Table 6.

Illustrative Quotes Theme Three. Nb quotes have been condensed for readability.

Theme 3: Education, knowledge and skills Sub Theme – Cal-taker dissatisfaction and high staffing turnover
Q36	P11	“they leave because of stress or shifts or lack of fulfilment or the job’s not been what they expected, they go elsewhere. Yeah, we have a massive turnover of staff. …So it’s scary. It means that lots of people are within the first few months or years…”.
Q37	P06	“…the ones that are good at it get experienced with it, they sort of get a bit sick of it because nothing seems to change no matter what you do. So then they end up leaving to go and do other stuff”.
Q38	P11	”… more senior staff and management don't seem to listen to any advice that… or ideas that we might have … there's no platform for EMDs' (call-takers) thoughts …”
Theme 3: Education, knowledge and skills Sub Theme – Implications for education and research
Q39	P07	“… like our first aid training was one day … only four weeks of training, and most of that is learning the system of how to use the computers and how to use all the different systems and protocols and everything”.
Q40	P05	“…if we can get something, if we can move to a position where we’re more intimately understand the sort of correlation between kind of red flags or red flag phrases or, you know, what are those early warning signs…”
Q41	P02	“..by the time they get to week four, I think they need to be using actual calls to triage through the system because no call is ever simple. Nobody ever phones up about one thing. It’s generally three or four things by the time they come to phoning 999. The patient’s been unwell for several weeks and their abdo… dominal pain is worse, and they’ve now got chest pain…”.
Q42	P06	“There’s no training on that at all really. They’d play you hysterical callers, but they (trainers) [never] tell you how to deal with it.”
Q43	P10	“… public awareness of what will happen on a 999 call is really important… “Okay, you’re going to get through to somebody that, you know, is quite skilled and that he’s going to be able to triage you and look after you and, you know, the help’s already started from that point.” I think public awareness of that is massively important …”.
Q44	FGP12	“I think educating people is the way forwards, really. We really ought to educate more than what we do: you know, educating people why they should be ringing 999, educating people what happens when they ring 999”.
Theme 3: Education, knowledge and skills Cal-taker feedback and learning from experiences
Q45	P07	“So yeah, like getting the feedback on especially ones that suddenly go to arrest, I think is really important, at least so that I've got the chance to go, actually, can I listen back to that? Actually, is there something I did wrong?”.
Q46	P11	Absolutely, yeah. Yeah, it could highlight faults in AMPDS or, like I said, our allocation of categories to each code. That could highlight a problem as well”.
Theme 3: Education, knowledge and skills Variation in call-taker practice
Q47	P08	“I feel like although you can develop communication skills, emotionally being in tune with someone, is something unfortunately some people don’t have and you can’t really, you know I think it does come into play quite a lot. I think that’s why it’s such a hard job”.
Q48	P01	“…then that's when the EMD (call-taker) has to make their first proper decision about which protocol do they then select. So this is when the knowledge or the experience or the skill of the EMD (call-taker) makes a big difference, and can make a big difference to those patients…”.
Q49	P09	“… a lot of people are just wanting to tick a box and move on and if you actually just take the time to listen and like focus on what's going on around them you might pick it up more.”