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Resuscitation guidance advocates the teaching of non-technical skills (NTS) to improve team performance for an out-of-hospital cardiac arrest (OHCA), which is critical to patient survival. To assist in the training and education of NTS, behavioural marker systems (BMS) provide a method for assessment and are common in other areas of healthcare, such as surgery and anaesthetic practice. Despite this, specific NTS have not been identified for the paramedic managed OHCA and no BMS exists. The primary aim of this study was to develop and evaluate a BMS for the paramedic managed OHCA. A scoping review revealed a paucity of literature related to NTS and an OHCA. This identified a gap and to investigate further a mixed methods approach was used to inform the design and development of a BMS. An initial survey of student and qualified paramedics (n=70) at a central England university was conducted to explore the use of NTS in an OHCA. This was followed by four focus groups of student and qualified paramedics (n=16), which identified five NTS and the effect that an unfamiliar ad hoc team has on the effective management of an OHCA. Four NTS were validated using semi-structured interviews of subject matter experts, all with experience in prehospital medicine, NTS and OHCAmanagement (n=7), before triangulation was performed to integrate the results of a narrative literature review of comparable BMS with the previously collected data. These results informed the design of the prototype Paramedic Out-of-Hospital Cardiac Arrest Assessment Tool (POHCAAT). It consists of four NTS categories: team coordination; situation assessment; communication; decision-making; each supported by three sub-components (elements) of each NTS category, behavioural markers, and a rating scale. Two evaluation phases were performed to measure the reliability, validity, and usability of the POHCAAT. After completing a day long workshop and two-hour online refresher session, a selection of HEMS clinicians, university staff and advanced paramedics all experienced in NTS and OHCA management acted as novice raters (n=25). The raters, using the POHCAAT across the two evaluation phases, observed a range of simulated OHCA scenarios. Preliminary results indicated an overall good Cronbach's α (0.85-0.93) but with noted item duplication, a moderate level of inter-rater reliability for each NTS category (ICC 0.53-0.70), a moderate level of absolute agreement (ICC 0.44-0.67), as well as the ability to distinguish between poor and good behaviour. Following the preliminary evaluation, the POHCAAT was modified to improve the design, with results indicating a reduction in item duplication and an acceptable/good level Cronbach's α (0.71-0.81). Inter-rater reliability was measured as moderate-good for each NTS category (ICC 0.69-0.84), with substantial to almost perfect levels of agreement (ICC 0.69-0.84). Sensitivity was improved with raters able to distinguish poor - acceptable - good behaviour, and consistent test-retest results (ICC average for paired films 0.96-0.98), raters commenting that the POHCAAT was easy to use and applicable to practice. This research has resulted in the identification of specific NTS for the paramedic managed OHCA, which has resulted in the development of a reliable, valid, and usable BMS that works well in simulated practice. Recommendations include the integration of the POHCAAT into undergraduate paramedic programmes and ambulance trusts as a method for training in the assessment of NTS in a paramedic led simulated OHCA. This will allow further evaluation to assess the generalisability of the POHCAAT's ability to provide structured feedback for a range of ambulance clinicians.