Jitka Gurnakova - Academia.edu (original) (raw)

Papers by Jitka Gurnakova

, to increase discriminatory, verbal and physical attacks on health care providers by the public ... more , to increase discriminatory, verbal and physical attacks on health care providers by the public in a number of countries. The aim of this study was to pilot the prevalence and types of unwanted behaviour by patients and their relatives towards health professionals during the COVID-19 pandemic in Slovakia. The population: 379 health professionals (79% female, 21% male) with a mean age of 44 years (SD = 11.12; min = 23, max = 76) from all regions of Slovakia. Method: frequency and thematic analysis of written responses to open-ended questions. Results: 135 (38%) respondents who work directly with patients felt stigmatised or discriminated against because of their work. 96 respondents (25%) had experienced violence because of their work in health care. Of the 340 health professionals, 59% had experienced conflict with family members of COVID-19 patients during the pandemic. Problems or conflicts with family members of non-COVID-19 patients during the pandemic were reported by 204 respondents (61%). The specific manifestations of the individual behaviour were described using a thematic analysis approach.

The COVID-19 pandemic has placed an unprecedented burden on healthcare professionals in doctor's ... more The COVID-19 pandemic has placed an unprecedented burden on healthcare professionals in doctor's offices, hospitals, emergency medical services (EMS), and pharmacies. The aim of this paper was to identify the most important sources of occupational stress during this period among representatives of different healthcare professions. Results: A thematic analysis of the free statements of 125 doctors, 102 nurses, 29 health care assistants, 55 paramedics, 36 health care managers and 42 pharmacists from all over Slovakia illustrates the complex impact of the spread and management of the pandemic on all levels of the health care delivery system. The lack of personal protective equipment, limited functioning of general practitioners and the increase in infected patients led to an increased number of calls to EMS and increased the pressure on pharmacy staff, who were forced to substitute the role of general practitioners. Hospitals faced changes in the way each department operated, the number and severity of infected patients, and significant limitations in the implementation of the usual-white medicine. All healthcare professionals were negatively affected by the obligation to work regardless of their individual risks, preferences and needs, extreme public pressure, frequent changes in rules and regulations, and increased media attention.

Studia Psychologica, 2004

Simulation in healthcare : journal of the Society for Simulation in Healthcare, May 21, 2019

The below simulation cases were introduced in the 19th International EMS Competition "RALLYE REJV... more The below simulation cases were introduced in the 19th International EMS Competition "RALLYE REJVÍZ" which was held in Kouty nad Desnou (Czech Republic) on May 27-31, 2015. The cases were designed by experienced EMS instructors and modelled just as close to actual situations as possible. Each case was performed in a corresponding natural environment (e.g., in forest, at school, in a pub) in Kouty nad Desnou and surrounding communities; trained actors served as patients. Firefighters and the police with their standard equipment were also present in the case they were part of the simulation scenario. Before the competition, EMS crews received a schedule and a map with the locations where the scenes were set. The crews used their own ambulances (fully equipped) for transportation between the scenes. In the main competition, the results of which are reported in this study, the daily tasks were completed on May 29, 2015, and the night tasks in the night from May 29 to 30. Description of the tasks is presented below. Detailed scoring system for each task is presented in Supplemental Digital Content 2. Reproduced with permission from http://rallye-rejviz.com/rallye-rejviz-2015/ BRAVE MAN Case Summary: A biker (man, 25 years) has bumped into tree branches during a downhill ride through the forest and fallen from bike; he has massive hemorrhage from the right side of the neck and from the front area right side of the chest. He has helmet, lies on his left side, is pale, has wet skin, is conscious, answers with latency, is oriented, and dyspneic. Pharmacological anamnesis: negative; allergological anamnesis: NSAID; personal history: negative. Assessment: GCS 4-5-6; SpO2 88%; glycaemia 20.2 mmol/l (363.6 mg/dl); BP 90/50 mmHg; peripheral pulses 120/min; weak radial pulse; capillary refill time 4s; RR 24/min; normal neurological status; breaking contused wound on the right side of the neck with massive bleeding from the vena jugularis externa; deviation of trachea to the left; penetrating injury in right front axillar line in the 3th-4th intercostal space; breath sounds are normal on the left, they are absent on the right; begin subcutaneous emphysema and hyperresonance by percussion; abdomen negative; pelvis fixed; legs without edema; abrasions on the legs and arms. Objectives: Assess the scene; demonstrate a safe approach; take the patient's history (incl. allergological anamnesis); perform a thorough clinical examination; AcBCDE approach; stop bleeding from the v. jugularis externa l. dx.; take off the helmet; put a neck collar; treat the pneumothorax l. dx. by semipermeable dressing or chest drain; treat the evolving hemorrhagic shock and pain; direct the patient to the trauma center optimally by helicopter rescue; recognition of diabetes mellitus. INSTRUCTION FOR PERSONNEL Emergency Dispatch Center has received an emergency call from a woman: A man, 25 years old, has fallen from MTB bike in the forest, massive hemorrhage from the neck and the chest, he is conscious, further details not known. Your task: • Assess the scene and provide correct care on-site. • Examine and treat the patient(s). • Define a working diagnosis, administer a proper therapy. • Specify further steps according to the local situation (see bellow). • If a hospitalization is necessary, determine the mean of transportation (see the list bellow) and prepare the patient(s) for the transport. • Report any further steps to the judges on-site. Time limit: 10 minutes. Conditions on the scene: May 29, 11:00, clear, no wind, 19°C (66°F). The time from call to arrival on-scene is 8 minutes. If any further information necessary, report to the judge marked as DISPATCHER. Local situation: A. The nearest hospital is 20 km away overland. Depts.: surgery, internal medicine with ICU, neurology, anesthesia and general intensive care, gynecology and obstetrics, CT, and biochemistry. B. A higher-level hospital is 42 km away overland. Depts.: as A + ED, ENT, oncology, psychiatry, infectious diseases, and pediatric department. C. A specialized center is 55 km away overland. Depts.: as B + trauma center, burn unit, cardio center, stroke unit, and NMR. D. Leave the patient at the scene. Means of transportation: E. Air; helicopter rescue (by request; arrival 15 min after the request; landing at the scene possible). F. Road; team's own ambulance. G. Road; another ambulance with paramedic crew (by request; arrival 15 min after the request). H. Road; another ambulance with a physician (by request; arrival 15 min after the request). I. Others (describe and justify to the judge). Report the transportation to the judge. An example: "Direction A, transport F".

The European health psychologist, Dec 31, 2016

Many health professionals regularly experience severe stress during their practice. The way they ... more Many health professionals regularly experience severe stress during their practice. The way they cope with the resulting emotions may create additional health concerns. The aim of this study is to assess the relationships between Big Five personality traits, sensation seeking, and health behaviours as means of affective regulation among health professionals. Data were collected in 2010 among emergency medical dispatchers, paramedics and nurses across Slovakia (N=206; 22.3% males; mean age 39.4±9.0 years). The Big Five traits, sensation seeking and affective regulation styles (alcohol use, smoking, and physical exercise) were measured by Ten Item Personality Measure (TIPI), Brief Sensation Seeking Scale (BSSS), and Measure of Affect Regulation Styles (MARS), respectively. The associations between the personality traits and health behaviours were calculated using Pearson’s correlation coefficient. No associations between Big Five traits and health behaviours were found, except for openness to experience, associated with alcohol use (r=.15; p<0.05) and physical exercise (r=.25; p<0.001). Sensation seeking was positively associated with all three behaviours (r’s between .22 and .29; all p-values under 0.01) but within the sub-scales, the relationships varied widely by particular behaviour. Sensation seeking was associated with both positive and harmful health behaviours as means of affective regulation. This suggests that highly sensation-seeking individuals might benefit from health promotion activities that provide greater arousal, in order to compensate for the pleasure derived from the use of psychoactive substances. However, further studies need to explore this, and confirm the causal nature of the given relationships in the first place.

Qualitative Health Research, Oct 7, 2021

Managing one’s own and others’ emotions is a necessary part of emergency medical services (EMS) p... more Managing one’s own and others’ emotions is a necessary part of emergency medical services (EMS) professionals’ work. For that reason, we explored their emotion regulation strategies in a simulated task which focused these skills. Short semistructured interviews were conducted with 48 EMS professionals immediately after completing the task. They described their experience during this task as distressing on a manageable level. Emergent emotion regulation strategies are largely in line with established theoretical frameworks, but their specification is unique and offers new insights. Focusing on the task along with emotional distancing is a crucial combination employed by many EMS professionals. Pre-existing cognitive frames also help with processing of emotional stimuli. Among interpersonal strategies, allowing the relatives of a deceased child to cope with their grief was the most typical reaction. However, attempts to distract them or positively reframe their situation were also present, along with few other strategies.

Studia Psychologica, 2013

The aim of the study was to investigate the relationship between affect regulation styles and dec... more The aim of the study was to investigate the relationship between affect regulation styles and decision making in health-care professionals. The authors suppose that emotions and affect regulation are closely connected with decision making in professional situations. 133 health-care professionals participated in the study which employed Melbourne Decision Making Questionnaire, Measure of Affect Regulation Styles, Multidimensional Health States Scale and subjective measure of decision making effectiveness. Using cluster analysis, the authors derived a typology of four types based on affect regulation strategies and well-being and ill-being variables. The individual types were compared in regard to decision making styles and decision self-efficacy. The results showed that highest subjective effectiveness and vigilance were found in types with high cognitive and behavioral engagement. Low subjective effectiveness with high hypervigilance, buck-passing and procrastination were found in types with low use of all affect regulation strategies, especially when they were connected with higher ill-being.

Studia Psychologica, 2004

Studia Psychologica, 2020

In spite of a large body of research in the field of emotion regulation, this subject has not yet... more In spite of a large body of research in the field of emotion regulation, this subject has not yet been studied vigorously in naturalistic settings, especially not in the context of task performance. Therefore, it remains uncertain whether predominant theoretical conceptualizations of emotion regulation (e.g., Gross, 1998) can be applied to this sort of situation. In this qualitative study, we aimed to identify emotion regulation strategies of paramedic crew leaders (n = 30) in a simulated task with a sudden onset of a stressful incident. For this purpose, we analyzed their emotional behavior (i.e., facial expression, voice volume, body posture and movements etc.) on video recorded performance, and their affective states and emotion regulation strategies based on interviews conducted right after the task. Verbal reports were analyzed via phenomenologically-laden template analysis. W e classified emergent strategies into two basic categories: task-related (e.g., attention narrowing, mobilization to action, monitoring) and self-supportive (e.g., emotional distancing, behavioral withdrawal, detachment and selective attention). Results of our analysis suggest that regulatory strategies are largely implemented on an implicit level of processing and their function might be a better criterion for their distinction than a type of mental process.

Studia Psychologica, 2014

The study is focused on the question how the need for structure and the Big Five personality trai... more The study is focused on the question how the need for structure and the Big Five personality traits predict decision making styles in health professionals. The sample included 225 health care professionals from different areas (physicians, nurses, paramedics, emergency link operators). Need for structure was measured by Personal Need for Structure scale, Big Five Traits by Ten Item Personality Inventory, and the decision making styles by Melbou rne Decision Making Questionnaire. The results showed that the best predictor of vigilance was need for structure, while extroversion was a negative predictor of non-vigilant styles. Analysis of interaction showed that neuroticism interacts with need for structure in prediction of non-vigilant decision making styles (hypervigilance, procrastination and buck-passing). Specifically, persons with low neuroticism and low need for structure tend to use more non-vigilant decision making styles in comparison to others.

Introduction: We examined the process of decision making related to diagnosis in paramedic teams ... more Introduction: We examined the process of decision making related to diagnosis in paramedic teams in an international competition. Method: Observation of 28 paramedic teams in selected task was compared with objective medical evaluation of their performance in the whole competition. Results and discussion: The real process of examining the patient and establishing the diagnosis by the paramedics is not in accordance with the prescribed procedures. Paramedics show a tendency to make assumptions about the case from early steps of dealing with it, which has a strong influence on the subsequent process of examination of the patient and establishing diagnosis.

The study material (Supplemental Digital Content 1 and 2) and statistical details (Supplemental D... more The study material (Supplemental Digital Content 1 and 2) and statistical details (Supplemental Digital Content 3 and 4) for the manuscript "Testing the Rescue Personality: Personality Variables as Predictors of Team Performance in Emergency Medical Services".<br>

Data, codebook, and analysis code (SPSS) to the manuscript "Testing the Rescue Personality: ... more Data, codebook, and analysis code (SPSS) to the manuscript "Testing the Rescue Personality: Personality Variables as Predictors of Team Performance in Emergency Medical Services"

, to increase discriminatory, verbal and physical attacks on health care providers by the public ... more , to increase discriminatory, verbal and physical attacks on health care providers by the public in a number of countries. The aim of this study was to pilot the prevalence and types of unwanted behaviour by patients and their relatives towards health professionals during the COVID-19 pandemic in Slovakia. The population: 379 health professionals (79% female, 21% male) with a mean age of 44 years (SD = 11.12; min = 23, max = 76) from all regions of Slovakia. Method: frequency and thematic analysis of written responses to open-ended questions. Results: 135 (38%) respondents who work directly with patients felt stigmatised or discriminated against because of their work. 96 respondents (25%) had experienced violence because of their work in health care. Of the 340 health professionals, 59% had experienced conflict with family members of COVID-19 patients during the pandemic. Problems or conflicts with family members of non-COVID-19 patients during the pandemic were reported by 204 respondents (61%). The specific manifestations of the individual behaviour were described using a thematic analysis approach.

The COVID-19 pandemic has placed an unprecedented burden on healthcare professionals in doctor's ... more The COVID-19 pandemic has placed an unprecedented burden on healthcare professionals in doctor's offices, hospitals, emergency medical services (EMS), and pharmacies. The aim of this paper was to identify the most important sources of occupational stress during this period among representatives of different healthcare professions. Results: A thematic analysis of the free statements of 125 doctors, 102 nurses, 29 health care assistants, 55 paramedics, 36 health care managers and 42 pharmacists from all over Slovakia illustrates the complex impact of the spread and management of the pandemic on all levels of the health care delivery system. The lack of personal protective equipment, limited functioning of general practitioners and the increase in infected patients led to an increased number of calls to EMS and increased the pressure on pharmacy staff, who were forced to substitute the role of general practitioners. Hospitals faced changes in the way each department operated, the number and severity of infected patients, and significant limitations in the implementation of the usual-white medicine. All healthcare professionals were negatively affected by the obligation to work regardless of their individual risks, preferences and needs, extreme public pressure, frequent changes in rules and regulations, and increased media attention.

Studia Psychologica, 2004

Simulation in healthcare : journal of the Society for Simulation in Healthcare, May 21, 2019

The below simulation cases were introduced in the 19th International EMS Competition "RALLYE REJV... more The below simulation cases were introduced in the 19th International EMS Competition "RALLYE REJVÍZ" which was held in Kouty nad Desnou (Czech Republic) on May 27-31, 2015. The cases were designed by experienced EMS instructors and modelled just as close to actual situations as possible. Each case was performed in a corresponding natural environment (e.g., in forest, at school, in a pub) in Kouty nad Desnou and surrounding communities; trained actors served as patients. Firefighters and the police with their standard equipment were also present in the case they were part of the simulation scenario. Before the competition, EMS crews received a schedule and a map with the locations where the scenes were set. The crews used their own ambulances (fully equipped) for transportation between the scenes. In the main competition, the results of which are reported in this study, the daily tasks were completed on May 29, 2015, and the night tasks in the night from May 29 to 30. Description of the tasks is presented below. Detailed scoring system for each task is presented in Supplemental Digital Content 2. Reproduced with permission from http://rallye-rejviz.com/rallye-rejviz-2015/ BRAVE MAN Case Summary: A biker (man, 25 years) has bumped into tree branches during a downhill ride through the forest and fallen from bike; he has massive hemorrhage from the right side of the neck and from the front area right side of the chest. He has helmet, lies on his left side, is pale, has wet skin, is conscious, answers with latency, is oriented, and dyspneic. Pharmacological anamnesis: negative; allergological anamnesis: NSAID; personal history: negative. Assessment: GCS 4-5-6; SpO2 88%; glycaemia 20.2 mmol/l (363.6 mg/dl); BP 90/50 mmHg; peripheral pulses 120/min; weak radial pulse; capillary refill time 4s; RR 24/min; normal neurological status; breaking contused wound on the right side of the neck with massive bleeding from the vena jugularis externa; deviation of trachea to the left; penetrating injury in right front axillar line in the 3th-4th intercostal space; breath sounds are normal on the left, they are absent on the right; begin subcutaneous emphysema and hyperresonance by percussion; abdomen negative; pelvis fixed; legs without edema; abrasions on the legs and arms. Objectives: Assess the scene; demonstrate a safe approach; take the patient's history (incl. allergological anamnesis); perform a thorough clinical examination; AcBCDE approach; stop bleeding from the v. jugularis externa l. dx.; take off the helmet; put a neck collar; treat the pneumothorax l. dx. by semipermeable dressing or chest drain; treat the evolving hemorrhagic shock and pain; direct the patient to the trauma center optimally by helicopter rescue; recognition of diabetes mellitus. INSTRUCTION FOR PERSONNEL Emergency Dispatch Center has received an emergency call from a woman: A man, 25 years old, has fallen from MTB bike in the forest, massive hemorrhage from the neck and the chest, he is conscious, further details not known. Your task: • Assess the scene and provide correct care on-site. • Examine and treat the patient(s). • Define a working diagnosis, administer a proper therapy. • Specify further steps according to the local situation (see bellow). • If a hospitalization is necessary, determine the mean of transportation (see the list bellow) and prepare the patient(s) for the transport. • Report any further steps to the judges on-site. Time limit: 10 minutes. Conditions on the scene: May 29, 11:00, clear, no wind, 19°C (66°F). The time from call to arrival on-scene is 8 minutes. If any further information necessary, report to the judge marked as DISPATCHER. Local situation: A. The nearest hospital is 20 km away overland. Depts.: surgery, internal medicine with ICU, neurology, anesthesia and general intensive care, gynecology and obstetrics, CT, and biochemistry. B. A higher-level hospital is 42 km away overland. Depts.: as A + ED, ENT, oncology, psychiatry, infectious diseases, and pediatric department. C. A specialized center is 55 km away overland. Depts.: as B + trauma center, burn unit, cardio center, stroke unit, and NMR. D. Leave the patient at the scene. Means of transportation: E. Air; helicopter rescue (by request; arrival 15 min after the request; landing at the scene possible). F. Road; team's own ambulance. G. Road; another ambulance with paramedic crew (by request; arrival 15 min after the request). H. Road; another ambulance with a physician (by request; arrival 15 min after the request). I. Others (describe and justify to the judge). Report the transportation to the judge. An example: "Direction A, transport F".

The European health psychologist, Dec 31, 2016

Many health professionals regularly experience severe stress during their practice. The way they ... more Many health professionals regularly experience severe stress during their practice. The way they cope with the resulting emotions may create additional health concerns. The aim of this study is to assess the relationships between Big Five personality traits, sensation seeking, and health behaviours as means of affective regulation among health professionals. Data were collected in 2010 among emergency medical dispatchers, paramedics and nurses across Slovakia (N=206; 22.3% males; mean age 39.4±9.0 years). The Big Five traits, sensation seeking and affective regulation styles (alcohol use, smoking, and physical exercise) were measured by Ten Item Personality Measure (TIPI), Brief Sensation Seeking Scale (BSSS), and Measure of Affect Regulation Styles (MARS), respectively. The associations between the personality traits and health behaviours were calculated using Pearson’s correlation coefficient. No associations between Big Five traits and health behaviours were found, except for openness to experience, associated with alcohol use (r=.15; p<0.05) and physical exercise (r=.25; p<0.001). Sensation seeking was positively associated with all three behaviours (r’s between .22 and .29; all p-values under 0.01) but within the sub-scales, the relationships varied widely by particular behaviour. Sensation seeking was associated with both positive and harmful health behaviours as means of affective regulation. This suggests that highly sensation-seeking individuals might benefit from health promotion activities that provide greater arousal, in order to compensate for the pleasure derived from the use of psychoactive substances. However, further studies need to explore this, and confirm the causal nature of the given relationships in the first place.

Qualitative Health Research, Oct 7, 2021

Managing one’s own and others’ emotions is a necessary part of emergency medical services (EMS) p... more Managing one’s own and others’ emotions is a necessary part of emergency medical services (EMS) professionals’ work. For that reason, we explored their emotion regulation strategies in a simulated task which focused these skills. Short semistructured interviews were conducted with 48 EMS professionals immediately after completing the task. They described their experience during this task as distressing on a manageable level. Emergent emotion regulation strategies are largely in line with established theoretical frameworks, but their specification is unique and offers new insights. Focusing on the task along with emotional distancing is a crucial combination employed by many EMS professionals. Pre-existing cognitive frames also help with processing of emotional stimuli. Among interpersonal strategies, allowing the relatives of a deceased child to cope with their grief was the most typical reaction. However, attempts to distract them or positively reframe their situation were also present, along with few other strategies.

Studia Psychologica, 2013

The aim of the study was to investigate the relationship between affect regulation styles and dec... more The aim of the study was to investigate the relationship between affect regulation styles and decision making in health-care professionals. The authors suppose that emotions and affect regulation are closely connected with decision making in professional situations. 133 health-care professionals participated in the study which employed Melbourne Decision Making Questionnaire, Measure of Affect Regulation Styles, Multidimensional Health States Scale and subjective measure of decision making effectiveness. Using cluster analysis, the authors derived a typology of four types based on affect regulation strategies and well-being and ill-being variables. The individual types were compared in regard to decision making styles and decision self-efficacy. The results showed that highest subjective effectiveness and vigilance were found in types with high cognitive and behavioral engagement. Low subjective effectiveness with high hypervigilance, buck-passing and procrastination were found in types with low use of all affect regulation strategies, especially when they were connected with higher ill-being.

Studia Psychologica, 2004

Studia Psychologica, 2020

In spite of a large body of research in the field of emotion regulation, this subject has not yet... more In spite of a large body of research in the field of emotion regulation, this subject has not yet been studied vigorously in naturalistic settings, especially not in the context of task performance. Therefore, it remains uncertain whether predominant theoretical conceptualizations of emotion regulation (e.g., Gross, 1998) can be applied to this sort of situation. In this qualitative study, we aimed to identify emotion regulation strategies of paramedic crew leaders (n = 30) in a simulated task with a sudden onset of a stressful incident. For this purpose, we analyzed their emotional behavior (i.e., facial expression, voice volume, body posture and movements etc.) on video recorded performance, and their affective states and emotion regulation strategies based on interviews conducted right after the task. Verbal reports were analyzed via phenomenologically-laden template analysis. W e classified emergent strategies into two basic categories: task-related (e.g., attention narrowing, mobilization to action, monitoring) and self-supportive (e.g., emotional distancing, behavioral withdrawal, detachment and selective attention). Results of our analysis suggest that regulatory strategies are largely implemented on an implicit level of processing and their function might be a better criterion for their distinction than a type of mental process.

Studia Psychologica, 2014

The study is focused on the question how the need for structure and the Big Five personality trai... more The study is focused on the question how the need for structure and the Big Five personality traits predict decision making styles in health professionals. The sample included 225 health care professionals from different areas (physicians, nurses, paramedics, emergency link operators). Need for structure was measured by Personal Need for Structure scale, Big Five Traits by Ten Item Personality Inventory, and the decision making styles by Melbou rne Decision Making Questionnaire. The results showed that the best predictor of vigilance was need for structure, while extroversion was a negative predictor of non-vigilant styles. Analysis of interaction showed that neuroticism interacts with need for structure in prediction of non-vigilant decision making styles (hypervigilance, procrastination and buck-passing). Specifically, persons with low neuroticism and low need for structure tend to use more non-vigilant decision making styles in comparison to others.

Introduction: We examined the process of decision making related to diagnosis in paramedic teams ... more Introduction: We examined the process of decision making related to diagnosis in paramedic teams in an international competition. Method: Observation of 28 paramedic teams in selected task was compared with objective medical evaluation of their performance in the whole competition. Results and discussion: The real process of examining the patient and establishing the diagnosis by the paramedics is not in accordance with the prescribed procedures. Paramedics show a tendency to make assumptions about the case from early steps of dealing with it, which has a strong influence on the subsequent process of examination of the patient and establishing diagnosis.

The study material (Supplemental Digital Content 1 and 2) and statistical details (Supplemental D... more The study material (Supplemental Digital Content 1 and 2) and statistical details (Supplemental Digital Content 3 and 4) for the manuscript "Testing the Rescue Personality: Personality Variables as Predictors of Team Performance in Emergency Medical Services".<br>

Data, codebook, and analysis code (SPSS) to the manuscript "Testing the Rescue Personality: ... more Data, codebook, and analysis code (SPSS) to the manuscript "Testing the Rescue Personality: Personality Variables as Predictors of Team Performance in Emergency Medical Services"