PHTLS training increases knowledge but paradoxically decreases self-efficacy in emergency healthcare professionals: a cross-sectional study

Trauma remains a leading cause of death globally, with prehospital care quality critically influencing outcomes. While the Prehospital Trauma Life Support (PHTLS) course improves trauma management knowledge among emergency healthcare professionals, the relationship between knowledge acquisition and self-efficacy remains underexplored, though clinical confidence is as important as theoretical knowledge for effective trauma care. This study evaluated PHTLS course effectiveness on trauma management knowledge and self-efficacy of emergency healthcare professionals, investigating whether PHTLS training, while improving objective knowledge, is associated with decreased self-perceived competence, in a pattern compatible with a Dunning-Kruger-like effect whereby training reveals the complexity of trauma care. This cross-sectional study was conducted at a trauma center in Istanbul, Turkey, in 2022, including 98 healthcare professionals (physicians, paramedics, nurses, emergency medicine technicians EMT) divided into PHTLS-trained (n = 48) and non-trained control (n = 50) groups. Data were collected using a sociodemographic questionnaire and a 50-item multiple-choice knowledge test from the PHTLS curriculum (Cronbach’s alpha = 0.82). Self-perceived competence (as a proxy for self-efficacy) was assessed with a singledirect yes/no question. Statistical analyses included Mann-Whitney U, chi-square tests, and logistic regression. Subgroup analyses by profession and effect size (Cohen’s d) were calculated. Paradoxically, self-perceived competence was significantly lower in the trained group. The PHTLS-trained group demonstrated significantly higher mean knowledge scores than the non-trained group (70.46 ± 14.68 vs. 55.28 ± 11.44; p < 0.001), with a large effect size (Cohen’s d = 1.15). Consequently, 43.8% of the trained group met the PHTLS certification threshold of ≥ 76 points, compared to only 4% of the non-trained group (p < 0.001). Paradoxically, self-perceived competence (self-efficacy proxy) was significantly lower in the trained group (25%) than the non-trained group (62%; p < 0.001). Subgroup analysis revealed physicians in the non-trained group had disproportionately high self-efficacy despite lower knowledge scores compared to trained paramedics. Logistic regression confirmed PHTLS training as the strongest independent predictor of passing (OR: 3.2, 95% CI: 1.8–5.6, p < 0.001). PHTLS training effectively increases theoretical trauma management knowledge but is paradoxically associated with lower self-perceived competence, a pattern consistent with increased awareness of limitations and the theory-practice gap following training. This suggests theoretical training alone is insufficient. Standardized training programs must be combined with high-fidelity, simulation-based practical skills training to build both competence and confidence.