Nasim Shahr were included in the study. People with a medical condition that prevented them from participating in the course or those who did not want to participate in the study for any reason. Those absent from the workshop for at least 3 h were excluded from the study.

Intervention

Thirteen hours of training were provided. The training topics included the basic principles of working with a psychiatric patient. They also covered a step-by-step approach to dealing with an aggressive patient, helping with a patient threatening suicide, managing agitation, managing a patient suffering from panic attacks, and finally dealing with a delirious patient. The training was based on a booklet prepared by four faculty member psychiatrists with experience working in the emergency department of a psychiatric hospital. This booklet explains the official protocol for dealing with psychiatric patients in a pre-hospital emergency. This protocol was notified by the National Medical Emergency Organization of Iran to emergency centers across the country.

We explained to the subjects that participation in this research was voluntary and written consent was obtained.

To maximize the possibility of interaction in the workshops, we limited the number of participants to a maximum of 20 people.

Also, the self-confidence and sense of mastery in decision-making in dealing with psychiatric patients were evaluated by asking some questions to the technicians, which were asked them before and three months after the training.

Data collection

A demographic checklist was filled out at the beginning of the research for all participants. This included age, gender, and years working in the emergency department.

Pre-test

This test included 21 multiple-choice questions measuring the level of knowledge and decision-making skills in dealing with psychiatric patients in areas related to the educational package. The questions were from 12 scenarios designed for different psychiatric emergencies. This test was prepared by the educators and authors of the educational package and reviewed and finalized by an expert panel.

Feeling of technician mastery

This questionnaire contained five questions about the technician’s mastery and self-confidence in dealing with acute psychiatric patients and included the following items:

I have sufficient confidence in dealing with a patient with acute psychiatric symptoms.

I feel confident in diagnosing patients with acute psychiatric symptoms.

I have sufficient confidence in the behavioral management of patients with acute psychiatric symptoms.

I have sufficient confidence in prescribing medications for acute psychiatric patients.

Post-test

The pre-test and the questionnaire for technicians’ mastery were completed again by the participants at the end of the training course and three months later to detect any possible changes.

Data analysis

The findings were analyzed with SPSS software. Quantitative data were reported using descriptive statistics with mean and standard deviation and qualitative data with numbers and percentages. The three times assessment was compared with repeated-measures ANOVA and Bonferroni post-hoc analysis. The two stages were compared using the Related-Sample Wilcoxon Signed Rank Test. The tests were significant at 0.05.

Results

In this study, 40 people completed all three stages of the tests. Forty-eight people participated in our study, and eight dropped out. Three people continued the workshop at the end and five did not fill in the questionnaire after three months.

All participants were male, and their age range was 25–44 years. Their average age was 33 ± 5.4, and their work experience was 5–22 years (with an average of 9 ± 4.1 years).

In analyzing the answers to the questions, the highest amount of errors in the pre-test was related to the medication management of agitated patients and the management of panic disorder. In the post-test, the most errors were observed in panic and delirium management. After three months, questions related to medication management of agitated patients and panic had the highest number of errors (Table 1).

Table 1 The percentage of correct answers to each question

The subject of the question	Pre-test	Post-test	After three months of training	
Q1: Dealing step-by-step with an acute patient at the scene				
Q1a: Calling the police	60%	78%	88%	
Q1b: Site Safety Check	58%	88%	85%	
Q1c: Taking a brief history of the family	55%	88%	85%	
Q1d: Safe entry to the scene	60%	83%	58%	
Q1e: Verbal relaxation	63%	78%	73%	
Q1f: Use of medication	63%	75%	70%	
Q2: Ruling out the physical causes of psychiatric symptoms	78%	80%	80%	
Q3: Evaluation of aggression in acute patients	65%	73%	75%	
Q4: Agitation management	20%	60%	48%	
Q5: Dealing with the patient’s psychosis	45%	75%	70%	
Q6: Contraindications to physical restraint	50%	80%	70%	
Q7: Suicide risk assessment	65%	68%	53%	
Q8: Delirium management	33%	53%	53%	
Q9: Panic management	25%	45%	40%	
Q10: Step-by-step dealing with suicide				
Q10a: Evacuation of the scene	35%	70%	60%	
Q10b: Managing the scene with the police help	38%	60%	60%	
Q10c: Creation of therapeutic communication with the patient	30%	60%	60%	
Q10d: Checking vital signs	45%	63%	58%	
Q10e: Using verbal techniques	45%	73%	63%	
Q11: Aggression management	53%	63%	70%	
Q12: Complete suicide risk assessment	33%	65%	63%	

In other words, the descriptive results of the participants’ answers before and after the training indicate that the training improved the primary condition. Over time, in some cases, the correct answers have decreased slightly, such as Safe entry to the scene of aggression, Agitation management, Contraindication of physical restraint, Suicide risk assessment and Using verbal techniques in suicidal patient, although the percentage of correct answers decreased between the post-test and three months after the training. There was no significant relationship between the two response categories in general, so we ignored it. but the status is still better than the baseline condition (Table 2).

The scores of the participants in the three stages are as follows:

Table 2 Distribution of scores obtained in consecutive tests by the participants

	Number	Minimum	Maximum*	Mean	Standard deviation	
Pre-test	40	2	19	10.2	4.46	
Post-test	40	7	20	14.7	3.09	
After three months of training	40	6	21	13.8	3.87	
* The maximum score is 21

ANOVA of repeated measurements indicates a statistically significant difference between the three measurements. Bonferroni’s post-hoc analysis concluded that the difference between pre-tests and post-tests is noteworthy. However, the observed differences between the post-test and the measurement three months later are insignificant.

Technicians also answered the following questions regarding their mastery of dealing with psychiatric emergency patients. Their responses are given in Table 3.

Table 3 Participants’ confidence responses

		Always	Often	Sometimes	Rarely	P value*	
I have confidence in dealing with patients	Before	15	18	4	0	0.045	
After	27	7	3	0	
I am confident in the diagnosis	Before	4	17	12	0	< 0.001	
After	22	13	2	0	
I have confidence in the behavioral management of patient	Before	10	15	10	2	0.001	
After	21	14	2	0	
I have confidence in prescribing medications	Before	8	15	10	5	< 0.001	
After	18	16	2	1	
* Related Samples Wilcoxon Signed Rank Test

According to the statistical test, the measurements in two evaluations in all four areas of dealing with the patient, diagnosis, management and prescription of the medications have improved significantly.

Discussion

Our research revealed several pertinent points. First, workshop training improves pre-hospital emergency technicians’ knowledge and skills in dealing with acute psychiatric patients. Second, this training decreases with time. Third, not all subject areas are improved to the same extent.

Combined methods, such as scenarios and practical work during training as a substitute for the classical lecture method, make learning more effective and durable. This may be why, in our study, the subjects’ learned knowledge remained relatively high. The effect of training remains stable.

In a research, emergency nurses’ knowledge of chest trauma management was evaluated. In this study, nurses were divided into two groups of 80 people. One group was trained with a traditional lecture, and the other with a scenario-based approach. This study showed that although training with both methods is practical for emergency technicians’ attitudes and knowledge, scenario-based training is preferred over lecture-based training [11].

In a 2017 study conducted in Germany, 135 emergency technicians underwent training that incorporated multimedia elements and focused on managing psychiatric disorders like catatonia, agitation, and alcohol poisoning. The training sessions included recorded videos for instruction, and an expert group consisting of a psychiatrist, psychologist, and emergency medicine specialist was available to address any questions from the trainees. The study found that 75% of the participants rated the learning rate as very high, and 85% believed that the effectiveness of this teaching method was significantly superior to traditional methods [12].

Our second finding highlights a concerning trend where the percentage of correct responses decreased after 3 months of training, particularly in questions related to sensitive and critical stages such as entering the scene of aggression, assessing the risk of suicide, and more. These are situations where technicians experience high levels of stress, which can potentially weaken their professional performance. Previous studies have indicated that high-stress situations can adversely impact the performance of emergency technicians, leading to a decrease in the accuracy of their responses in such circumstances. This was a contributing factor to the observed reduction in correct responses in our study [13]

Our study provided the summary protocol for managing behavioral disorders in pre-hospital emergency (based on which our training package was written) to the emergency technicians studied. Previously, in 2020, at the University of Massachusetts, a two-page protocol was used for emergency technician training [14]. These texts summarize the main titles and sequences of the necessary actions to deal with acute psychiatric patients and can help memorize the information.

Our third finding was that education only affected some aspects. Some aspects responded better, and some deteriorated.

In the pre-test, the most common problem of emergency technicians was the choice of a suitable medication for agitated patients and managing the panic disorder. In the post-test, panic disorder management and delirium management were the most frequently incorrectly answered questions by technicians. Three months after training, the technicians again had the weakest performance in answering the questions of choosing the appropriate medication for an agitated patient and managing panic disorder.

The reasons for these weak answers are:

Panic management in the pre-hospital emergency setting is one of the challenging issues. Panic symptoms overlap with threatening physical issues such as cardiovascular accidents and acute respiratory problems that can have catastrophic consequences for the patient. Therefore, management training is very critical [15].

Medical management of agitated and aggressive patients is another common challenge in a pre-hospital emergency. Protocols for acute pharmaceutical management of agitation emphasize the priority of non-invasive and oral treatments [16, 17]. However, in our study, the number of incorrect responses to medical agitation management was high. Most participants had opted for injectable medications such as haloperidol instead of oral ones. Although this issue was corrected in the post-test immediately after the training, it again received the most incorrect answers in the test three months after the training. This issue points to the need for frequent and regular training.

Delirium management, considered one of the most complex cases in a pre-hospital emergency, was one of the most error-prone questions in the post-test in our research. Previous studies also mentioned delirium management in the emergency department. A study that dealt with the systematic review of studies on managing delirium in the pre-hospital emergency room concluded that managing delirium in the emergency room is very complicated and associated with many uncertainties [18]. In addition to treatment, uncertainty exists regarding delirium diagnosis. The fluctuating nature of the symptoms makes the task difficult. In addition, it is difficult to screen these patients in a pre-hospital emergency [19–22].

In general, the complexity of psychiatric emergencies is high and causes the growing necessity for practical training in the real environment. Previous studies have illustrated that emergency technicians require theoretical and practical knowledge, communication skills and a non-judgmental attitude towards patients to provide adequate services [23]. Although workshop training can fulfill the technician’s need for theoretical knowledge and, to some extent, practical knowledge, training in the real environment can improve decision-making skills at the bedside, which is one of the essential skills for a pre-hospital emergency technician [24]. According to the authors of this article, one solution for pre-hospital technicians is to complete internships in the emergency department during their education or practical refresher courses every few years. Another way of such training is the presence of nurses familiar with psychiatric emergencies in ambulances with pre-hospital technicians. Similar experiences have already been made in Sweden. An ambulance for a psychiatric emergency PAM (Mobile Psychiatric Ambulance) was deployed in which two psychiatric nurses and one registered nurse worked, and they were also in contact with the police and non-psychiatric ambulances. This method improved the service level. More accurate psychiatric diagnoses were given, and patients were referred to more proper levels of treatment [25]. Also, the technician’s performance improved; in some cases, evaluation and intervention crises were done at the same place [26]. In this way, the burden of referrals to psychiatric hospitals also decreased, and this reduction in referrals enhanced the quality of services for patients [27].

In our study, participants reported enhanced proficiency in diagnosing psychiatric disorders and pharmacotherapy three months after training. A similar study stated that teaching the standard PHTLS method to emergency technicians increased self-confidence and mental security in these personnel. The participants in this study underwent standard PHTLS training for two days and were evaluated immediately after training and one year later. The participants in this study underwent standard PHTLS training for two days and were assessed immediately after training and one year later. This study’s questionnaire was self-made and included knowledge and questions about self-confidence and subjective safety [28]. In a study conducted in the United States, 55 emergency department nurses participated in a 2-day workshop and received practical skills training in dealing with trauma patients. After the training, they achieved higher proficiency scores and reported higher self-confidence [29].

It was also found that the self-confidence of the pre-hospital emergency technician improved after participating in the simulation workshop to deal with the trauma patient [30].

Another point is that although the technicians’ sense of mastery in prescribing medicine was significantly different three months after the training compared to before the training, still the most wrong answer of the technicians was related to the question of medication selection in agitated patients. In other words, pre-hospital emergency technicians overestimated their capability.

Similar findings were repeated in other studies. Competence of skill and adequacy for trauma management in pre-hospital emergency technicians was compared with their self-perceived confidence level. The authors used a researcher-made questionnaire and found that technicians’ perception of their capabilities was much higher than reality [31].

Teske also reported this discrepancy between nurses’ self-evaluation and actual skills in his study. He realized that with increasing clinical experience, this difference was reduced. In other words, nurses’ self-evaluation became closer to reality [32].

Study limitations

Our study focused only on emergency technicians in Rabat Karim and Baharestan counties. The educational needs of technicians in other regions of the country may be different. It is necessary to investigate the impact of training on technicians in other areas of the country in future studies.

Conclusion

Training courses can improve pre-hospital emergency technicians’ theoretical and practical knowledge of acute psychiatric patients. For the increased impact of these trainings, it is better to hold workshops with group discussion methods, scenario use, role-playing and hands-on skill exercises instead of the traditional lecture method. On the other hand, in challenging and common cases such as panic management, agitated patient management, and delirium, this training had no significant effect. Therefore, although such training is necessary, more is needed. It is required to provide a workshop and a practical internship in a real environment.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Acknowledgements

Our sincere gratitude goes out to all individuals and organizations who contributed to the success of this research project. First and foremost, we extend our most profound appreciation to the deputy of health of Iran University of Medical Science for providing us with the necessary resources and support to carry out this study. Our sincere gratitude goes out to all the emergency technicians (115) within the Rabat Karim and Nasim Shahr regions who contributed to this study. Their willingness to participate in this research and their active involvement in the training sessions were instrumental in achieving our research objectives. Special acknowledgment is due to the Emergency Organization of Iran disseminating the comprehensive protocol for dealing with psychiatric patients in pre-hospital emergencies. The protocol was a valuable resource for developing training content and will improve emergency response nationwide.

Author contributions

FSH, FH and SVS and MGH planned the workshop program. FSH and FH managed and taught the workshop. NM and AF designed the pre-test questions. FSH collected the results and entered them into SPSS software, LGH. analyzed the findings. All authors participated in writing the article.

Funding

Vice President of Health, Iran University of Medical Sciences, Tehran, Iran.

Data availability

The data that support the findings of this study are available from Fatemeh Shirzad (Corresponding author). but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Emergency Organization of Iran.

Declarations

Ethics approval

The Iran University of Medical Sciences Ethics Committee approved the study under number IR.IUMS.REC.1398.362. All participants were informed about the research and only those providing written informed consent were enrolled.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Confidentiality and Data Protection

To ensure participant confidentiality, all collected data was anonymized and stored securely. Only authorized researchers had access to the data, and all personal identifiers were removed to maintain privacy and confidentiality. The data obtained from participants were used solely for this study and not disclosed to unauthorized individuals or entities.

Data analysis and reporting

The data supporting this study’s findings are available from the Vice President of Health, Iran University of Medical Sciences. However, restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available.

Publication and dissemination

Research findings may be published or presented at conferences, but all information will be reported in a way that preserves participant anonymity. The research team will ensure that the results are accurately and ethically reported without misrepresentation or manipulation of data.

Any future use of the data collected in this study for additional research purposes will be subject to separate ethics review and approval.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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