Development of examination objectives for the Korean paramedic and emergency medical technician examination: a survey study

Purpose The duties of paramedics and emergency medical technicians (P&EMTs) are continuously changing due to developments in medical systems. This study presents evaluation goals for P&EMTs by analyzing their work, especially the tasks that new P&EMTs (with less than 3 years’ experience) find difficult, to foster the training of P&EMTs who could adapt to emergency situations after graduation. Methods A questionnaire was created based on prior job analyses of P&EMTs. The survey questions were reviewed through focus group interviews, from which 253 task elements were derived. A survey was conducted from July 10, 2023 to October 13, 2023 on the frequency, importance, and difficulty of the 6 occupations in which P&EMTs were employed. Results The P&EMTs’ most common tasks involved obtaining patients’ medical histories and measuring vital signs, whereas the most important task was cardiopulmonary resuscitation (CPR). The task elements that the P&EMTs found most difficult were newborn delivery and infant CPR. New paramedics reported that treating patients with fractures, poisoning, and childhood fever was difficult, while new EMTs reported that they had difficulty keeping diaries, managing ambulances, and controlling infection. Conclusion Communication was the most important item for P&EMTs, whereas CPR was the most important skill. It is important for P&EMTs to have knowledge of all tasks; however, they also need to master frequently performed tasks and those that pose difficulties in the field. By deriving goals for evaluating P&EMTs, changes could be made to their education, thereby making it possible to train more capable P&EMTs.


Background/rationale
According to the Korean Emergency Medical Services Act, paramedics and emergency medical technicians (P&EMTs) can engage in first aid work at the scene of an incident, during transportation, and within medical institutions.P&EMTs are key personnel who provide high-level first aid and counseling to patients on-site and deliver patient information to hospital-based medical personnel.
The competencies of P&EMTs include the ability to provide consultation, rescue, transport, and first aid to emergency patients, as well as invasive first aid through direct medical guidance, patient evaluation, and management of the emergency medical service system [1].P&EMTs have recently entered diverse fields, such as private organizations and the Coast Guard, and must be able to treat patients in various environments [2].P&EMTs must possess a variety of abilities; therefore, it is necessary to train P&EMTs who are experts in performing complex tasks related to saving patients' lives.To qualify as P&EMTs, candidates must pass an examination administered by the Korea Health Personnel Licensing Examination Institute (KJPLEI), which oversees emergency medical technician qualification tests.The KJPLEI must establish a framework for P&EMTs' qualification examinations.In particular, because P&EMTs work in a variety of jobs, various patients and work environments must be evaluated.
Therefore, this study investigated the tasks that P&EMTs currently perform, those that they consider important, and those that they consider difficult through a comprehensive job analysis.The current curriculum of P&EMT Departments is taught through a national exam.Therefore, deriving goals for evaluating P&EMTs would be helpful in training P&EMTs to respond to a variety of medical emergencies.

Objectives
This study aimed to present the evaluation goals necessary for the national examination by analyzing the work of P&EMTs.In addition, we present tasks that new P&EMTs find difficult to perform.Therefore, analyzing the characteristics of the duties of P&EMTs will help educate and evaluate P&EMTs who could respond to any medical emergency.

Ethics statement
This study was approved by the Institutional Review Board of Eulji University (EUIRB2023-058).
Informed consent was obtained from all participants.This study conformed to the guidelines for the study of humans and animals stipulated in the Declaration of Helsinki.

Study design
This study was qualitative in nature.A survey was conducted among qualified P&EMT members from July to October 2023.The survey investigated the frequency, importance, and difficulty of nine duties, 54 tasks, and 253 task elements implemented in the field by 448 participants.Dataset 1 presents the questionnaire results.

Setting
This study was based on two prior job analyses to create evaluation goals for the P&EMT.The previous study was limited to two occupations; however, here, data were collected from participants engaged in six occupations in which P&EMTs currently work.In addition, the tasks currently performed by P&EMTs were incorporated into this research.The questionnaire was modified through focus group interviews (FGIs).Survey analyses were conducted through public hearings to establish opinions, and guidance was provided by the faculty council.Fig. 1 shows the study's overall flowchart.

Participants
This study's participants were P&EMTs.A survey was administered to P&EMTs from six areas where P&EMTs are currently employed: fire departments, hospitals, industry, coast guard, military, and others (mountain rescue teams, civil servants, etc.).For paramedics, the researcher explained the survey contents and received the survey through a paper questionnaire, and 199 people completed the survey.For the EMTs, contact information was received through the EMTs' Association, and a Google Form was sent via the internet to 1,200 people.Among them, 249 completed the survey.Table 1 lists the age and sex of the participants.A total of 448 (199+249) participants responded to the survey.

Variables
The main results were the scale used in the questionnaire.

Data sources/measurement
Before 2023, two surveys were administered to EMTs.The first was conducted in 2000 (166 questions) and the second in 2013 (240 questions).For the second survey, questionnaire questions were created using the DACUM analysis technique [3].The current research was based on a third survey.In this survey, questions were created by revising and securing the contents of the first and second surveys and were verified after recruiting a group of experts (253 questions) (Table 2).
This study solicited answers to 253 questions for six job positions.Paramedics primarily work in fire departments or hospitals, whereas EMTs work in fire departments or the military.The overall work frequency, importance, and difficulty levels were assessed for all paramedics, and the comparison between new and experienced paramedics was divided into P&EMTs.The goal of the study was to survey 480 people: 40 from each occupational group (240 paramedics and 240 EMTs).However, most of the participants worked in fire departments and hospitals, and only paramedics (no EMTs) worked as marine rescuers.In addition, the military employs more EMTs than paramedics.This study's goal was to identify the abilities needed in the current job field, and Supplement 1 provides the survey information for each job group.This survey used a 6-point Likert-type scale, with 1 point = 0%-10%, 2 points = 11%-30%, 3 points = 31%-50%, 4 points = 51%-70%, and 5 points = 71%-90%.A score of 6 points was recorded as 91%-100%.

Bias
This study presents participants' individual value judgments for each job, which might vary depending on the job.In addition, second-level paramedics mainly perform duties other than actual emergency services because they have obtained qualifications from the fire academy and military.

Study size
The study size was not estimated since this was a descriptive study.The authors conventionally selected the targets.

Statistical methods
The data were analyzed using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA).The results were obtained via Pearson correlation analysis of the average values of frequency, importance, and difficulty, without distinguishing between P&EMTs.In addition, to compare new and experienced paramedics versus EMTs, the independent sample t-test was conducted.

Participants
Table 1 presents the characteristics of the participants, and Fig. 1 shows the stages of the study.A survey was conducted with 448 people.We collected the opinions of eight external experts regarding this study's results through public hearings.

Analysis of P&EMTs' curriculum and question scope in the national examination for P&EMTs
To analyze the learning goals for each of the subjects taken by the P&EMTs, the final subject names were derived by analyzing the scope of the questions for the five subjects in the national examination (Table 3) and the connections between those subjects derived from 15 schools.Those who have received a regular degree from a university or college could take the paramedics exam, and EMTs can take the examination after completing at least 243 hours of theory and 100 hours of practical training at an institution.The subjects studied by the paramedic students were related to the national examination, while those unrelated to the paramedics' national examination included water lifesaving, research methodology, and fire science.
Students training to become EMTs studied topics related to the national examination only.

Questionnaire-based study (P&EMTs' job frequency-importance-difficulty)
In the survey involving 448 P&EMTs, the mean (SD) for the 253 questions were as follows: frequency 3.52 ± 2.062, importance 5.10 ± 1.321, and difficulty 3.60 ± 1.565 on paramedics, and frequency 3.11 ± 1.776, importance 4.05 ± 1.647, and difficulty 3.41 ± 1.584 on EMTs.We calculated which task elements the P&EMTs performed the most, which tasks they considered important, and which tasks they found difficult to perform.The paramedics reported that the task they were most frequently responsible for was taking chief complaints, whereas the most important task for paramedics was related to advanced cardiovascular life support (ACLS) for cardiac arrest.The most difficult areas were found to be difficulties in taking a pertinent history.The EMTs reported that the task they were most frequently responsible for was checking body temperature, whereas the most important task for paramedics was applying an automated external defibrillator (AED).The most difficult area was difficulties in treating neonatal cardiac arrest.(Tables 4-6).
Dataset 1 presents all the survey data.

Frequency-importance-difficulty correlation analysis based on the job analysis
A statistically significant positive correlation was found between importance and frequency, with Pearson correlation coefficients of 0.504 for paramedics and 0.556 for EMTs (Fig. 2A and D; Dataset 2).A statistically significant negative correlation was found between difficulty and frequency, with a Pearson correlation coefficient of -0.638 for paramedics and -0.564 for EMTs (Fig. 2A and D).There was no correlation between difficulty and importance, with Pearson correlation coefficients of 0.064 for paramedics and 0.207 for EMTs, and the importance of the task elements was found to be unrelated to the difficulty level (Fig. 2C and F).

Difficulty analysis among new and experienced P&EMTs
All P&EMTs responded that emergency deliveries and pediatric CPR were difficult tasks.The new paramedics responded that drug addiction, childhood fever, and bone marrow were difficult (Table 7), whereas the new EMTs responded that emergency logs, ambulance management, and infection control were difficult (Table 8).

Key results
This study's goal was to investigate the work performed by P&EMTs and to reflect the results of national examinations to facilitate smooth work.An additional goal of this study was to provide guidelines for training P&EMT who could be deployed in the field immediately after obtaining a certification.The task elements with high importance included communication with patients, such as applying an AED, conducting CPR, providing relief from choking, and taking the chief complaint.CPR is a skill related to life preservation and is considered important, as it is an item with which P&EMTs must be fully familiar.

Interpretation
It has been reported that CPR training increases CPR knowledge, and that considerable experience is important.In addition, it has been reported that upper limb muscle mass and body weight are important for CPR.Therefore, P&EMTs consider continuous CPR training and physical strength to be important elements of their work.
High-frequency tasks were evaluated as relatively easy, whereas low-frequency tasks were rated as difficult.The difficult tasks were general and emergency deliveries, as well as the treatment of neonatal or child cardiac arrest.In addition, P&EMTs with less than 3 years of work experience were compared with P&EMTs with more than 3 years of work experience.Paramedics were found to have great difficulty in treating injection poisoning, drug overdoses, fractures and dislocations, sprains and strains, and children with fever.It is believed that EMTs who have more experience with patients could perform their work more smoothly.If school studies focused on these tasks, new EMTs would be able to resolve the difficulties of their work.EMTs were found to have difficulty documenting pre-hospital care reports, disinfecting ambulances, and responding to infectious diseases.It was found that the training time for EMTs was short: 2 hours for documenting pre-hospital care reports, 5 hours for responding to infectious diseases, and 0 hours for disinfecting ambulances.They responded that common difficulties faced by P&EMTs involved providing treatment related to the heart, brain, or delivery.Paramedics needed indepth learning and EMTs needed to add the ability to assist paramedics.
This study examined the task elements of P&EMTs.In Korea, P&EMTs, who were previously only responsible for transporting patients, have now become active in various fields; therefore, their scope of work had to be expanded.The core goal of the national P&EMT examination is to develop P&EMTs who could perform fieldwork in response to changing emergency medical environments.Therefore, an evaluation goal was necessary.

Comparison with previous studies
The previous national examination for P&EMTs was based on P&EMTs working only in hospitals and fire departments [3].However, owing to the expansion of P&EMTs' duties, surveys were needed in various field contexts; therefore, we conducted a survey targeting P&EMTs working in the military, private industry, and the Coast Guard.In addition, a previous study conducted a survey targeting two fire departments, suggesting limitations in generalizability.However, in this study, the survey targeted fire stations nationwide.
The duties of P&EMTs include the delivery of newborns.We examined the reasons behind the difficulties encountered during this task.Education on newborn delivery often emphasizes theoretical learning.This issue is not unique to Korea; other countries have also reported a lack of delivery-related education for paramedics [4].

Limitations
This study conducted a survey of various occupations, focusing primarily on paramedics and EMTs.Most paramedics work in fire departments and hospitals, while the majority of EMTs are employed in fire departments.This trend is likely because many EMT training programs are conducted at fire academies.
The research results in the frequency section may not represent all occupations comprehensively.Although this study cannot present results for all occupations, it aims to improve the education of paramedics and EMTs based on difficulty analyses.It is believed that this improvement is achievable.

Generalizability
The purpose of this study was to propose directions for the development of P&EMTs' education and to guide the direction of national examinations.P&EMTs worldwide perform work directly related to the lives of patients in the field, necessitating a wide range of knowledge and skills.The types of patient incidents may vary by country, making it essential to train high-quality P&EMTs by examining the frequency of different patient circumstances.Recent research has shown that the older population (65 years and above) of many other countries is gradually increasing.It is important to establish a medical system suited to the aging population [5].P&EMTs tend to have difficulty communicating with older patients, which has been attributed to a lack of older adult-related education and practical training [6].
Furthermore, smooth communication with not only patients, but also other medical personnel is a competency that P&EMTs must possess.This might apply not only to Korea, but also to other countries [7].

Suggestions
In Korea, P&EMTs mostly work in hospitals and fire departments.In addition, P&EMTs must collaborate with various professionals with health-related licenses, not just with other P&EMTs.Future studies should examine the necessity of collaboration between occupations.In particular, a plan for work collaboration among P&EMTs is required.

Conclusion
It was not possible to test P&EMTs for all tasks that they performed.However, high-quality P&EMTs could be trained through tests on important and frequent tasks in paramedical work.Furthermore, more work experience regarding a specific task was associated with a lower level of reported difficulty.This implies that experience is important.A significant amount of experience could be acquired in schools.
The development of examination objectives could lead to changes in school education, and P&EMTs with professional knowledge and skills could be trained.

Table 1 . Participants' demographic characteristics
a Under 3 years: Within 3 years of obtaining paramedic or EMT certification b Over 3 years: After 3 years of obtaining paramedic or EMT certification

Table 7 . Difficult task elements for new paramedics Independent-samples test for paramedics
a Treating injection poisoning b Treating drug overdose c Treating fracture and dislocation d Treating sprain and strain e Treating childhood fever

Table 8 . Difficult task elements for new emergency medical technicians Independent samples test for emergency medical technicians
a Documenting pre-hospital care report b Disinfecting ambulance c Responding to infectious disease