Around the World Photos / Shutterstock.com
Why this article matters
Paramedic airway management is often viewed as a matter of individual skill, yet technical ability alone does not explain why endotracheal intubation (ETI) performance varies so widely across emergency medical services (EMS) systems. This qualitative study suggests that the larger issue lies within the systems that support, or fail to support, ongoing competency. Drawing on interviews with EMS educators, administrators, and emergency physicians, the findings identify declining clinical exposure, organizational leadership, and integrated training systems as key influences on airway performance.
For EMS leaders, improving airway competency requires more than periodic training. It requires creating organizational structures that promote continuous practice, meaningful feedback, clinical experience, and a culture of sustained performance improvement. These findings offer practical insights for agencies seeking to strengthen airway readiness, improve quality assurance, and build more reliable systems for maintaining one of EMS’s most critical lifesaving skills.
Introduction
Advanced airway management remains one of the most critical and technically demanding procedures performed by paramedics in the prehospital environment.1 ETI is frequently required during high-acuity emergencies, yet research continues to demonstrate considerable variability in overall paramedic endotracheal intubation success rates.
Across EMS systems, reported overall ETI failure rates range from approximately 10% to 40%, depending on provider experience, training exposure, and operational conditions.2 This variability raises important concerns regarding patient safety, procedural reliability, and the effectiveness of current EMS training and oversight systems. Although discussions of paramedic airway management have traditionally focused on technical competence and training, growing evidence suggests that organizational leadership, quality assurance processes, and agency culture also play important roles in shaping clinical performance.1,3
High-Reliability Organization (HRO) principles emphasize continuous learning, structured feedback, and proactive performance improvement, yet many EMS systems continue to face challenges implementing these practices consistently.4 At the same time, declining clinical exposure to ETI, workforce shortages, and increased reliance on supraglottic airway devices may further accelerate procedural skill decay among practicing paramedics.2,5
Together, these factors suggest that airway management performance is not simply a training issue but a broader organizational and systems issue. While simulation-based education and competency training remain essential, relatively little research has explored how EMS educators, administrators, and emergency physicians collectively view the organizational, educational, and operational factors that influence paramedic airway performance.1
This qualitative study addresses that gap by examining the perspectives of EMS educators, administrators, and emergency physicians involved in paramedic training and clinical oversight. Through semi-structured interviews, the study explores how leadership practices, training systems, and workforce conditions influence ETI performance and identifies system-level factors that may inform leadership strategies, training reforms, and quality improvement initiatives designed to strengthen airway competency across EMS systems.3
Methods
Participants
This qualitative study explored factors influencing paramedic ETI performance through the perspectives of individuals directly involved in paramedic education, clinical oversight, and airway management. A purposive sampling strategy was used to recruit participants from municipal, fire-based, and private EMS organizations serving urban and suburban regions of the western United States. The final sample included 16 participants representing three stakeholder groups: EMS supervisors and administrators, paramedic educators and examiners, and emergency physicians. Recruitment continued until thematic saturation was reached, with no new themes emerging from additional interviews.6
Interviews
Semi-structured interviews were conducted between December 2025 and February 2026 using secure videoconferencing or telephone. Interviews lasted approximately 28 to 63 minutes and explored participants’ perspectives on training adequacy, clinical airway experience, organizational leadership, and decision-making during high-stress airway management. All interviews were audio-recorded with participant consent and transcribed verbatim for analysis.
Analysis
Transcripts were analyzed using thematic analysis with Dedoose qualitative analysis software. Coding combined deductive concepts informed by Adult Learning Theory, Cognitive Load Theory, and High-Reliability Organization theory with inductive themes that emerged directly from participant responses.7 Themes were refined through iterative comparison across interviews until a coherent set of recurring patterns was identified. To enhance rigor, the study incorporated field notes, reflective memos, an audit trail, member checking, and ongoing comparison of findings across participant groups.
Why Qualitative Methods Were Appropriate
A qualitative approach was selected because the study sought to understand how organizational, educational, and operational factors influence airway management performance from the perspectives of EMS stakeholders. Semi-structured interviews provided the flexibility to explore experiences that cannot be adequately captured by quantitative measures alone, making this approach well-suited for examining the complex system-level influences on paramedic ETI performance.8,9
Ethics
The study received approval from the University Institutional Review Board before data collection. All participants provided informed consent, participation was voluntary, and confidentiality was maintained through pseudonym assignment, removal of identifying information, and secure data management.
Results
Thematic analysis of interviews with 16 EMS stakeholders identified three major themes influencing paramedic ETI performance. Participants included paramedic supervisors, educators, and emergency physicians, providing perspectives from training, clinical oversight, and operational leadership. The three themes were: (1) declining clinical exposure and procedural skill decay, (2) organizational leadership and EMS system culture, and (3) integrated training systems combining simulation with real clinical experience.
Theme 1: Declining Clinical Exposure and Procedural Skill Decay
Theme Explanation
Participants consistently described declining clinical exposure to endotracheal intubation as a major factor influencing paramedic airway management performance.10
Evidence Summary
Stakeholders across all participant groups reported that paramedics have fewer opportunities to perform ETI than in previous years. Educators noted that many students complete training with limited live intubation experience despite meeting competency requirements.
EMS administrators observed that increasing use of supraglottic airway devices has reduced opportunities to maintain ETI proficiency in the field. Emergency physicians also described noticeable differences in airway technique between providers with frequent ETI experience and those with limited recent exposure. Participants consistently emphasized that maintaining proficiency requires regular practice and reinforcement.
Participant Quotations
One paramedic educator explained: “The biggest issue is simply lack of exposure. You can teach the skill in the classroom, but if someone only performs a few real intubations over several years, it becomes very difficult to maintain confidence and proficiency.”
An emergency physician participant similarly observed: “When paramedics bring patients into the emergency department, you can sometimes see the difference between providers who intubate frequently and those who rarely do it. Experience really matters with a procedure like this.”
Theme 2: Organizational Leadership and EMS System Culture
Theme Explanation
Participants emphasized that organizational leadership practices and EMS system culture strongly influence airway management performance.6,11
Evidence Summary
Participants described leadership as a key factor affecting airway competency. Supervisors reported that operational demands, including call volume, staffing shortages, and response time expectations, often reduce opportunities for ongoing training. Educators noted considerable variation in agency quality assurance processes, with some organizations conducting regular airway reviews while others provided little structured feedback. Emergency physicians highlighted the value of collaboration between hospitals and EMS agencies in supporting continued competency development.
Participant Quotations
An EMS supervisor stated: “Leadership plays a huge role. If the organization values clinical excellence and supports training, paramedics have more opportunities to practice and improve their skills.” An emergency physician participant added: “When EMS agencies regularly review airway cases and provide feedback, you can see the difference in performance. Those systems create an environment where clinicians are constantly learning.”
Theme 3: Integrated Training Systems Combining Simulation and Clinical Experience
Theme Explanation
A third theme centered on the need for integrated airway training systems that combine simulation-based instruction with real clinical experience.8,12
Evidence Summary
Participants agreed that simulation is valuable for developing foundational airway skills but emphasized that it cannot fully maintain ETI proficiency by itself. Educators highlighted the importance of high-fidelity simulation, while many participants stressed the need for clinical experience in settings such as operating rooms or intensive care units.
Administrators emphasized mentorship, case reviews, and continuing education as additional components of competency maintenance. Emergency physicians observed that paramedics who regularly participate in both simulation and clinical experiences generally demonstrate greater procedural confidence and consistency.
Participant Quotations
A paramedic instructor summarized this perspective: “Simulation is an excellent training tool, but it cannot fully replace real patient experience. The best systems combine simulation with operating room rotations and ongoing case review.” An EMS administrator similarly stated: “Airway proficiency requires a system approach. Training, feedback, and clinical exposure all have to work together if we want paramedics to maintain these critical skills.”
Summary of Findings
Across all participant groups, three consistent themes emerged: declining clinical exposure, organizational leadership, and integrated training systems. Participants described airway competency as being influenced by opportunities for practice, structured feedback, leadership support, and access to both simulation and real clinical experience.
Discussion
This study explored how EMS educators, supervisors, and emergency physicians perceive the factors influencing paramedic ETI performance. The findings identified three interconnected influences on airway management reliability: declining clinical exposure, organizational leadership and system culture, and the need for integrated training systems that combinesimulation with real clinical experience. Collectively, these findings suggest that variability in paramedic airway performance is not simply an individual provider issue but the product of educational, organizational, and operational systems that either support or undermine competency over time.8,13
Declining Clinical Exposure and Skill Retention
Participants consistently identified declining clinical exposure as one of the greatest threats to maintaining ETI proficiency. Reduced opportunities to perform intubation during both initial education and routine field practice contribute to skill decay, reduced confidence, and greater variability in performance.14,7
The increasing use of supraglottic airway devices has improved patient care in many circumstances but has also unintentionally reduced opportunities for paramedics to maintain proficiency with ETI.2, 5 These findings reinforce Adult Learning Theory, which emphasizes that complex psychomotor skills require repeated, meaningful practice to remain proficient.15
When providers have few opportunities to perform ETI on actual patients, even high-quality initial education becomes increasingly difficult to sustain.
What should EMS chiefs do?
Chiefs should recognize that declining ETI exposure is an organizational challenge rather than an individual provider deficiency. Agencies should establish systems that provide regular opportunities for skill reinforcement, including scheduled simulation, clinical partnerships, and ongoing competency monitoring.
What should training officers do?
Training officers should move beyond periodic recertification by incorporating short, frequent airway practice into routine operations. High-fidelity simulation, structured scenario-based exercises, and operating room rotations can help offset declining field exposure while reinforcing procedural confidence.
What should medical directors do?
Medical directors should regularly review airway performance data, identify providers with limited procedural exposure, and support policies that encourage ongoing competency development through clinical experience, continuing education, and evidence-based remediation when necessary.
Organizational Leadership and EMS System Culture
Participants consistently emphasized that leadership priorities and organizational culture strongly influence airway competency. Agencies that invest in education, quality improvement, structured feedback, and clinical oversight appear better positioned to sustain provider proficiency than organizations focused primarily on operational metrics such as response times or staffing efficiency.
These observations align closely with High-Reliability Organization principles, which emphasize continuous learning, transparent communication, and proactive performance improvement in high-risk environments.16 Participants repeatedly described the value of airway case reviews, post-event debriefings, and supportive leadership cultures that encourage learning rather than assigning blame.
What should EMS chiefs do?
Chiefs should foster a culture in which clinical excellence is valued alongside operational performance. Airway competency should be viewed as a strategic organizational objective supported through appropriate staffing, dedicated training time, and measurable quality improvement initiatives.
What should training officers do?
Training officers should integrate airway performance into ongoing quality improvement activities rather than treating training as a separate function. Regular review of airway cases, structured feedback sessions, and competency tracking can help identify trends before performance declines become significant.
What should medical directors do?
Medical directors should actively participate in airway quality assurance programs by reviewing difficult airway cases, collaborating with educators, and providing clinically meaningful feedback that reinforces learning while promoting consistent standards of care.
Integrated Training Systems and Experiential Learning
The third major finding highlights the importance of combining simulation-based education with real clinical experience. Participants viewed simulation as an essential component of airway education but consistently emphasized that simulation alone cannot replicate the complexity, stress, and decision-making demands encountered during actual patient care.9
Participants described effective airway competency as the product of multiple reinforcing experiences, including simulation, operating room rotations, mentorship, structured feedback, and ongoing performance evaluation. Clinical operating room experience remains valuable for reinforcing technical airway skills, patient positioning, and laryngoscopy technique. However, operating room intubations occur under controlled conditions with optimized patients and do not fully replicate the physiologic instability, contaminated or emesis-filled airways, environmental constraints, or time pressures encountered during emergency prehospital airway management.
For this reason, operating room experience should complement, rather than replace, high-fidelity simulation, structured field training, and ongoing competency programs. This layered approach also supports Cognitive Load Theory by allowing repeated practice to automate procedural steps, reducing cognitive burden during high-stress emergencies and improving clinical decision-making.17
What should EMS chiefs do?
Chiefs should support integrated competency systems rather than relying on isolated training events. Partnerships with hospitals, investment in simulation resources, and organizational commitment to continuous competency development can strengthen long-term readiness.
What should training officers do?
Training officers should design longitudinal airway education programs that combine simulation, clinical exposure, mentorship, and performance review. Competency should be evaluated continuously rather than only during annual skills verification.
What should medical directors do?
Medical directors should collaborate with hospitals and educators to expand opportunities for clinical airway experience while ensuring that competency standards remain aligned with current evidence and local protocols.
Implications for EMS Systems
Taken together, these findings indicate that improving paramedic ETI performance requires a systems-based approach integrating leadership, education, quality improvement, and workforce development. Participants consistently described airway competency as an organizational responsibility rather than solely an individual provider responsibility. For EMS leaders, the practical implications are clear.
Agencies should create structured systems that promote frequent skill practice, monitor competency over time, encourage multidisciplinary feedback, and provide meaningful opportunities for clinical experience. Leadership engagement should extend beyond policy development to include active participation in quality improvement, education, and performance evaluation.
Ultimately, improving airway performance requires more than better training. It requires organizations to build systems that continuously support learning, reinforce competency, and strengthen clinical readiness throughout a paramedic’s career. By viewing airway management through a systems perspective rather than an individual performance perspective, EMS agencies may be better positioned to improve procedural reliability, enhance patient safety, and sustain competency in one of prehospital medicine’s most critical lifesaving interventions.
Practical Recommendations for EMS Agencies
The findings of this study suggest that improving paramedic airway competency requires more than periodic retraining or individual remediation. Instead, EMS agencies should consider implementing coordinated organizational strategies that support continuous skill development, performance evaluation, and leadership engagement.
Increase Deliberate Airway Practice
Because opportunities to perform endotracheal intubation in the field continue to decline, agencies should create regular opportunities for deliberate practice outside of patient care. Short, structured airway exercises incorporated into normal shift routines, combined with high-fidelity simulation and periodic clinical experiences, can help reinforce psychomotor skills and procedural confidence. Frequent, low-dose practice may be more effective for long-term skill retention than infrequent, intensive training sessions.
Strengthen Quality Assurance Review
Quality assurance should extend beyond documenting procedural success rates. Agencies should routinely review airway cases to identify trends in first-pass success, decision-making, equipment use, protocol adherence, and opportunities for system improvement. A structured quality improvement process can help identify educational needs before they become performance problems while promoting continuous organizational learning.
Incorporate Structured Feedback
Participants consistently emphasized the importance of timely, constructive feedback following airway encounters. EMS agencies should establish standardized post-event debriefings and multidisciplinary case reviews that encourage learning rather than blame. Feedback from medical directors, training officers, peers, and receiving physicians can reinforce effective practices while identifying opportunities for improvement.
Expand Clinical Exposure
Simulation remains an essential component of airway education but should be complemented by real clinical experience whenever possible. Partnerships with hospitals that provide operating room or other supervised airway rotations allow paramedics to maintain procedural proficiency under controlled clinical conditions. These experiences should be integrated into broader competency maintenance programs rather than viewed as isolated educational events.
Monitor Competency Longitudinally
Competency should be evaluated as an ongoing process, rather than an annual event. Agencies should establish systems that track procedural exposure, simulation participation, clinical rotations, continuing education, and airway performance over time. Longitudinal monitoring allows organizations to identify declining proficiency early and implement targeted educational interventions before patient care is affected.
Support Leaders with Meaningful Metrics
Agency leaders require more than simple intubation success rates to evaluate airway readiness. Meaningful performance measures may include procedural frequency, first-pass success, simulation participation, clinical exposure, quality assurance findings, case review outcomes, and competency trends over time.
These metrics provide leadership with actionable information to guide resource allocation, educational priorities, and quality improvement initiatives while supporting a culture of continuous competency development. Collectively, these recommendations reinforce the central finding of this study: sustainable airway competency is achieved not through isolated training events, but through organizational systems that integrate education, clinical experience, leadership engagement, performance measurement, and continuous quality improvement. EMS agencies that adopt this systems-based approach may be better positioned to maintain procedural proficiency, improve patient safety, and strengthen long-term clinical readiness.
Limitations
This study has several limitations. First, the findings are based on qualitative interviews with 16 EMS stakeholders and are intended to provide in-depth insights rather than statistically generalizable results. Second, participants represented EMS educators, administrators, supervisors, and emergency physicians; frontline paramedics and patients were not included and may have offered additional perspectives. Finally, participants were drawn from EMS systems in the western United States, and organizational practices may differ in other regions.
Despite these limitations, the diversity of stakeholder perspectives and achievement of thematic saturation provide meaningful insights into the organizational and educational factors influencing paramedic airway performance.
Conclusion
This study explored how EMS educators, supervisors, and emergency physicians perceive the factors influencing paramedic ETI performance. The findings identify three interconnected influences on airway competency: declining clinical exposure, organizational leadership and culture, and the need for integrated training systems that combine simulation with real clinical experience.
Together, these findings reinforce growing evidence that airway performance is shaped not only by individual technical ability but also by the educational and organizational systems in which paramedics practice.9,7 Participants consistently emphasized that maintaining ETI proficiency requires sustained opportunities for experiential learning, structured feedback, and active leadership engagement. EMS agencies that invest in continuous competency development, multidisciplinary collaboration, and quality improvement processes may be better positioned to maintain procedural reliability, strengthen provider confidence, and improve patient safety.
These findings support previous research demonstrating that organizational culture and leadership play a critical role in developing and sustaining clinical excellence.6 As EMS systems continue to evolve, agencies must adapt their approach to maintaining high-acuity, low-frequency skills. The challenge is no longer simply teaching paramedics how to perform endotracheal intubation: it is creating organizational systems that enable them to maintain proficiency throughout their careers. Ultimately, airway competency should not be viewed as a provider problem but as an organizational responsibility requiring continuous leadership attention.
Agencies that treat airway management as a system-wide commitment, integrating education, clinical exposure, performance measurement, and quality improvement into everyday operations, will be better positioned to sustain competency, improve patient outcomes, and strengthen the reliability of one of prehospital medicine’s most critical lifesaving interventions.
Disclosure
The author is the founder and president of Sentinel Skills Systems, Inc., an organization focused on EMS training and competency maintenance. No Sentinel products or services are discussed or promoted in this article.
Disclaimer
I used CoPilot, ChatGPT, and Google AI to assist with grammar, spelling, formatting, and improving the readability of my writing.
About the Author
Dr. Ronald Rivers, DM, MBA, is a retired paramedic, researcher, and founder of Sentinel Skills Systems, Inc. His doctoral research at the University of Phoenix examined the organizational, educational, and operational factors influencing paramedic endotracheal intubation performance. His work focuses on airway competency, procedural skill retention, organizational leadership, and evidence-based strategies for improving EMS system performance.
References
1. Jarvis, J. L., Panchal, A. R., Lyng, J. W., Bosson, N., Donofrio-Odmann, J. J., Braude, D. A., Browne, L. R., Arinder, M., Bolleter, S., Gross, T., Levy, M., Lindbeck, G., Maloney, L. M., Mattera, C. J., Wang, C.-T., Crowe, R. P., Gage, C. B., Lang, E. S., & J. Matthew Sholl. (2023). Evidence-Based Guideline for Prehospital Airway Management. Prehospital Emergency Care (Print), 28(4), 1–13. https://doi.org/10.1080/10903127.2023.2281363
2. Cross, S. J. (2018, January 2). Airway management and endotracheal intubation by paramedics for cardiac arrest. Journal of Paramedic Practice. https://www.paramedicpractice.com/content/features/airway-management-and-endotracheal-intubation-by-paramedics-for-cardiac-arrest
3. Wang, H. E., Levy, M., & Cone, D. C. (2022). The National Association of EMS Physicians Compendium of Airway Management Position Statements and Resource Documents. Prehospital Emergency Care, 26(sup1), 1–2. https://doi.org/10.1080/10903127.2021.1988776
4. Carney, N., Totten, A. M., Cheney, T., Jungbauer, R., Neth, M. R., Weeks, C., Davis-O’Reilly, C., Fu, R., Yu, Y., Chou, R., & Daya, M. (2021). Prehospital Airway Management: a Systematic Review. Prehospital Emergency Care, 26(5), 1–12. https://doi.org/10.1080/10903127.2021.1940400
5. Alghamdi, R., Ashraf, & Alghamdi, R. (2024, January 3). Simulation-Based Training Program for Continuing Professional Development of Paramedics in Endotracheal Intubation. EMS Airway. https://emsairway.com/2024/01/03/simulation-based-training-program-continuing-professional-development-paramedics-endotracheal-intubation/
6. Braithwaite, S., & Barcinas, S. (2025). Paramedic professional identity: A qualitative case study using a role theory lens. Paramedicine. https://doi.org/10.1177/27536386251383541
7. Poranen, A., Kouvonen, A., & Nordquist, H. (2022). Perceived human factors from the perspective of paramedics: A qualitative interview study. BMC Emergency Medicine, 22(178). https://helda.helsinki.fi/items/78bfb463-bdad-44ad-acea-7fabcb1e74c9/full
8. Newton, J., Carpenter, T., & Zwicker, J. (2024). Exploring paramedic perspectives on emergency medical service (EMS) delivery in Alberta: a qualitative study. BMC Emergency Medicine, 24(1). https://doi.org/10.1186/s12873-024-00986-z
9. McClelland, G., Limmer, M., & Charlton, K. (2023). The RESearch PARamedic Experience (RESPARE) study: a qualitative study exploring the experiences of research paramedics working in the United Kingdom. British Paramedic Journal, 7(4), 14–22. https://doi.org/10.29045/14784726.2023.3.7.4.14
10. Hornick, I. (2024). Supraglottic airway use in emergency medical service events rises in 2022 vs. 2011. Healio. https://www.healio.com/news/pulmonology/20241119/supraglottic-airway-use-in-emergency-medical-service-events-rises-in-2022-vs-2011
11. Almazrua, A. A., Smith, C. M., Brown, T. P., & Hawkes, C. A. (2026). Paramedics’ experiences of treating Out-of-Hospital Cardiac Arrest (OHCA) patients during the COVID-19 pandemic in the United Kingdom (UK): A qualitative reflexive thematic analysis. Paramedicine. https://doi.org/10.1177/27536386251380855
12. Weile, J., Nebsbjerg, M. A., Ovesen, S. H., Paltved, C., & Ingeman, M. L. (2021). Simulation-based team training in time-critical clinical presentations in emergency medicine and critical care: a review of the literature. Advances in Simulation, 6(1). https://doi.org/10.1186/s41077-021-00154-4
13. Jong, A. D., Jaber, S., & Myatra, S. N. (2025). Best practices in airway management in critically ill adults. Intensive Care Medicine, 51(12), 2414–2417. https://doi.org/10.1007/s00134-025-08181-9
14. Gu, A., Leal-Méndez, F., Lewén, A., Hånell, A., Holmberg, L., Enblad, P., Svedung-Wettervik, T., & Linder, F. (2026). Lead times in the early management of traumatic brain injury: relation to geographic conditions and clinical outcomes in a nationwide Swedish registry study. Acta Neurochirurgica, 168(1). https://doi.org/10.1007/s00701-026-06817-3
15. Livingston, M., & Cummings-Clay, D. (2023). Advancing adult learning using andragogic instructional practices. International Journal of Multidisciplinary Perspectives in Higher Education, 8(1), 29–53. https://files.eric.ed.gov/fulltext/EJ1386100.pdf
16. Veazie, S., Peterson, K., & Bourne, D. (2019). Evidence Brief: Implementation of High Reliability Organization Principles. In PubMed. Department of Veterans Affairs (US). https://www.ncbi.nlm.nih.gov/books/NBK542883/
17. van Merriënboer, J. J. G., & Sweller, J. (2005). Cognitive Load Theory and Complex Learning: Recent Developments and Future Directions. Educational Psychology Review, 17(2), 147-177. https://doi.org/10.1007/s10648-005-3951-0
Dr. Ronald Rivers, DM, MBA, is a retired paramedic and the founder of Sentinel Skills Systems, Inc. located in the San Francisco Bay Area. He recently completed doctoral research at the University of Phoenix examining organizational, training, and operational factors affecting paramedic endotracheal intubation performance. His work focuses on airway competency, skill retention, simulation-based training, and EMS performance improvement.
