Educational Aspects Affecting Paramedic Preparedness and Sustainability of Crisis Management: Insights from V4 Countries and the Role of Innovative Technologies

Abstract

Recent major disasters, including the COVID-19 pandemic and floods in Europe, highlight the unpredictability of crises and the necessity for systemic preparedness at all levels of crisis management, including pre-hospital emergency medical services. Paramedics observed, under these challenging conditions (but not exclusively during them), cases of insufficient knowledge and skills in providing pre-hospital medical care, which lead to inadequate or prolonged decision making in delivering assistance. For this reason, the authors aimed to determine the extent to which such situations occur and to examine their causes, focusing on potential gaps and shortcomings in the education of paramedics. This study examines the impact of educational systems on the professional preparedness of paramedics in V4 European countries (the Slovak Republic, the Czech Republic, Hungary, and Poland) during pre-hospital care through a questionnaire survey. A survey involving over 1600 respondents revealed significant disparities in perceived knowledge and skill gaps, with Poland demonstrating the highest deficiencies (78%) and the Slovak Republic the lowest (57%). Key factors influencing these gaps included the frequency of external educational and training activities, years of experience, and expertise in managing critical conditions. The findings underscore the importance of innovative technologies, such as simulations and virtual reality, in enhancing paramedic training, along with integrating digital solutions across all phases of disaster management. Recommendations focus on strengthening system resilience, fostering interdisciplinary approaches, and improving system sustainability and adaptability. By using the results obtained and leveraging technological advances, the study aims to contribute to more effective crisis preparedness, population protection, and sustainable development goals (SDGs), namely (3, 4, 9, and 11), especially in the field of crisis management. This reinforces the broader role of SDGs in building more robust, future-ready disaster management frameworks.

1. Introduction

Crisis events such as the COVID-19 pandemic or devastating floods in Europe highlight the key role of pre-hospital emergency medical services (EMS) in crisis management. EMS teams, especially paramedics, are often the first responders to critical incidents and disasters where their expertise significantly affects outcomes. The quality of their education and training plays a key role in their ability to effectively manage unforeseen and high-stress scenarios. Education and training are a critical element of prevention in the crisis management process.

The emergency medical services (EMS) system represents an important component of the delivery of emergency care to patients in the pre-hospital setting worldwide. The EMS sector began to take shape in the mid-20th century as a response to the increasing frequency of traffic accidents [1]. The structure of training and education of paramedics who make trips to patients varies greatly from country to country [2]. The experience of different educational systems may present new opportunities for professional growth in the management of critically ill patients for a certain group of professional paramedics [3]. The paramedic profession is usually associated with medical procedures in emergency situations. However, members of this professional group are knowledgeable in multiple medical fields due to their education and experience [4]. The actual scheme of healthcare provision and its financing varies to a large extent from country to country. Therefore, the educational requirements of individual EMS providers also differ. The mission of paramedics also diversified due to changes in the nature of diseases such as cardiac, neurological, and other critical conditions that immediately threaten the life and health of the patient [5]. Therefore, health care in the pre-hospital setting is a common entry point into the continuum of care. In addition, the presence of paramedics is essential to provide necessary emergency medical care in the pre-hospital setting [6]. EMS crews often perform their work in environments where they are regularly exposed to stressful situations [2], frequent shifts, increased levels of work violence [7], physical and psychological fatigue [8], irregular work schedules [9], repetitive overtime [10], and higher workloads compared to other health care workers [11]. One of the main factors affecting them is stress. It is caused by an unfavorable working environment associated with constant contact with suffering, pain, trauma, and death. Another factor that determines the quality and effectiveness of the training and education system for the activities performed by paramedics is the aggressive behavior of the patients themselves, or of their surroundings. They are not always the result of fear or pain but may also be the result of previous alcohol or other substance abuse [12]. Regardless of its source, the aggression experienced by the paramedic leads to lower job satisfaction, which in turn can cause burnout syndrome [13], which will have a destructive effect on his/her relationship with the patient. In addition, other stress factors during emergency intervention in pre-hospital settings are noise, working hours (long, with shifts, inconsistent), physical exhaustion, and feeling of task incompletion or inadequate remuneration at the level of professional responsibility [14]. The sufficiently high yet specific nature of paramedics’ comprehensive training should be based on their professional education, additional courses, and personal initiatives to expand their knowledge. The wide range of duties involved in working in a rescue team suggests that the profession is not only based on medical skills and knowledge, but also requires a sufficiently high level of non-technical skills [7].

There is no doubt that EMS officers perform a demanding activity that places high demands on physical, mental, but also material equipment. This profession goes well beyond the scope of a “normal” occupation and requires lifelong learning and practical rehearsal of model situations [15]. Most European Union countries define minimum training requirements for EMS personnel. These criteria include graduation from a specific school or course, as well as an internship and the necessary work experience [16]. There are differences in the training of paramedics between the countries of the European Union [17,18]. The reasons for this are various, including historical ones. Both the education and practice of pre-hospital emergency medical care developed differently in different countries [17]. However, we believe that the European Paramedic Curriculum (EPaCur) could potentially increase the number of nations offering such education at the bachelor’s level, which could increase the level of competency of paramedics overall [19].

Despite the differences across the European Union countries, the education systems for paramedics in the Slovak Republic, the Czech Republic, Hungary, and Poland show significant similarities, which are related to their goal of preparing professionals to provide emergency health care and partly to similar historical developments (they are also neighboring countries). All four countries underwent a transformation of their healthcare systems after 1989 (the fall of the previous regime), with each country developing a specific, but in many aspects comparable, model of paramedic training. The similarity of educational systems, legislative similarity, and prior V4 cooperation (including in healthcare: e.g., a long-term tradition of professional cooperation, e.g., in the EPaCur) were key reasons for evaluating these countries, as this allowed us to gain a deeper understanding of the challenges they face and identify common challenges. The educational programs primarily encompass theoretical and practical training, emphasizing their integration, and additionally address the organizational, legal, and ethical dimensions of the profession. The theoretical part includes medical basics such as anatomy, physiology, and pathophysiology, with an emphasis on acute conditions, including shock, trauma, and cardiovascular or respiratory disorders. Pharmacology focuses on drugs used in emergency medicine, emphasizing their correct dosage, indications, and contraindications. The practical part includes, e.g., training in cardiopulmonary resuscitation according to current recommendations, working with medical devices such as defibrillators and ventilators, and practicing model interventions using simulators. Field practice allows students to gain real work experience during internships in hospitals and on emergency medical service trips. Special attention is paid to organizational cooperation with the integrated rescue system, especially in the areas of coordination, effective communication, and managing crisis situations such as mass accidents. Educational programs also include legal and ethical aspects of this work, which prepare rescuers to resolve conflicts, comply with legislation, and protect patients’ rights. Educational systems are gradually incorporating modern technologies, with the integration of simulation methods (still in their initial phase) and an emphasis on continuous education, while maintaining a strong focus on connecting theory with practice. Harmonization of these basic elements between individual countries supports international cooperation and uniform standards in emergency medicine [19,20,21].

In recent years, countries outside the European region, such as the United States, Canada, Australia, and selected Asian countries, increasingly focused on practical paramedic training and the use of simulations or virtual reality [1,22,23,24,25]. In addition to simulations, North America and Australia also use so-called “scenario-based” training, in which paramedics deal with complex situations based on real-life case studies [26,27]. Compared to the V4 countries, these countries tend to have more innovative training programs, and these methods improve the ability of paramedics to respond more flexibly to unexpected circumstances [28].

Previous research (abovementioned studies) primarily focused on analyzing paramedic education in specific countries and examining individual aspects related to the effectiveness and quality of work of paramedics, mainly including (1) the impact of the work environment and stressors: regular exposure to stressful situations, long and irregular work shifts with frequent overtime, physical and mental fatigue, high workload, workplace violence, and exposure to suffering, pain, trauma, and death in a family environment; (2) the consequences of stress: burnout and decreased job satisfaction, negative effects on relationships between paramedics and patients, and feelings of unfinished tasks or inadequate recognition of their work; (3) paramedic education and professional training (in terms of the scope and content) of education: the requirements for paramedics’ skills (also beyond medical expertise in context of non-medical competencies such as communication skills, psychological resilience, and stress management, a continuous need for education, supplementary courses, and personal initiative (including basic life support (BLS) training or various certification models); and (4) the organization of healthcare services: the structure and financing of healthcare systems. However, there is still a lack of a more comprehensive view of the extent to which various educational aspects (theoretical, practical, and external forms of education, methods, satisfaction with education approaches, etc.) influence the feeling of sufficient knowledge and skills among paramedics (especially missing in the Central European region (V4 countries)). The causal relationships between educational aspects and the perceived lack of knowledge and skills experienced by paramedics during their practice is rather underexplored. This gap in the literature points to the need for further exploration of how the educational activities, programs, methods, and other conditions affect paramedics’ ability to respond adequately to emergencies, their decision-making processes, and their overall preparedness for the challenges that may arise in practice. This article aims to bridge this gap by providing a comprehensive understanding of the impact of the reported areas on practice outcomes and perceived competence among paramedics in pre-hospital emergency healthcare, contributing to a better understanding of paramedics’ needs and preferences within their professional and sustainable development. Moreover, the study explores paramedics’ preferences for the use of innovative learning technologies, such as virtual reality, and their impact on improving learning outcomes. The results of this work can contribute to a better understanding of the needs of paramedics and provide a framework for the development of sustainable educational standards that would make the healthcare system more resilient and prepared for future challenges through improved educational strategies.

2. Materials and Methods

2.1. Study Design and Setting

Between 2 August 2023 and 4 March 2024, an institutional cross-sectional study was conducted among 23,000 EMS paramedics (based on personal communication and [2,3]) in the neighboring countries of the European Union: the Slovak Republic, the Czech Republic, Poland, and Hungary (V4 countries) using the Survio platform (the distribution of respondents across countries is described in Section 2.3).

On the territory of the Slovak Republic, after obtaining permission from EMS providers, an email with a questionnaire (link to platform) and instructions was sent to the responsible personnel at the EMS stations requesting a response from the paramedics (in the Slovak language via email invitations sent directly to employees). The cover letter explained the study objectives, data anonymity, and voluntary participation. Similarly, as in the Slovak Republic, based on permission from the EMS providers in the Czech Republic, Poland, and Hungary, questionnaires (in local language) were distributed to responsible persons at dispatch stations requesting response from paramedics. The inclusion criteria for this study required that all participants be certified and active paramedics, with at least 1 year of field experience, have a willingness to complete an online questionnaire, and consent to the processing of anonymous data for the purposes of the study (informed consent). We did not include administrative staff, ambulance drivers without paramedic qualifications, or volunteers. Sociodemographic parameters such as age and gender were not considered critical for our research. To ensure reliability and diversity of respondents, the study aimed to cover paramedics working under different EMS providers, reflecting structural differences between countries (e.g., the Slovak Republic, the Czech Republic, and Poland have multiple providers, while Hungary has only one) [29,30,31,32,33,34,35]. Different EMS providers operate across various regions within the countries, ensuring territorial diversity in the respondents’ areas of practice. Since only paramedics were explicitly contacted, it was impossible for anyone else to complete the questionnaire. These criteria ensured that the data came from paramedics with practical experience and a real overview of the educational processes in the given countries.

To determine the content of specific questions for the questionnaire, some studies, e.g., refs. [2,23,24,36,37,38,39,40,41] related to the issue were first reviewed. The basis for determining the questions was to understand and find parameters (variables) of the educational system that are the same or, at least, very similar across the spectrum of countries surveyed. The questions were formed based on previous studies (mainly abovementioned sources) and additionally on the basis of the direct experience of one of the authors with the education system in the Slovak Republic and a deeper discussion of the issue with experts and colleagues in the field, who indicated certain factors that influence the quality of paramedic education in conditions of the Slovak Republic with an overlap also abroad, as the education systems in the V4 countries are quite similar.

The authors created a structured, self-administered, and anonymous questionnaire. This study covers only a part of the authors’ objectives (related to wider research activities with a specific focus on healthcare and preparedness issues). The questionnaire was therefore designed more broadly, with only specific sections intended for use in this study. The survey consisted of six parts, which are presented below, with this study primarily utilizing the first four and the sixth part. The first part of the questionnaire, concerning individual and organizational characteristics, included the number of years of experience and the name of the employer with whom the respondents worked. The second part related to the work environment, for example, expressing the degree of satisfaction with their employer’s training on a Likert scale (1 [completely dissatisfied] to 9 [completely satisfied]), the number of theoretical, practical training activities completed with their employer, and those that respondents completed outside the training opportunities offered by their employer. Other questions were aimed at expressing the extent (subjective rating) of expertise in management and primary triage during a mass casualty incident, management of critically ill patients, and expressing satisfaction with the current training opportunities provided outside of those offered by their employer. The third part consisted of three questions aimed at the frequency of occurrence and defining situations where paramedics directly in practice felt that they lacked knowledge, skills, and could identify that the shortcomings were based on the educational system. In the fourth part of the questionnaire, questions aimed at expressing the level of satisfaction with the quality of existing continuing education, its professional relevance, and the level of knowledge of continuing education possessed by paramedics in a given country. These questions were completed on a Likert scale (1 [completely dissatisfied] to 9 [completely satisfied]). The fifth part consisted of questions focusing on continuing education and its real added value to the paramedic profession, reported as a percentage on a scale from 1% to 100% (1% [does not bring the expected quality] to 100% brings the expected quality]). Further, in the area of continuing education, the questions focused mainly on the criteria paramedics choose when selecting continuing education. The sixth part of the questionnaire focused on assessing the level of paramedics’ knowledge of the possibilities of using modern teaching methods such as virtual reality, etc., as well as on the Likert scale (1 [I have no knowledge] to 9 [I have sufficient knowledge]). The last questions explored the preferred methods of education and at the same time the sources of knowledge and information about continuing education, its functioning, and structure in the country. Finally, paramedics had the opportunity to express their recommendations for practice that could positively influence the improvement of the training and education of ambulance service members in the country.

After completion of the questionnaire a pilot test was conducted to verify its clarity, unambiguity, and relevance to the target group. The pilot test was conducted by experts from practice, namely paramedics working in the field of healthcare provision in the Slovak Republic. The experts’ assessment of the questions’ wording, logical coherence, and overall structure contributed to increasing the questionnaire’s validity and reliability, ensuring the relevance and reliability of the data obtained. No fundamental changes were made to the questionnaire, only minor adjustments were made to the wording of the questions.

2.2. Key Variables of the Study

Based on the identification of gaps in the investigated issue, practical experience in providing pre-hospital ambulatory care, and an analysis of professional and scientific literature, the dependent and explanatory variables for this study were defined. Variables were selected that allowed us to support the research objectives. Some could be found in other studies (the rationale for the choice described in Section 2.1, partially in the introduction section), while others were chosen specifically for their potential to address the gap we aimed to explore in more detail. A summary of the selected variables is presented in

Table 1. Variables of the study.

Dependent Variable	Independent (Explanatory) Variables
y-frequency of feeling a lack of knowledge and skills (understood as a number of situations in which paramedics directly experienced a lack of knowledge and skills in practice)	a-years of experience
	b-level of satisfaction with employer’s training and education
	c-number of practical training activities
	d-number of theoretical training activities
	e-number of external educational activities
	f-level of expertise in primary triage of casualties during Mass casualty incident management response
	g-level of expertise in practical handling of life-threatening emergencies
	h-level of expertise in mass casualty incident management response

. These variables were directly involved in examining potential causal relationships related to the perception of knowledge and skills gaps in paramedic practice.

2.3. Sample Size

The numbers of actively working paramedics in ambulance services in each of the V4 countries were as follows at the date of the questionnaire survey:

• The Slovak Republic: 2960 paramedics,
• The Czech Republic: 4350 paramedics,
• Poland: 8259 paramedics,
• Hungary: 7542 paramedics.

To obtain acceptably reliable results (confidence level = 95%) with a maximum margin of error (margin of error = 5%), the authors needed to obtain a sufficient number of valid responses. A given confidence level with an acceptable margin of error was obtained. The number of valid questionnaires obtained were as follows:

• the Slovak Republic (n = 408), survey success rate: 408/2960 = 13.78%, confidence level 95%, and margin of error 5%.
• the Czech Republic (n = 414), survey success rate: 414/4350 = 9.52%, confidence level 95%, and margin of error 5%.
• Poland (n = 440), survey success rate: 440/8259 = 5.33%, confidence level 95%, and margin of error 5%.
• Hungary (n = 417), survey success rate: 417/7542 = 5.53%, confidence level 95%, and margin of error 5%.

2.4. Statistics

The univariate analysis, regression analyses, and analysis of variance (ANOVA) were conducted. First, it was important to determine whether respondents from different countries assess their perceived lack of knowledge and skills differently (dependent variable-frequency of feeling a lack of knowledge and skills). In order to assess and confirm the differences between the country samples, ANOVA (one-way test) was used. ANOVA was used to compare the means of perceived lack of knowledge and skills between the four countries, allowing us to verify whether there is a statistically significant difference in this characteristic). The distribution of these perceptions was also analyzed (univariate analysis) to provide a foundational understanding of the frequency of these deficiencies across the studied countries and to identify potential differences between them.

This was followed by a univariate analysis of independent variables. Descriptive statistics were reported as mean ± standard deviation for normally distributed variables. For other variables, their distribution within the defined intervals was statistically described. Categorical variables were not included in this investigation.

The analysis further explored the impact of potential causes or factors (represented by independent variables) on the perceived lack of knowledge and skills. The objective was to evaluate the significance of these variables in adapting the educational process and developing a sustainable education system, as well as enhancing the crisis management system and mass casualty incident management responses. To investigate the importance of these factors, multiple linear regression analyses were performed. The regression analyses were conducted for selected variables that could potentially influence the respondents’ knowledge and skills, as well as their perception of any gaps in these areas. A regression model allows for testing the simultaneous influence of all variables and identifying which ones have a statistically significant effect. This approach provides a more comprehensive view of the causes of perceived shortcomings than simple correlations. The analyses were carried out separately for each of the four countries, and the results were subsequently compared. In some cases (e.g., the Czech Republic), correlation analyses were also performed to test the influence of independent variables individually on the dependent variable outside the regression model.

3. Results

First, the results of ANOVA (

Table 2. ANOVA for perceived lack of knowledge and skills in the study countries.

Summary Groups	Count	Sum	Average	Variance
the Slovak Republic	408	1748	4.284	46.194
the Czech Republic	414	1892	4.570	32.318
Poland	440	6196	14.082	198.608
Hungary	417	4728	11.338	227.758
ANOVA	Df	F	p-value	F crit
Between groups	3	79.966	2.399 × 10−48	2.610

) and descriptive statistics are presented for dependent and all independent variables (

Table 3. Distribution of the study variables.

Descriptive Statistics		Feeling a Lack of Knowledge and Skills
		No = 0				Yes = 1				Total
Variables *		SVK (n = 175)	CZE (n = 145)	PLN (n = 97)	HUN (n = 118)	SVK (n = 233)	CZE (n = 269)	PLN (n = 343)	HUN (n = 299)	SVK (n = 408)	CZE (n = 414)	PLN (n = 440)	HUN (n = 417)
a	0–9	125	120	75	35	168	191	202	76	293	311	277	111
	10–19	37	18	18	41	51	73	117	119	88	91	135	160
	20–29	9	5	4	26	9	4	18	71	18	9	22	97
	29–39	4	1	0	12	5	1	4	25	9	2	4	37
	>40	0	1	0	4	0	0	2	8	0	1	2	12
b	1 to 9	4.65 ± 2.06	6 ± 1.27	5.95 ± 1.44	6.42 ± 2.11	3.35 ± 1.80	3.35 ± 1.80	4.90 ± 1.15	6.20 ± 1.58	3.91 ± 2.02	5.86 ± 1.32	5.13 ± 1.29	6.26 ± 1.75
c	0–9	119	102	59	30	182	186	163	46	301	288	222	76
	10–19	27	29	30	30	34	66	129	71	61	95	159	101
	20–29	15	12	6	21	9	10	34	92	24	22	40	113
	30–39	6	1	0	16	5	5	9	41	11	6	9	57
	>40	8	1	2	21	3	2	8	49	11	3	10	70
d	0–9	92	62	41	34	124	86	66	37	216	148	107	71
	10–19	41	52	40	30	77	129	164	60	118	181	204	90
	20–29	19	24	8	23	16	40	69	80	35	64	77	103
	30–39	8	5	4	10	10	11	22	51	18	16	26	61
	>40	15	2	4	21	6	3	22	71	21	5	26	92
e	0–9	122	125	74	64	167	226	156	65	289	351	230	129
	10–19	23	12	11	24	37	33	72	45	60	45	83	69
	20–29	8	2	5	11	19	4	61	65	27	6	66	76
	30–39	9	0	2	10	2	3	26	55	11	3	28	65
	>40	13	6	5	9	8	3	28	69	21	9	33	78
f	1 to 9	5.22 ± 1.97	5.65 ± 1.33	6.28 ± 1.45	6.25 ± 1.82	4.47 ± 2.01	5.10 ± 1.55	5.02 ± 1.30	5.40 ± 1.46	4.80 ± 2.03	5.30 ± 1.50	5.25 ± 1.40	5.64 ± 1.61
g	1 to 9	5.33 ± 2.00	5.37 ± 1.56	6.27 ± 1.45	6,77 ± 1,77	4.68 ± 1.90	5.22 ± 1.50	4.98 ± 1.26	5.87 ± 1.51	4.97 ± 1.97	5.27 ± 1.52	5.26 ± 1.41	6.12 ± 1.64
h	1 to 9	5.01 ± 2.07	5.24 ± 1.71	5.97 ± 1.52	6.26 ± 1.90	3.99 ± 2.00	4.75 ± 1.75	4.69 ± 1.30	5.22 ± 1.64	4.43 ± 2.10	4.92 ± 1.75	4.97 ± 1.45	5.51 ± 1.78
y	1–4	-	-	-	-	94	92	23	75	-	-	-	-
	5–9	-	-	-	-	89	135	87	17	-	-	-	-
	10–14	-	-	-	-	23	25	80	76	-	-	-	-
	>15	-	-	-	-	27	17	159	118	-	-	-	-

* a = years of experience; b = level of satisfaction with employer’s training and education; c = number of practical training activities; d = number of theoretical training activities; e = number of external educational activities; f = level of expertise in primary triage of casualties during mass casualty incident management response; g = level of expertise in practical handling of life-threatening emergencies; h = level of expertise in mass casualty incident management response; y = frequency of feeling a lack of knowledge and skills; SVK = the Slovak Republic; CZE = the Czech Republic; PLN = Poland; and HUN = Hungary.

), followed by the results of examining the relationships between the dependent and explanatory variables.

3.1. Assessing the Differences Between the Countries Studied

The assessment of the differences or similarity of the samples for the investigation of perceived knowledge or skill gaps was carried out by ANOVA. The main results are summarized in the table below.

The results of the ANOVA indicate that at a significance level of p = 0.01 (p = 2.39 × 10⁻⁴⁸ < 0.01), we can claim that there is a statistically significant difference between the average perceived lack of knowledge and skills in the four countries under study. This means that respondents from the individual countries assess their perceived lack of knowledge and skills differently, with the differences between them being significant enough not to be attributed to chance.

This result suggests that factors such as educational systems, experience, or organizational approaches in individual countries may influence how individuals perceive their knowledge and skills. Further analysis (3.3) aims to identify specific factors or differences between countries that contribute to these variations.

3.2. Descriptive Statistics

Table 3 presents a description of variables with the potential to influence the perception of a lack of knowledge and skills of paramedics as well as the distribution of respondent’s answers according to the frequency of perceiving a lack of knowledge and skills (Table 3, Figure 1). The variables given were calculated for all countries studied to show differences in each variable across countries. The description of explanatory variables in Table 3 was simultaneously divided into three groups: (1) without perceived lack of knowledge and skills (no = 0), with perceived lack of knowledge and skills (yes = 1), and also combined (total).

3.2.1. Dependent Variable

The distribution of respondent’s answers according to the frequency of perceiving a lack of knowledge and skills is presented in Table 3 and Figure 1.

As indicated by the ANOVA, there are statistically significant differences in the perception of knowledge and skills gaps between the countries. This fact is clearly illustrated by the preceding graph. At the same time, certain similarities between the countries are also apparent. In the Slovak Republic and the Czech Republic, a higher frequency is observed in the first intervals (1–4 or 5–9), while in Poland and Hungary, the highest numbers are distinctly seen in the last group (>15).

The results of the study suggest that the differences in the perception of knowledge and skill gaps between countries are a complex phenomenon, likely related to several factors, such as educational systems, experiences, age structure, and organizational approaches of individual employers. Although the countries under study have a similar system of institutional education and training for healthcare paramedics, they may approach the preparation of professionals in different ways. While some countries place greater emphasis on practical training, others focus more on theoretical foundations, support modern technologies, and so on. These differences in educational approaches may be the main factors influencing the perception of knowledge and skill gaps in emergency medical services. Specific factors are explored in the following Section 3.2.2.

A common factor influencing the differences in results between countries, as shown in Figure 1, appears to be employee turnover and retention in the paramedic profession or emergency medical services. This trend is analyzed in the discussion section.

3.2.2. Independent Variables

The results of descriptive statistics for the independent variables are summarized in Table 3 and described below. The descriptions are divided into areas related to the experience (length of practice) of paramedics, satisfaction with the educational system in a given country, the number of educational activities of various kinds completed, and self-assessment of their level of preparedness for various stressful situations that they may encounter in practice.

Years of Experience

In most countries (the Slovak Republic 72%, the Czech Republic 75%, and Poland 63%), the largest group of respondents falls into the 0–9 years of experience category (Hungary only 27%). In Hungary, where the majority of respondents fall into the 10–19 years of experience category (38%). Except for Hungary, the largest proportion of paramedics in the system consists of people with little experience.

Level of Satisfaction with Employer’s Training and Education

It can be stated that the most satisfied with the training provided by their employer are paramedics in the Republic of Hungary (6.26 ± 1.75) and the least satisfied with the training provided by their employer are paramedics in the Slovak Republic (3.91 ± 2.02).

Educational Activities

This area was investigated across the following variables: (1) number of practical training activities, (2) number of theoretical training activities, and (3) number of external educational activities.

In the Slovak Republic, the Czech Republic, and Poland, a similar pattern emerges in the distribution of completed practical training activities, with the majority concentrated in the lowest frequency range. This trend indicates that paramedics in these countries generally participate in relatively few practical training activities, which could have a significant impact on their ability to perform their professional duties effectively. In contrast, Hungary demonstrates a higher proportion of participation in the upper frequency ranges, suggesting that practical training in this country is afforded greater importance and is implemented in a more systematic manner.

A comparable trend is observed in theoretical educational activities across the Slovak Republic, the Czech Republic, and Poland, where the highest proportion of activities is concentrated in the lower frequency intervals (0–9 and 10–19). However, Hungary again stands out, with the highest proportion of completed educational activities occurring in the 20–29 interval. It is worth noting that these findings are partly influenced by the length of professional experience among respondents. As previously mentioned, Hungarian paramedics generally have more years of practice compared to their counterparts in other countries, which may explain their higher engagement in ongoing training activities.

Similarly to practical training, external educational activities in the Slovak Republic, the Czech Republic, and Poland show a significant predominance of low participation rates, most frequently in the range of 0–9 activities. In Hungary, while the majority of activities also fall within this range, their occurrence is two to three times lower. Moreover, Hungary demonstrates a more balanced distribution of the frequency of these external activities across the higher ranges (10–19, 20–29, 30–39, and even above 40). It is important to note that paramedics with knowledge gaps completed significantly more training activities outside their employer. This fact is most evident in Hungary.

Evaluation of Expertise in Critically Ill Patient Management

This area was investigated by three main variables: (1) level of expertise in primary triage of casualties during mass casualty incident management response, (2) level of expertise in practical handling of life-threatening emergencies, and (3) level of expertise in mass casualty incident management response.

The results indicate a clear difference in the assessment of self-perceived preparedness (expertise) for managing the examined situations between those who reported feelings of insufficient knowledge and skills and those who did not. Respondents who did not perceive a lack of skills consistently rated their abilities and competencies higher. However, this difference is relatively small, amounting to approximately one point on the evaluation scale (1–9). For example, in the Slovak Republic, the self-assessment score for respondents with no = 0 (did not perceive a lack of knowledge) was 5.22 ± 1.97, compared to 4.47 ± 2.01 for yes = 1 (perceived a lack of knowledge). A similar difference, though at slightly higher levels, was observed in other countries, e.g., Hungary: 6.28 ± 1.45 vs. 5.02 ± 1.30.

Differences between countries are most pronounced in the number of training activities undertaken and in the average feeling of educational attainment. These findings point to the need to improve the training programs provided by employers to better meet the needs of paramedics and increase their confidence in practice.

3.3. Variables Affecting How Often Paramedics Feel They Lack Knowledge and Skills

Given the confirmed variation between countries (results of ANOVA), it was necessary to investigate whether we could identify the same (at least some) factors (independent variables) influencing the perception of lack of knowledge and skills in the countries studied. Multiple linear regression analysis was used for this purpose. The results of the multiple linear regression analysis are presented in

Table 4. Multiple linear regression analysis investigating factors related to respondent’s perceived lack of knowledge and skills (the Slovak Republic).

The Slovak Republic	Coeff.	p-Value	Lower 95%	Upper 95%
years of experience	0.152	0.0174	0.027	0.278
level of satisfaction with employer’s training and education	−0.378	0.069	−0.786	0.030
number of practical training activities	−0.001	0.977	−0.095	0.092
number of theoretical training activities	−0.020	0.568	−0.090	0.049
number of external educational activities	0.065	0.0453	0.001	0.128
level of expertise in primary triage of casualties during mass casualty incident management response	0.454	0.088	−0.069	0.977
level of expertise in practical handling of life-threatening emergencies	0.107	0.629	−0.327	0.541
level of expertise in mass casualty incident management response	−0.787	0.0028	−1.303	−0.271

,

Table 5. Multiple linear regression analysis investigating factors related to respondent’s perceived lack of knowledge and skills (the Czech Republic).

The Czech Republic	Coeff.	p-Value	Lower 95%	Upper 95%
years of experience	0.072	0.267	−0.055	0.198
level of satisfaction with employer’s training and education	−0.429	0.053	−0.864	0.005
number of practical training activities	0.078	0.223	−0.048	0.204
number of theoretical training activities	0.056	0.232	−0.036	0.147
number of external educational activities	−0.014	0.675	−0.079	0.051
level of expertise in primary triage of casualties during mass casualty incident management response	−0.351	0.091	−0.758	0.057
level of expertise in practical handling of life-threatening emergencies	−0.240	0.208	−0.614	0.134
level of expertise in mass casualty incident management response	−0.281	0.116	−0.632	0.070

,

Table 6. Multiple linear regression analysis investigating factors related to respondent’s perceived lack of knowledge and skills (Poland).

Poland	Coeff.	p-Value	Lower 95%	Upper 95%
years of experience	0.291	0.011	0.066	0.516
level of satisfaction with employer’s training and education	−0.427	0.405	−1.434	0.580
number of practical training activities	0.140	0.085	−0.019	0.300
number of theoretical training activities	−0.065	0.339	−0.197	0.068
number of external educational activities	0.161	0.0009	0.066	0.255
level of expertise in primary triage of casualties during mass casualty incident management response	−1.043	0.072	−2.182	0.095
level of expertise in practical handling of life-threatening emergencies	−1.862	0.0002	−2.849	−0.875
level of expertise in mass casualty incident management response	−0.322	0.584	−1.477	0.833

and

Table 7. Multiple linear regression analysis investigating factors related to respondent’s perceived lack of knowledge and skills (Hungary).

Hungary	Coeff.	p-Value	Lower 95%	Upper 95%
years of experience	−0.040	0.664	−0.220	0.140
level of satisfaction with employer’s training and education	−0.181	0.661	−0.989	0.628
number of practical training activities	0.021	0.649	−0.070	0.113
number of theoretical training activities	0.017	0.712	−0.073	0.106
number of external educational activities	0.143	0.0001	0.071	0.215
level of expertise in primary triage of casualties during mass casualty incident management response	−0.109	0.859	−1.322	1.103
level of expertise in practical handling of life-threatening emergencies	−1.194	0.032	−2.283	−0.106
level of expertise in mass casualty incident management response	−1.056	0.079	−2.233	0.122

. The results are reported separately for all countries studied.

The statistically significant influencing variable affecting the frequency of knowledge and skills gaps for the Slovak Republic, Poland, and Hungary was the variable number of external educational activities (the Slovak Republic-p < 0.05; Poland-p < 0.001; and Hungary-p < 0.001). Another statistically significant influencing variable for the Slovak Republic and Poland was years of experience in the emergency medical service (the Slovak Republic-p < 0.05; Poland-p < 0.05). The common variable for Poland and Hungary was level of expertise in practical handling of life-threatening emergencies (Poland p < 0.001; Hungary-p < 0.05). In the Slovak Republic, a statistically significant factor was also identified related to the feeling of the degree of preparedness, but it was a factor that tracked level of expertise in mass casualty incident management response (the Slovak Republic-p < 0.01). Only in the Czech Republic, no statistically significant independent factor associated with the feeling of inadequacy was demonstrated. It should be added that the independent variables related to the feeling of educational attainment indicate a negative relationship with the perception of lack of knowledge.

All countries studied show a certain pattern where paramedics with a higher perception of a lack of knowledge and skills tend to undergo more educational activities outside their employer. They also have fewer years of experience and a lower feeling of being educated in specific areas of their work. The study shows that paramedics with a higher perception of lack of knowledge and skills tend to seek additional educational activities outside of their employer.

3.4. Critical Situations

In the questionnaire, in addition to the above analyzed variables, authors were also interested in what situations paramedics were in if they directly experienced a lack of knowledge and experience in practice. From the results obtained, we can identify several areas in which paramedics most often experienced a lack of knowledge and skills directly in practice:

Pediatric patient—this area was most frequently identified as problematic in all four countries, with the highest frequency in Hungary (124 responses). Paramedics perceive caring for pediatric patients as challenging, which may be due to a lack of specific training focused on pediatric emergencies.

Patient resuscitation—patient resuscitation represented very frequent area where paramedics felt a lack of knowledge and skills, with a significant occurrence mainly in Hungary (112) and the Czech Republic (45). This may indicate a need for more intensive practical training in cardiopulmonary resuscitation (CPR).

Mass casualty events—this area emerged as significant only in the Slovak Republic (14 responses), which may reflect the specific conditions and situations in this country or the lower frequency of simulated patient management exercises in the event of a mass casualty event.

Differential diagnosis—the area of differential diagnosis of the critically ill patient was cited particularly in the Slovak Republic and Hungary as a frequent reason for lack of knowledge in practice. This points to the need for better education in diagnostic procedures, which are essential for decision making in the field.

The last areas where paramedics felt a lack of skills and knowledge directly in practice were patient delivery and the polytrauma patient. These areas were perceived as problematic, especially in Hungary, which may indicate the need for specialized training focused on dealing with complicated deliveries and the treatment of polytrauma patients.

The results suggest that there is considerable variability in the areas where paramedics perceive a lack of knowledge and skills. The greatest challenge for paramedics in the V4 region is the care of pediatric patients and resuscitation, suggesting the need to strengthen training programs in these areas.

4. Discussion, Recommendations, and Limitations

Based on the results obtained, the authors discuss the relationship between the impact of statistically significant factors on the perception of a lack of knowledge and skills among paramedics and also discuss the possibilities of more effective training and education of paramedics for their profession across the V4 countries (recommendations). The reasons for the differences in results (e.g., satisfaction) for individual countries are also discussed, as these may be the basis for recommendations or lessons learned for other countries. Limitations of the study are presented as well.

This study provided some important insights into the impact of the educational system of paramedics in the V4 countries studied on their perceived lack of knowledge and skills in the provision of pre-hospital health care. These findings are relevant for further research and practical measures to improve paramedic education.

4.1. Factors Influencing Perceived Lack of Knowledge

External educational activities provided outside the employer’s framework emerged as a significant influencing factor for rescuers in the Slovak Republic, Poland, and Hungary. This finding suggests that professionals who engage in supplementary training are more likely to perceive gaps in their knowledge and skills. Other studies, e.g., [36,37], consistently emphasized that participation in external educational activities, such as courses, training sessions, or workshops, significantly increases professional confidence and reduces the perception of knowledge gaps. A plausible explanation for this apparent paradox is that participation in such activities broadens their professional perspective, enhancing their awareness of the complexities of their role and they are more aware of their gaps in expertise and are motivated to improve their skills through further training. Consequently, this heightened understanding may lead to an increased recognition of areas where their expertise is insufficient. We hypothesize that these additional learning opportunities cultivate a greater sensitivity to professional limitations, thereby encouraging a more critical self-assessment of their competencies. The studies [7,27] confirm that paramedics who were actively involved in external training programs were more critical of their own abilities and felt a greater need (motivation) for ongoing professional development. Similarly, Sedlar [5] points out the importance of continuing education for the quality of pre-hospital healthcare provided. The findings also underline the crucial role of employer-provided training in shaping the professional confidence of paramedics, as it currently appears insufficient to achieve this goal.

At the same time, there is a connection between these results and the years of experience during which paramedics predominantly engage in these external educational activities. As seen in the analysis, the majority of these activities were carried out by less experienced paramedics, indicating an effort among younger rescuers to acquire more knowledge and skills, thereby reducing their feelings of inadequacy. The key conclusion drawn from these findings confirms the authors’ assumption that the education and training provided by employers are predominantly insufficient, and the sustainability of effective healthcare delivery by paramedics is intrinsically linked to the need for additional education beyond that offered by employers.

The mere existence of external educational formats might not be problematic, as continuous education is generally expected, encouraged, and even legislatively required of healthcare personnel in many countries. However, the issue lies in the fact that these forms of education are not systematized, often fail to address the most pressing and current challenges faced by paramedics, and may not be accessible to all due to various barriers, such as time constraints, financial limitations, or course capacity. Although paramedics in V4 countries have to earn a certain number of credits or points for participating in educational activities, practice reveals several shortcomings. Many courses and workshops are held outside of working hours, requiring paramedics to schedule their free time in ways that can be physically and mentally exhausting—especially for those working shifts. Furthermore, these activities are not always financially supported by employers. It is often unclear to what extent participation fees or costs related to transportation and accommodation are reimbursed, leaving paramedics to cover some or all expenses from their own resources. High costs can deter many from attending higher-quality but more expensive training programs.

Another significant issue is that healthcare professionals frequently participate in educational events merely to meet the required number of credits, regardless of whether the content aligns with their professional needs. In such cases, the purpose of education and its potential benefits for practice are undermined. The situation is further complicated by an unsystematic offering of educational events, which are not always coordinated by professional societies or educational institutions. Paramedics are often left to search for suitable courses on their own, which can result in key topics related to emergency care, new protocols, or modern technologies being unavailable continuously or not taught at all. These factors contribute to a system of continuing education in V4 countries that is suboptimal, creating a disconnect between formal credit accumulation and the actual development of practical skills.

The factor years of experience was also a significant factor for the Slovak Republic and Poland, suggesting that paramedics with fewer years of experience are more likely to feel a lack of knowledge and skills. It can be concluded that increasing years of experience may have an impact on the frequency of errors and deficiencies during pre-hospital healthcare delivery in different countries, not only in the Slovak Republic. Research e.g., [40,41] suggests that the number of years of experience among paramedics may influence their perceived competence and the frequency of errors during the provision of pre-hospital healthcare. Conversely, there are also study findings where no correlation was found between years of experience and the feeling of preparedness [42]. In the Slovak Republic and Poland, it has been found that paramedics with fewer years of experience often report a greater lack of knowledge and skills. This trend may be due to the fact that with increasing years of experience, paramedics become more skilled in dealing with complex situations, thus reducing the likelihood of errors. A study on the competence of pre-hospital care providers [9] highlighted that experienced paramedics tend to make fewer errors due to accumulated practical knowledge and familiarity with emergency situations. In addition, a review of critical care paramedics suggested that more experienced paramedics are better prepared to handle situations under pressure, which is critical in the pre-hospital setting. In addition, younger or less experienced paramedics may face a wider range of emergency scenarios, making them more prone to errors. This highlights the importance of continuous professional development and mentorship to bridge the gap between theoretical knowledge and practical application in pre-hospital care. Years of practice are generally associated with lower perceptions of skill gaps, though not always. In some cases, routine work and lack of challenges may lead to outdated procedures and errors even in more experienced rescuers, but our study did not reveal this association. These findings point to the need for specialized training programs that address the specific needs of paramedics at different stages of their careers, so that even those with less experience can provide quality care with confidence, and those more experienced can gain the ability to use more innovative methods, e.g., related to use of modern technology.

A sense of being educated and trained in life-threatening emergencies and mass casualty incident management response was a significant factor for Poland and Hungary, highlighting the importance of specific education in this area. Foreign studies [24,27,28] have shown that specific training in critical condition management is crucial for paramedics, improving their preparedness and reducing the likelihood of errors during pre-hospital care. This is particularly important in regions such as Poland and Hungary, where rescuers who received such specialized training report greater confidence and competence in dealing with emergencies. Specialized training in this area can increase the confidence and effectiveness of rescuers in dealing with critical situations. If rescuers do not have sufficient training in these specific areas, they may feel less prepared and more likely to experience a lack of knowledge.

In Poland and Hungary, level of expertise in critical condition management was negatively associated with perceived lack of knowledge and skills. That is, a higher feeling of being prepared in this area was associated with a lower feeling of a lack of knowledge. This relationship highlights the importance of quality education in specific areas to increase confidence and reduce feelings of inadequacy.

Within regression analysis, in the Czech Republic, no statistically significant independent factor was found to be associated with perceived deficiencies. Variables from regression analysis were separately examined also through correlation analysis, indicating relationships at the p < 0.05 level of significance. However, the strength of the relationships was still weak. This relationship may have little practical significance, even though statistical tests indicate that it is unlikely for this relationship to occur by chance. This could indicate that the factors affecting perceived inadequacy in the Czech Republic are more evenly distributed across variables or that the perception of knowledge and skill gaps is less pronounced among Czech paramedics. Further research may be needed to identify latent variables or structural differences in the training system.

Although the regression analysis did not show a statistically significant effect of satisfaction with employer-provided education within the proposed model of independent variables (independently, this factor has a statistically significant effect on perceived deficiencies, which was confirmed by the correlation analysis at the p < 0.05 level), the study points to significant differences between countries. Paramedics in Poland showed the highest rate of perceived lack of knowledge and skills (78%), followed by paramedics in Hungary (72%), the Czech Republic (65%), and the Slovak Republic (57%). These differences may be due to different education systems and the level of support provided by employers. Paramedics in Hungary rated satisfaction with training highest (mean score 6.26), while paramedics in the Slovak Republic showed the lowest satisfaction (mean score 3.91). The data reveal a clear but statistically weak correlation between lower levels of satisfaction with employer-provided education and a heightened perception of knowledge and skills gaps among paramedics. This relationship emphasizes the importance of continuously improving and adapting training programs to align with the evolving needs of paramedics.

The trend related to the employee turnover and retention in the paramedic profession or emergency medical services (illustrated in Figure 1) suggests that employee turnover is higher in the first years of paramedic practice in the Slovak Republic and the Czech Republic, which may be related to organizational conditions among different employers. For example, in the Slovak Republic, the competition for pre-hospital healthcare services occurs every 6 years, affecting the working conditions of individual employees. In contrast, in Hungary, paramedics work for one national provider of pre-hospital healthcare services, which may lead to greater stability and lower employee turnover. This model may contribute to reducing staff rotation and provide paramedics with longer periods of practice in emergency medical services, ultimately improving their professional preparedness and efficiency in providing healthcare in the field. However, this factor was not directly studied in this particular study; instead, the study focuses on the length of paramedics’ practice in this regard.

The results of this study correlate in many aspects with findings from other international studies. However, unlike them, the results highlight the fact that in Central Europe, there is significant room for (1) improvement in the education provided directly by employers (in terms of content, systematic approach, etc.) and/or for (2) a more systematic approach to supporting external education (see the results of the regression analysis) in order to prevent errors and problems in providing healthcare to citizens. The findings suggest that training programs should be continuously updated and adapted to the needs of paramedics, with a special emphasis on practice-oriented teaching in critical areas such as the management of life-threatening emergencies. There is also a clear demand among paramedics for innovative methods, such as simulations or virtual reality tools. Respondents identified these as the most preferred forms of training to enhance and support their job performance, with preferences ranging from 79% to 95%; specifically, the Slovak Republic 79%, the Czech Republic at 93%, Poland at 95%, and Hungary at approximately 87%. The results of the study are consistent with international findings that show that practical and simulation-supported teaching can reduce perceived gaps and increase competencies in managing critical conditions [22,28]. Similar trends are observed in Canada, Australia, and some Western European countries, where they have long-term investments in modern forms of continuing education for paramedics [26,27,43]. The key factors are not just the number of training hours, but also the quality of the content and its practical applicability. The study did not conduct an in-depth analysis of the quality of educational content and its practical applicability, although it partially addressed this aspect. Future research by the authors aims to explore these factors more comprehensively to enable a more accurate assessment of educational systems in the analyzed countries and identify opportunities for their improvement. By addressing these educational gaps, employers can enhance job performance, reduce perceived inadequacies, and better equip paramedics to handle the challenges of their roles effectively.

4.2. Recommodations

Recommendations for improving training programs for paramedics in the V4 countries are essential not only to enhance their professional preparedness and ability to respond effectively to critical situations, but also to ensure the sustainability of the emergency medical services system and broader crisis management frameworks. The results of this study highlight several areas that require special attention.

Enhancing targeted training programs provided by employers is essential. Training programs should be regularly updated and should reflect the latest knowledge and trends in pre-hospital healthcare (take into account the specificities and needs of less experienced rescuers as well as more experienced ones). A focus on practice-oriented education that concentrates on the areas that paramedics feel to be the most challenging is key. These areas include pediatric patient care, resuscitation, and differential diagnosis. Regular targeted training should address the most frequently identified deficiencies and align with current clinical practices. It would be beneficial to partially shift the costs or organization of such courses into working hours. This measure would reduce the financial and time burden on employees while contributing to a sustainable model in which paramedics are not forced to choose educational activities based solely on their availability during personal time. It is crucial to regularly assess the areas where paramedics feel the greatest lack of skills and adapt the content and format of educational activities accordingly. This requires targeted programs developed in collaboration with professional organizations that can promptly respond to the evolving needs of field practice. Financial and time accessibility of external courses could be improved through grant schemes or subsidy programs specifically aimed at supporting paramedics’ continued education. Encouraging educational institutions and schools to develop flexible forms of learning, such as e-learning or blended learning, would also have a positive impact, as these formats facilitate balancing work duties with study. Technological innovations, including online platforms, simulations, and virtual reality, offer the opportunity to practice complex or critical scenarios in simulated environments, which is especially valuable when space and financial resources are limited [5,26,44,45]. Furthermore, modern educational applications can enhance self-directed learning by providing quick access to up-to-date standards, protocols, and case studies. As indicated in the survey results, there is also a clear demand among paramedics for this method and form of education and training.

Increasing support for less experienced paramedics should be another priority. Younger and less experienced rescuers often experience a greater lack of knowledge and skills, which can affect their performance in critical situations. Mentoring, supervision [46], and continuing education programs should provide regular practical exercises, simulations, and training focused on decision making in challenging conditions. This will ensure that less experienced rescuers gain the necessary skills and confidence. It is therefore no less important to ensure that more experienced rescuers also update their training so that they can adequately hold this position and partly act as motivators for younger colleagues. The significance in this regard lies primarily in adaptive professional training, which begins in the early stages of a paramedic’s career. Strengthening adaptive training provided by employers through the introduction or expansion of such programs would enable newly graduated paramedics to solidify their foundational skills and respond more effectively to critical situations. Currently, the emphasis on adaptive education is relatively low, with the exception of the Czech Republic, where it recently received greater support. In the coming periods, the impact of this change could potentially be explored.

The implementation of modern learning technologies is another key step towards increasing the effectiveness of training. The use of technologies such as virtual reality and simulations can improve the preparedness of rescuers for real-life situations, which is particularly important in critical areas of care. These technologies allow a wide range of scenarios to be simulated, giving paramedics valuable experience without risk to patients. Weile et al. (2021) [26] (but also others [44,45,47,48]) analyze the effectiveness of simulation-based team training in emergency medicine. Their findings support our assertions that modern educational technologies, such as simulations, can enhance paramedics’ preparedness for critical situations. They found that teams that underwent simulation-based training showed better performance in dealing with time-critical situations, which coincides with our recommendation to improve training programs provided by competent organizations. An experimental study [43] conducted abroad focuses on the effectiveness of training pediatric paramedics, where the results show that simulation training leads to better preparedness and reduced errors in practice. This approach also corresponds with our findings on the importance of practice-oriented learning for increasing the competencies of paramedics, especially in specific areas such as critical condition management.

As it was mentioned, improving specific training in the management of critical conditions is also important. Specific training should focus on the management of critical conditions, including mass casualty events and the care of pediatric patients. Such training can increase the confidence of rescuers and improve their ability to respond quickly and effectively to critical situations.

It also appears justified to adjust the credit system so that it does not reward mere attendance at events but also verifies the actual acquisition of new knowledge and skills. An important aspect is the differentiated assessment of course quality in terms of relevance to clinical practice and the necessary competencies of paramedics. This would prevent healthcare professionals from deciding to participate in educational activities solely based on available dates or the ease of earning credits. Overall, these measures would lead to a more effective model of continuing education that balances the need for formal credit acquisition with the genuine strengthening of professional skills.

Based on the results, the following priorities are recommended for the countries studied:

Slovak Republic: Increase the number of practical trainings organized directly by employers, as satisfaction with internal training was the lowest (3.91). More simulations and exercises focused on pediatric patients and polytrauma, which were identified as the most problematic areas (see Section 3.4). Adjustment of the financial support system for external training activities.

Czech Republic: Although many respondents reported less statistically significant factors of skill shortages, adaptive programs for newly graduated paramedics can reduce turnover. Support for so-called “adaptive training” (more weeks to gain experience directly in the field) would be appropriate. Interest in resuscitation courses was also high. Maintain the current relative satisfaction with internal training by expanding the range of topics (e.g., management of births in an ambulance).

Poland: The highest proportion of respondents (78%) reported a perceived lack of knowledge and skills. We recommend strengthening mentoring and supervision of less experienced paramedics and introducing systematic sharing of case studies in emergency situations. Strengthen collaboration with professional societies and universities to make the offer of specialized courses (pediatric emergencies, advanced resuscitation) more accessible. It is also important to support more frequent mass casualty exercises.

Hungary: Although satisfaction with internal training was relatively high (6.26), the results show a stronger perception of deficiencies in specific situations (e.g., childbirth, polytrauma). Targeted courses should focus on managing rare, but high-risk, conditions. Introduce or expand the use of modern technologies (virtual reality), as according to the survey, 87% of respondents are interested in it.

These recommendations can serve as a basis for further improving paramedic education programs and preparedness, which can contribute to reducing perceived knowledge and skills shortages and to improving the quality of care provided in the pre-hospital setting.

4.3. Limitations of the Study

The study encountered several limitations. Participation was not uniform across emergency medical service providers in the four European Union countries, as some providers were unwilling to cooperate. Consequently, the inclusion criteria for paramedics varied between countries. The most favorable conditions for participation were observed in the Slovak Republic, where the response rate was the highest. Conversely, in other countries, participation was more challenging, as evidenced by lower questionnaire return rates. It is important to note that despite these limitations, the sample was sufficiently representative, with an acceptable margin of error in the findings. The self-reported nature of the data could lead to a socially desirable response or memory distortion of respondents, which may introduce bias in paramedics’ self-assessment.

At first glance, the study may appear to rely solely on questionnaire data, lacking qualitative insights such as interview findings. However, this is not entirely accurate, although we acknowledge certain limitations in this regard. Qualitative data were inherently integrated throughout the study’s development, as one of the authors actively works as a paramedic, and informal consultations on the topic were an integral part of the research process. Additionally, formal qualitative data were collected primarily during the pilot study. Nonetheless, it is recognized that structured interviews and their systematic analysis could have provided a more comprehensive understanding of paramedics’ experiences and perceptions.

Another limitation is the possible degree of inaccuracy in determining the frequency of feelings of lack of knowledge and skills, as this depends on the situation in which the rescuers had the feelings and especially whether they remembered accurately enough the experience from several years ago (some from several decades ago). Here, it comes into consideration to modify the dependent variable to a dichotomous one (had or did not have the feeling of lack of knowledge and skills, 0 and 1, respectively) and to use a logarithmic model for the regression analysis. Alternatively, in another survey, it may be possible to restrict the investigation to a certain recent period, e.g., how many times have you felt a lack of knowledge and skills in your job in the last 5 years? However, these changes may imply other complications, such as an overly simplified perception of the dependent variable or its insufficient coverage over time.

According to the results, it is evident that respondents with fewer years of experience generally report a greater sense of lacking knowledge and skills, while more experienced paramedics do not feel these deficiencies as strongly. However, it is essential to consider that this could imply that experienced paramedics, even when they were younger, did not perceive such deficiencies to the same extent, even during their early careers when they had less experience. This would suggest that the quality of education and training in earlier periods was either (1) higher or (2) the workload (required performance) of paramedics was not as demanding, reducing their exposure to situations that could trigger such feelings. To the best of our knowledge, these factors are unlikely to be true (primarily discussed for the Slovak Republic with an assumption of implications for other countries). Therefore, it is reasonable to assume that this phenomenon is more likely related to the inability to recall challenging situations from the past or the tendency to assign them less significance since, in most cases, the situations were ultimately resolved despite potential difficulties.

The regression analysis was conducted only for selected variables within a defined model. The selected variables exhibited varying levels of influence on the dependent variable across different countries. The reduction in these parameters could have been performed, for instance, by gradually simplifying the model to a so-called parsimonious model. This would identify the simplest and most effective model describing only the statistically significant factors influencing the perception of a lack of knowledge and skills. However, such a model would be applicable only to a specific country. The purpose of this study, however, was not to identify such a model, but rather to explore a broader range of factors that may influence the practical perception of knowledge and skill deficiencies among paramedics.

A partial limitation may also be the use of the cross-sectional design in the study. The cross-sectional design was chosen due to the study’s aim of identifying factors influencing the perception of knowledge and skill gaps among paramedics. Although this design does not allow for definitive determination of causal relationships, it provides a representative and time-efficient perspective on the issue being examined. The results can serve as a foundation for future longitudinal research and interventions, which was not the purpose of this article.

The study’s focus is on V4 countries only, which partially limits the generalizability of some findings to other regions, mainly into regions with different educational systems. However, we still believe that several findings are so general that, after a certain transformation, they can be considered across different educational systems.

4.4. Future Directions

The findings of this study, highlighting the complex interplay of factors associated with paramedics’ perceptions of knowledge and skills gaps in central europe, suggest several important directions for future research. The observed link between external educational activities and awareness of professional limitations calls for a deeper exploration of the types, frequency, and content of such activities, including potential barriers to access. Longitudinal studies tracking paramedics over time could establish causality between training and perceived competence, informing the design of more effective programs. Furthermore, the relevance of experience and expertise underscores the need for tailored training interventions, potentially utilizing specialized methods such as simulation or case-based learning. Future research could also expand to include cross-cultural comparisons, examining the influence of different healthcare systems and cultural factors on self-assessment and training needs, ultimately linking these factors to patient outcomes.

In addition to the above, future studies could delve into specific knowledge and skill areas where paramedics perceive deficiencies, enabling the development of highly targeted training programs. This research could also explore the optimal balance between external training and on-the-job experience, considering the resource constraints and time limitations faced by many emergency medical services. Although some studies have already been conducted on the use of innovative technologies in rescue, research should examine their impact on the provision of training and the assessment of the competence of rescue children also in Central Europe.

5. Conclusions

There was yet no direct study that scientifically examined the satisfaction with education and training, relationships, and factors influencing paramedics’ feelings of lack of knowledge and skills in practice of V4 countries. Therefore, the results of this study represent a valuable source of information that can form the basis for further investigation and, subsequently, possible quality improvement recommendations for EMS practice.

The findings of this study suggest a complex interplay of factors that may be associated with paramedics’ perceptions of knowledge and skills gaps in Central Europe. Notably, the frequency of external educational activities appeared to be an important factor in the Slovak Republic, Poland, and Hungary, indicating that paramedics who engage more frequently in external training might develop a greater awareness of their professional limitations. Additionally, years of experience in emergency medical services and expertise in managing life-threatening emergencies were observed as relevant variables, highlighting the potential importance of tailored training interventions.

These results have significant implications for sustainability by addressing educational shortcomings, addressing systemic preparedness, promoting innovative training methods, and enhancing systemic resilience within the crisis management system. The study aligns with multiple sustainable development goals (SDGs). Improving the capacity and preparedness of emergency services enhances population health and well-being during disasters and emergencies aligns with SDG 3 (good health and well-being). Focus on paramedic education supports lifelong learning and equitable access to quality training, which aligns with SDG 4 (quality education). Promoting technological advances in training and crisis management fosters innovation, which aligns with SDG 9 (industry, innovation, and infrastructure). Enhancing disaster preparedness contributes to the resilience of urban and rural communities, which aligns with SDG 11 (sustainable cities and communities). The study’s results have implications for the sustainability of emergency medical services and crisis management. Enhancing the quality and accessibility of training programs—both employer-provided and external—is essential to bridge the identified gaps and boost paramedics’ confidence and effectiveness in the field. Customized, scenario-based educational approaches targeting less experienced paramedics and those handling critical emergencies are particularly important. Regular evaluation of training methodologies, aligned with emerging medical standards and technologies, is necessary to ensure paramedics remain equipped to provide high-quality pre-hospital care across diverse and challenging circumstances.

Future research should explore the long-term effects of different educational interventions on paramedics’ performance in real-world scenarios, incorporating diverse cultural and operational contexts. A comparative study of the studied countries with those of countries with significantly different healthcare systems offers a promising avenue for future research. The integration of innovative technologies, such as virtual reality, augmented reality, and artificial intelligence, could transform training by offering immersive, simulation-based learning experiences. Moreover, studies should focus on developing standardized frameworks to assess the effectiveness of these technologies and their role in addressing specific gaps in knowledge and skills. This direction is vital not only for improving individual preparedness, but also for ensuring the resilience and adaptability of emergency medical systems in a rapidly evolving healthcare environment.