The perceived competence of paramedics to operate in different CBRNE incidents

Purpose – TheaimofthisstudywastoidentifytheperceivedcompetenceofFinnishparamedicstooperatein different chemical, biological, radiological, nuclear, and explosive (CBRNE) incidents. Design/methodology/approach – This was a descriptive cross-sectional survey study. The material was collected using a previously developed questionnaire, which was modified in accordance with the study aim. The target group was paramedics of the P € aij € at-H € ame region of Finland ( N 5 166), whose role entailed active operational duties during the survey. Descriptive statistical methods were used. Findings – Paramedics reported low levels of training related to CBRNE incidents, and most felt that more training was needed. Chemical and explosive-related incidents were regarded as more likely to occur than others. Additionally, paramedics with more work experience perceived themselves as having higher competence only in chemical and explosive-related incidents. Overall, paramedics perceived their CBRNE competence as low. Originality/value – The perceived CBRNE competence of paramedics has not been studied sufficiently. Paramedics felt chemical and explosive related incidents were more likely to occur than others, and competence related to those two was also better perceived. This study showed that paramedics could benefit from more training to respond to CBRNE incidents to improve perceptions of their competence. However, the desired competence,actualcompetence,andappropriatetrainingtorespondtoCBRNEincidentsrequirefurtherresearch.


Introduction
The role of Emergency Medical Services (EMS) is to offer prehospital emergency care around the clock to citizens.In major incidents or disasters, paramedics are often the first professionals on the front line (Horrocks et al., 2019;Beyramijam et al., 2020a, b).However, major incidents are significantly different from the daily work of paramedics.In addition to logistical challenges and possibly treating several patients simultaneously, staff must manage chaotic and stressful working conditions (Berben et al., 2021).Preparedness, IJES 13,2 140 hospital located in Lahti, the primary town of the region.The nearest university hospital is in Helsinki, approximately one hour away by ambulance.From September to December 2022, 166 paramedics worked in the region.
The P€ aij€ at-H€ ame region has 27 institutes where dangerous substances are stored.Six of these institutes are classified as being at risk of a major accident (P€ aij€ at-H€ ame Rescue Department, 2023).Dangerous substances are also transported by road and rail.Two major highways and one railway pass through the largest population center in P€ aij€ at-H€ ame.According to Str€ ommer (2019), 8.0 million tons of flammable liquids and 2.7 million tons of corrosive substances are transported by road.Accidents involving dangerous substances in rail traffic are rare, but there is such potential in Finland (Finnish Transport and Communication Agency, 2022).Up to 5.0 million tons of dangerous substances travel by rail annually (Str€ ommer, 2019).An accident related to a dangerous substance could result in a leak, explosion, or toxic gas cloud, which can travel up to 2 km, depending on the chemical and environmental properties.The nuclear power plant located in Loviisa, which is less than 40 kilometers from the P€ aij€ at-H€ ame border, is considered a risk site outside the area (P€ aij€ at-H€ ame Rescue Department, 2023).
All 21 Wellbeing Services Counties in Finland (Act on Wellbeing Services Counties, 2021) organize EMS in their own areas of responsibility (Decree of the Emergency Medical Services, 2017).There are 3,900 full-time EMS-personnel working in Finland (Venesoja et al., 2021).In Finland, ambulances are typically staffed by two paramedics working together.These paramedics handle a range of prehospital emergency care missions dispatched by the emergency response center.When an ambulance is sent to the scene of an incident, paramedics evaluate the patient's care needs and decide either to transport the patient to the hospital or make a non-conveyance decision.Multiple ambulances are dispatched for larger incidents.In larger incidents, EMS may have to cooperate with the rescue department, police, border guard, and Finnish defense forces (Health Care Act, 2010; Act on the Defense Forces, 2007).EMS cooperates most with the rescue department in daily operations (Regional State Administrative Agency, 2022).The EMS field supervisor manages the daily operational activities of EMS.Paramedics can always consult an on-call physician by phone, but only the largest cities have physicians actively working at the scene.In addition, helicopter EMS (HEMS) physicians operate across the entire country from seven bases.
In P€ aij€ at-H€ ame, paramedics work at three different levels: basic, advanced, and critical care.In addition to these professional groups, there is an EMS field supervisor who manages the units.The Finnish paramedic training system is unique and is not directly comparable to the EMS systems of other countries.In a basic level EMS unit, one paramedic must have health care professional training (a three-year vocational upper secondary qualification) specializing in prehospital emergency care; another must be a health care professional or firefighter.In an advanced-level EMS unit, one paramedic must hold at least a bachelor's degree.This can either be a bachelor's of emergency care (240 ECTS -European Credit Transfer and Accumulation System) from a University of Applied Sciences or a registered nurse bachelor's degree (210 ECTS) with the completion of a 30 ECTS advanced-level prehospital specialization course.In a critical care-level EMS unit, both paramedics must have the same education as an advanced level unit, and in addition, they must have completed an individual one-year training course organized by the P€ aij€ at-H€ ame region (Service level agreement, 2017; Decree of the Emergency Medical Services, 2017).
The EMS field supervisor has at least the same educational background as advanced level paramedics, with operative leadership training and sufficient work experience.The EMS field supervisors also contribute to the multi-authority tasks and participate in the patient's treatment when needed (Decree of the Emergency Medical Services, 2017).IJES 13,2

The questionnaire
The questionnaire used in this study was based on the validated New South Wales (NSW) ambulance survey of paramedics used in "Determinants of paramedic response readiness for CBRNE threats" by Stevens et al. (2010) from the University of Western Sydney, Australia.Permission to use parts of the questionnaire in this study was granted by the authors.
The original questionnaire (Stevens et al., 2010) was modified for this study (Appendix 1).The background questions were adapted for this study.We utilized work experience categories and age groups instead of specific years to ensure the anonymity of the respondents.We also omitted the original questions regarding gender, relationship status, and family size as they were outside the scope of this study, and the answers could make it easier to identify the respondents.Finally, the profession group, education level, work experience in prehospital emergency care, age group, and special training, experience, or responsibility related to CBRNE were included in this study as background questions.
In addition, the original Australian questionnaire (Stevens et al., 2010) was modified to reflect the local circumstances regarding the training and prehospital emergency care systems.There were no open-ended questions.Ten questions were included for each CBRNE threat (Appendix 1).The respondents were asked to evaluate the possibility of the threat and their perceived competence related to the CBRNEs.In contrast to the original questionnaire, each of the five sections had questions regarding an unintentionally caused event and an intentionally caused terrorist event occurring in Finland and the P€ aij€ at-H€ ame region.In addition, the terrorist bombing questions in the original questionnaire (Stevens et al., 2010) were modified to relate to an explosion incident, including the same ten questions as the CBRNEs.The original questions about the psychological burden/stress of CBRNE incidents were omitted as they were outside the scope of this study.

Data gathering
All paramedics in the P€ aij€ at-H€ ame region with operational duties were invited to participate in the study in the fall of 2022 by email.The cover letter explained the purpose of the study and included a link to the questionnaire in the Webropol platform.It also contained information about privacy and emphasized the voluntary nature of participation in the study.The data gathering was conducted between October 28 and December 31, 2022.The paramedics were reminded of the survey by e-mail and in weekly morning meetings.Eightyfour completed questionnaires were returned, of which 83 were suitable for analysis.The response rate was 50%.

Statistical methods
From the background information, CBRNE areas of special responsibility and received CBRNE training were reported in two groups: less than 10 years of work experience and 10 or more years of work experience, and these were reported as frequencies and percentages.
The ten-item questions related to CBRNE incidents were answered using a five-point Likert scale, as in the original survey.The answer options are: 1: Not at all, 2: A little, 3: Moderately, 4: Very, 5: Extremely, and Don't Know (Stevens et al., 2010).
The summary scales were formed for the perceived threat of an accident based on three questions (How likely do you think it is that an accident related to x (x being C, B, R, N, E) will occur in Finland?How likely do you think it is that an accident related to x will occur in P€ aij€ at-H€ ame?How concerned do you feel about a possible accident related to x?), and for the perceived threat of a terrorist attack based on three questions (How likely do you think it is that a terrorist act related to x will occur in Finland?How likely do you think it is that a terrorist act related to x will occur in P€ aij€ at-H€ ame?How concerned do you feel about a possible terrorist act related to x?) per C, B, R, N, and E separately.
Similarly, a summary scale for perceived competence was formed based on four questions (Within my work role, I feel competent to respond to the effects of a task related to x, Within my work role, I feel competent to respond to the effects of a terrorist task related to x, Within my work role, I have the resources to protect myself against the effects related to x, Within my work role, I have the training to manage the fear and behavior of members of the public who may have been exposed to x) respectively.
The three summary scores were analyzed separately for each of the CBRNEs.In perceived threats, higher scores (range 3-15 each) reflected a higher perceived threat.Higher scores (range 4-20) reflected a higher perceived competence, respectively.Mean, standard deviation (SD), minimum (min), and maximum (max) were calculated for each summary score in both groups.Differences between work experience groups were examined using the Mann-Whitney U test, and a p-value less than 0.05 was considered significant.In addition, further analyses were performed for the perceived competence questions, and mean, SD, min, max, and significance were reported.The analyses were performed using SPSS version 28.

Ethical considerations
According to Finnish law and the ethical guidelines provided by The Finnish National Board on Research Integrity TENK (2019), ethical pre-evaluation is not needed for survey studies with a non-sensitive topic, such as self-reported perceived competence, when conducted among working adults whose participation is based on informed consent.

Results
65.1% of the participants were advanced level paramedics and 75.9% had a bachelor's degree (Table 1).51.9% had ten or more years of work experience and 48.1% had less than ten years of work experience.89.2% of the participants did not have separately obtained special CBRNE training, experience, or a related responsibility area.28.9% had received basic CBRNE training within the last three years, 28.9% within the last five to ten years, and the remaining 42.2% had not received basic CBRNE training at all.However, 90.4% felt that they needed more training for CBRNE incidents.
More paramedics with ≥10 years of work experience had received CBRNE training (72.1%) than those with <10 years of work experience (42.5%) (Table 2).Among the less experienced, 17.5% of paramedics who received CBRNE training stated that the training gave them confidence, and 22.5% felt their confidence was unaffected by the training.Among the more experienced paramedics who had received CBRNE training, the training built confidence in 39.5% of the paramedics, while 20.9% did not feel that it had a positive effect on their confidence.
In the case of a perceived threat of an unintentional accident, those involving chemicals or explosives emerged as the biggest perceived threat in both work experience groups (Table 3).Paramedics with ≥10 years of work experience perceived the threat of chemical incidents and explosive incidents as greater than the less experienced paramedics, but the difference was not statistically significant.Similarly, in both groups, the biggest perceived threats of a terroristic incident were those involving chemicals or explosives.However, the only statistically significant difference was found in a perceived nuclear terroristic incident threat IJES 13,2 (p 5 0.029): the less experienced paramedics evaluated a nuclear terrorist incident as a greater threat (mean 6.85 (SD 2.424)) than the more experienced paramedics (mean 5.79 (SD 2.559)).
Notably, more experienced paramedics perceived themselves as having higher competence to respond to incidents involving explosives (p5 <0.001) (Table 3).The difference between the groups was also found in the chemical incident section (p 5 0.002).Paramedics with more work experience also perceived higher competence in biological, radiological, and nuclear incidents, but the results were not statistically significant.
The further analyses of perceived competence questions showed that those with more experience felt more competent (p 5 0.028) to respond to chemical-related incidents (Appendix 2).A similar result was found regarding explosives (p 5 <0.001).The results regarding perceived competence to respond to biological, radiological, and nuclear incidents were similar in both work experience groups.The lowest perceived competence was seen in nuclear incidents (mean 1.92 (SD 0.703) and mean 2.07 (SD 1.009), respectively).

Journal of Emergency Services
When paramedics evaluate their own competence to respond to incidents related to terrorism, the terrorist nuclear incidents received the lowest competence rating among the less experienced paramedics (mean 1.85 (SD 0.630)), but the corresponding value was clearly better with those who had more work experience (mean 2.97 (SD 1.121)) (Appendix 2).The difference was not statistically significant.The only statistically significant difference (p 5 0.001) was found in explosives-related terrorist incidents, where more experienced paramedics perceived themselves as being more competent.
The paramedics with less experience felt less competent to protect themselves against chemicals than the more experienced paramedics (p 5 <0.001) (Appendix 2).A similar significant difference (p 5 <0.001) was also seen in protecting themselves against explosives.The lowest and most similar perceived competence were felt against nuclear-related effects in both groups (mean 1.92 (SD 0.664) and mean 2.28 (SD1.182),respectively).
In the case of managing the fear and behavior of members of the public who may have been exposed to different CBRNE subjects, the perceived competence was similar in both work experience groups and lowest in terms of nuclear incidents (Appendix 2).Only in the case of explosives incidents did those who had more work experience feel more competent (p 5 0.012).

Discussion
The aim of this study was to identify the perceived competence of paramedics to operate in different CBRNE incidents.The main results were: (1) Paramedics reported low levels of training related to CBRNE incidents, and most of them felt that more training is needed; (2) Paramedics felt that chemical and explosive-related incidents are more likely than other types; (3) Paramedics with more work experience perceived their competence being higher only in chemical and explosive-related incidents; (4) Overall, paramedics perceived their CBRNE competence as low.The competence to respond to CBRNE incidents is currently emphasized due to the growing threat of hostility, at least in Europe.Finland is participating in the European Union's rescEU project, which aims to create a strategic reserve against CBRN threats (European Commission, 2023).Thorough preparedness is crucial, as paramedics risk their own health and safety when a major incident or disaster occurs.In this study, a significant proportion of paramedics felt that they needed more training to operate in CBRNE incidents, supporting the findings of Novack et al. (2022).Training should be available for paramedic students and paramedics already working to maintain and strengthen their perceived competence (Smith et al., 2018).Previous studies show that paramedics need to receive sufficient training to be competent enough to identify and prevent threats (Melnikova et al., 2019) and manage these incidents (Rebmann et al., 2019;Farhat et al., 2022).Previous studies also note that paramedics cannot be expected to participate in a mission for which they do not have the necessary training, resources, and support (Smith et al., 2018).However, it should be noted that this study only identified that the perception of competence is quite low, which does not mean that competence itself would be insufficient in the case of an CBRNE incident.
The findings of this study showed that explosive and chemical incidents were considered the most likely threats compared to other threats.The best perceived competence was felt in these two areas.One possible explanation is that incidents related to biological threats are not as practiced and familiar in prehospital emergency care, and preparedness for radiation and nuclear accidents might be generally weaker (Rebmann et al., 2019).In line with this, previous studies have shown that paramedics lack confidence in their competence in radiation and nuclear incidents (Dallas et al., 2017;Rebmann et al., 2019;Blumenthal et al., 2014).The radiological and nuclear threats had the lowest perceived level of competence in this study.
Since 2020, the global impact of the COVID-19 pandemic has heightened awareness of personal protective equipment and underscored the significance of proper protection (Bourassa et al., 2022).Overall, the need to proficiently use personal protective equipment is a commonality across CBRNE incidents.Proper usage is pivotal in ensuring safety.(Bourassa et al., 2022;Melnikova et al., 2019.)Future research could emphasize the safe and effective use of such resources, for example, paramedics' ability to operate in protective gear should be examined, for instance, regarding fine motor tasks when protective equipment hinders movement and obstructs visibility.The impact of individual characteristics on the functionality of protective gear would also be a good subject for more detailed studies, such as the effect of facial hair on the tightness of gas masks.
In this study, paramedics with more work experience perceived themselves as having higher competence only in chemical and explosive-related incidents.However, as the competence was self-reported and not tested, it is important to consider the possibility of the Dunning-Kruger effect, meaning that incompetent individuals may overestimate their abilities (Mazor and Fleming, 2021).Still, it should be noted that those who had worked more than ten years had received more CBRNE training than those who had worked for less than ten years, which could affect a higher perception of competence.For example, a study conducted in Sweden has shown that more work experience was associated with higher competence (Jansson et al., 2020).The finding that the length of work experience was not so important in this study may also be explained by the organization-driven improvement of CBRNE training and the increase of CBRNE preparedness in the region during the last ten years.
EMS organizations and educational institutions, in addition to the paramedics themselves, have an obligation to ensure the sufficient competence of paramedics (Tavares et al., 2012).In order to evaluate competence, it would be beneficial to have a predetermined level of desired competence (Tavares and Boet, 2015).Paramedics' daily work necessitates extensive knowledge of patient care and the ability to make independent decisions.Beyond routine tasks, they must also handle major incidents (Nilsson et al., 2020).The diverse areas of expertise required make defining the desired competence challenging (Tavares and Boet, 2015;Wihlborg et al., 2014).

International
Journal of Emergency Services Thus, paramedics and their supervisors might be the most informed to define and develop these desired competencies (Wihlborg et al., 2014).In this context, it would also be beneficial to determine how well paramedics can theoretically identify different toxicological syndromes in various scenarios when initially only the patient's symptoms are known.Overall, these issues have not been studied sufficiently (Nilsson et al., 2020).According to Houser (2022), the willingness to respond is part of preparedness.Unwillingness to work during major incidents can affect the preservation of the EMS system (Rebmann et al., 2020;Barnett et al., 2010) and increase the burden on those paramedics who do report to work (Rutkow et al., 2014).For example, previous studies have revealed that some paramedics would not be willing to respond to biological incidents (Rebmann et al., 2020;Barnett et al., 2010).However, training can increase their willingness to respond (Le et al., 2018;Rebmann et al., 2020;Houser, 2022).
The actual training and suitable pedagogy would benefit from a closer examination, as there is currently an insufficient understanding of how, for example, CBRNE competence should be developed.In this study, a quarter of paramedics trained in CBRNE incidents felt the training did not give them the confidence to respond effectively.According to a recent systematic review, paramedics' training for managing major incidents employs both traditional methods and technology-based training.While neither approach has been proven superior, technology-based training has been effective in enhancing paramedics' competence.(Baetzner et al., 2022.)In addition, scenario-based training helps to identify gaps in preparedness (Rebmann et al., 2020).

Methodological considerations
The present study was designed with a practical research question and a well-thought-out target group.In order to better align with the research question, the questionnaire developed by Stevens et al. (2010) was adapted accordingly.The results of this study are consistent with previous research on the topic, which enhances the reliability of the study.However, it is important to acknowledge that this study used self-reported data, which may contain respondent-originated biases for various reasons.Moreover, the descriptive nature of the results should be considered when interpreting the findings.Additionally, the modified questionnaire used in the study was not validated.It may not have included all relevant questions, even though it was well-targeted from the perspective of the research question.In follow-up studies on the subject, it would be beneficial also to consider qualitative approaches when examining perceived competence.
The target population of this study consisted of paramedics working in a single Finnish wellbeing county.In this study, a response rate of 50% was achieved from a total population of 166 paramedics.The paramedics were reminded of the survey several times, and the 2 weeks response time enabled reaching all the paramedics with operational duties during the study period.While the 50% is a substantial proportion, several factors must be considered when interpreting the results.The potential for non-response bias exists, as whether non-respondents systematically differ from respondents remains a consideration.Due to the small number of participants, the participants were divided into two work experience groups, each with an equal number of participants, and a non-parametric statistical test was used.Moreover, the small size of the target population may limit the generalizability of the study results both within Finland and internationally.Nonetheless, the findings of this study provide valuable insights and encourage further research in this area and among other EMS systems.

Conclusions
Paramedics assessed their CBRNE competence as low.According to the results of this study, paramedics would benefit from additional training to strengthen their perceived competence IJES 13,2 to work in CBRNE incidents.In this study, chemical and explosive-related incidents were felt more likely to occur than others, and competence related to those two subjects was perceived as better than others.The connections between work experience and CBRNE competence need further research.
Enhancing CBRNE awareness is important.The current prevailing global circumstances emphasize the need to enhance the competence and preparedness of EMS.Paramedics' desired competence, actual competence and appropriate training to respond in CBRNE incidents require further research.