Desirable non-technical skills for paramedicine: A Delphi study


Allied health personnel, Non-technical skills, Paramedicine, Patient Safety

How to Cite

Bennett R, Williams B. Desirable non-technical skills for paramedicine: A Delphi study . Australasian Journal of Paramedicine [Internet]. 2022Mar.22 [cited 2023Mar.26];19. Available from:



Non-technical skills (NTS) are a causative factor in many adverse events in health care. While this is the case, NTS has been explored in the paramedic literature in isolation, with no current list of desirable paramedic non-technical skills within the literature. This study aims to gather consensus opinions on which NTS are considered important for an operational paramedic.


A modified Delphi technique was utilised to achieve the study aim. Participants were required to rate each NTS on a ten-point Likert scale. For an NTS to reach a consensus, it was required to be rated within two Likert scale points of the mode score by 80% of participants.


There were 17 participants in the Delphi study (n=17). The study ran for a total of three rounds, and 33 of 35 NTS reached consensus. The top five NTS were communication, problem-solving, situational awareness, professionalism, and interpersonal skills. Two NTS did not reach consensus; these were empathy and cognitive offloading. These two did not reach consensus despite being rated six or higher by all participants.


The results of this Delphi study have created the first expert-based list of important NTS for a paramedic. This will have significant implications for the paramedic field as we now have a foundation of which NTS is vital for a paramedic to complete their duties. These results can begin to form the foundation of a future paramedic behavioural marker systems will improve paramedic performance and ultimately lead to improved patient safety.



Crichton M, O’Connor P, Rhona F. Safety at the Sharp End: A Guide to Non-Technical Skills.: Farnham, Surrey: Ashgate.; 2013.

Fletcher G, McGeorge P, Flin R, Glavin R, Maran N. The role of non-technical skills in anaesthesia: a review of current literature. . British Journal of Anaesthesia. 2002;88:418–29.

Flin R, Maran N. Basic concepts for crew resource management and non-technical skills. Best Practice & Research Clinical Anaesthesiology. 2015;29:27 - 39.

Flin R, O’Connor P, Mearns K. Crew resource management: improving team work in high reliability industries. Team performance management. 2002;8(3/4):68-78.

Helmreich R. On error management: lessons from aviation. British Medical Journal. 2000;320(March):781-5.

Panesar S, Carson-Stevens A, Mann B, Bhandari M, Madhok R. Mortality as an indicator of patient safety in orthopaedics: lessons from qualitative analysis of a database of medical errors. BMC Musculoskeletal Disorders. 2012;13(93):1-9.

Uramatsu M, Fujisawa Y, Mizuno S, et al. Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010–2013 national accident reports. BMJ Open. 2017;7:1-7.

Yule S, Flin R, Paterson-Brown S, Maran N. Non-technical skills for surgeons in the operating room: A review of the literature. Surgery. 2006;139(2):140-9.

Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Rating non-technical skills: developing a behavioural marker system for use in anaesthesia. Cognition, Technology & Work. 2004;6:165-71.

Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Development of a rating system for surgeons’ non-technical skills. Medical Education. 2006;40:1098-104.

Patey R, Flin R, Fletcher G, Maran N, Glavin R. Developing a Taxonomy of Anesthetists’ Non-technical Skills (ANTS). Advances in Patient Safety. 2005;4:325-36.

Shields A. Paramedic non-technical skills: aviation style behavioural rating systems. Journal of paramedic practice. 2011;3(12):676-80.

Bennett R, Mehmed N, Williams B. Non-technical skills in paramedicine: A scoping review. Advances in Simulations. Forthcoming 2019.

Alexander A. Reasoning processes used by paramedics to solve clinical problems. Dissertation. 2010.

Anderson NE, Gott M, Slark J. Beyond prognostication: ambulance personnel’s lived experiences of cardiac arrest decision-making. Emergency Medicine Journal. 2018;35(4):208-13.

Anderson NE, Gott M, Slark J. Grey areas: New Zealand ambulance personnel's experiences of challenging resuscitation decision-making. International Emergency Nursing. 2018;39:62-7.

Paramedic Association of Canada. National Occupational Competency Profile for Paramedic Association of Canada. October 2011 [Available from:

Shields A, Flin R. Paramedics' non-technical skills: a literature review. Emergency Medicine Journal. 2013;30(5):350-4.

Dalkey N, Helmer O. An Experimental Application of the Delphi Method to the Use of Experts. Management Science. 1963;9(3):458-67.

Hsu C, Sandford B. The Delphi Technique: Making Sense Of Consensus. Practical assessment, research and evaluation. 2007;12(10):1-8.

Keeney S, Hasson F, McKenna H. A critical review of the Delphi technique as a research methodology for nursing. International journal of nursing studies. 2001;38:195-200.

Dalkey NC, & Rourke, D. L. Experimental assessment of Delphi procedures with group value judgments. 1972.

Junger S, Payne S, Brine J, Radbruch L, Brearley S. Guidance on Conducting and REporting DElphi Studies(CREDES) in palliative care – recommendations based on a methodological systematic review. Palliative Medicine. 2017;31(8):684-706.

Ludwig BG. Internationalising Extension: An exploration of the characteristics evident in a state university Extension system that achieves internationalisation. . Unpublished doctoral dissertation, The Ohio State University, Columbus. 1994.

Wloszczak-Szubzda A, Jarosz MJ, Goniewicz M. Professional communication competences of paramedics--practical and educational perspectives. Annals of Agricultural and Environmental Medicine. 2013;20(2):366-72.

Campeau A. The paramedic kairotope theory: findings. Journal of paramedic practice. 2011;3(7):376-80.

Nordby H, Nohr O. Communication and empathy in an emergency setting involving persons in crisis. Scandanavian Journal of Trauma Resuscitation and Emergency Medicine. 2008;16:5.

Nordby H, Nøhr ØN. Care and empathy in ambulance services: paramedics’ experiences of communicative challenges in transports of patients with prolonged cancer. Journal of Communication in Healthcare. 2011;4(4):215-26.

Ross L, Williams B. Paramedics developing rapport with the elderly: a pilot study. Journal of Paramedic Practice. 2014;6(3):128-36.

Kilner T. Desirable attributes of the ambulance technician, paramedic, and clinical supervisor: findings from a Delphi study. Emergency Medical Journal. 2004;21(3):374-8.

Flin R, Patey R, Glavin R, Maran N. Anaesthetists’ non-technical skills. British Journal of Anaesthesia. 2010;105(1):38-44.

T. Reader, Flin R, Lauche K, Cuthbertson BH. Non-technical skills in the intensive care unit. British Journal of Anaesthesia. 2006;96(5):551-9.

Boyle M, Williams, B, Brown, T, Molloy, A, McKenna, L, Molloy, L, Lewis, B. Levels of empathy in undergraduate health science students. International journal of medical education. 2010;1.

Hojat M. Physician empathy in medical education and practice: experience with the Jefferson Scale of Physician Empathy. Seminars Integrative Medicine. 2003;1:25.

Hojat M. Empathy scores in medical school and ratings of empathic behavior in residency training 3 years later. Journal of Social Psychology. 2005;145:663.

Greene J, Morelli S, Lowenberg K, Nystrom L, Cohen J. Cognitive load selectively interferes with utilitarian moral judgment. Cognition. 2007;107(3):1144-54.

Croskerry P. ED cognition: any decision by anyone at any time. CJEM. 2014;16(1):13-9.