I Can’t Change The Direction Of The Wind, But I Can Adjust My Sails

By: Mike Billingham

It looks like the winds of change are reaching paramedicine in Canada with the paramedic degree initiative on the horizon. In case you haven’t heard, the Paramedic Association of Canada has a vision to move toward a degree paramedic program by 2025. As you might imagine, any change in the workplace usually triggers big questions. Like “What does this mean for me?” The short answer is “probably not much in the short term”. But we are definitely at a crossroads in the development of our profession.

In this article, I’d like to discuss this change, relate what has happened in other countries and outline some of the challenges for us moving forward.

The role of the paramedic has changed significantly since the early 1980s when I started my career. Our training was about two months long and we were bombarded with information. The information was excellent and due  to the time constraints, prioritized in a way that would prepare us for most high acuity situations that we might face. Looking at it from today’s perspective, it seems ridiculous to expect that we could be competent with such a short education. But you have to understand that we really had no protocols to speak of. We were trained to use the venturi mask and take spinal precautions. We learned a system to prioritize our assessments and this provided the framework for managing endocrine, cardiovascular, respiratory and trauma related emergencies. But if the patient needed an IV, Entonox, or even a Sager splint, we called ALS. Because we were so limited in scope, we really  couldn’t hurt anyone as long as we remembered to take  the patient to the hospital. As our system evolved, we pushed for more protocols.

It was obvious that our patients needed more than we could offer and our managers saw that as well. Most of these managers were once paramedics and they clearly empathized with the terrible feeling of watching someone die because our hands were tied. For these reasons, throughout most of my history as a paramedic, change has been driven by dedicated individuals and driven from the ‘bottom up’.

But more recently, change is occurring from the ‘top down’. In the United Kingdom, reforms to the National Health Service, resulted in a move to the paramedic degree  program and a shift from in-house and on the job training. These reforms came about as part of the government’s plan to deal with an aging population, cost pressures and changes to their society. We see the same factors at work here in Canada with an increased need from those suffering from psychiatric conditions, addictions and complex but non-emergent medical problems.

In the UK, it was thought that paramedics required greater critical thinking and clinical decision making to support making informed judgments about whether to  transport a patient for definitive care or leave the patient  at home with appropriate referrals and supports.

In some Australian states, particularly in rural communities suffering from health workforce shortages, consideration has been given to the expansion of the scope of paramedic practice to include roles and functions that are non-traditional and would normally be carried out by other health practitioners. These include minor surgery, investigative procedures such as endoscopies, anaesthetics and requesting diagnostic tests. (1)

 

There were other drivers of change however. There was a belief that achieving a degree was associated with being a professional. And being a ‘profession’ attracts many benefits such as an increase in earnings, respect and status, as well as acknowledgement from other degree based health professionals. Another compelling aspect to this drive for change was to protect the public from other non-registered and inadequately educated providers from providing care. By establishing a college and legally restricting entrance to those who had the proper credentials, it allowed ambulance services to ensure a mínimum standard of entry to practice to ensure patients were safe.

In the UK, the government led and financed the degree paramedic program and some employees were given the opportunity to upgrade and have their tuition paid for. In some services, a re-design of the workforce model provided this opportunity, but if employees declined the opportunity, their pay was maintained for five years before being reduced and they were transitioned into roles with reduced scope of practice. The reasons for this change are complex, but ultimately, when governmental and organizational budgets become scarce and consumers become more demanding, the government began to reorganize the nature of paramedic work so that it was more economic, more commercial in nature and more entrepreneurial. As a result of such market-driven management, paramedics have become part of large-scale organizational systems, with cost control; targets; indicators; quality models; and market mechanisms, prices, and competition. (2)

This has led to a loss of freedom due to standardized procedures and increased accountability based on adherence to institutional targets, performance review, and external regulation … this doesn’t sit well with street-level paramedics and they are seeking to sustain “occupational professionalism” that is founded upon collegial author ity, practitioner’s discretion and trust, and professional ethics. (2)

Due to the nature of change in the UK, it’s not surprising that there is a debate between the value of experience, empathy and emotional intelligence, and the increasing emphasis on the acquisition of academic knowledge. This  initially caused friction between those who were trained  before the degree program, and the “knowledgeable yet  often inexperienced” university graduates. However, paramedics who entered through the university route now find themselves in leadership roles within ambulance services, and requirements for advanced education is now  the new norm. Those supporting the changes believed that university education would provide greater job opportunities to the new graduates, but it may have had  a negative impact on job retention and on the sustainability of the paramedic workforce. This seems to be the  case in the United States where many of those who enter the paramedic profession with a degree seem to view paramedicine as a stepping stone to further opportunities. The change in licensure and regulation initially led to difficulties in retention. For example, during the period between February of 2012 and October of 2013, due to ‘lack of compliance with codes of professional practice’,

10 registered paramedics were discharged from the profession and 12 paramedics were suspended. This was by far the highest of all other professions in the UK. This in stark contrast to “the old days”, as ‘FM’, an experienced paramedic who has been trained during the “pre-reforms” era, recalls:

If I’d done something wrong I’d get a clip around the head, and that was it…

Nowadays, as ‘HK’ recalls from her first few shifts on the ambulance upon graduating from university,

….you suddenly think “I have to remember absolutely everything they’ve just taught me at university”… And you don’t want to get anything wrong, because that means that your career is gone. You don’t just think about your patient, you constantly think about your own registration. (2)

It should be noted that although new practitioners are concerned that technical errors will lead to dismissal, this not a realistic concern. A review of the Health and Care Professions Tribunal, shows clear evidence that ‘poor behaviour’ is by far the most common reason for disciplinary action. And in 2019, paramedic suspensions were significantly lower than many other professions.

Although the reforms in the UK have largely been a success, there have been significant missed opportunities. Due to its “top-down” nature and without engaging paramedics “on the ground” in the occupational change, the professionalization of British paramedics and the formalization of paramedic education did not quite grasp practitioners’ support and it did not bear the professional gains that are expected, such as better pay or better work conditions.(2)

The following table is summary of the perceived professional related influences of paramedic university education in the UK

Front-line paramedics Enhanced public health roles and with it, enhanced accountability and public trust Individualized practice and decreased sense of community and ‘camaraderie’ Cultural tension between the ‘pre-reforms’ trained paramedics and the university graduates
Paramedic students Formal education, certificates, enhanced societal status

University and clinical placement social- ization

Sense of achievement, professional pride, public recognition

Potential for greater job mobility Interaction with the academic community and with other professional groups Intensified scrutiny as an academic disci- pline

The ambulance service Injection of university-trained, knowledge- able workforce equipped with enhanced medical knowledge and skills

Greater job mobility may lead

to challenges in retaining paramedics

The host university Struggle to locate itself between academic and professional requirements

Struggle to locate itself between occupa- tional and organizational professionalism

 

Here in Canada, our existing post-employment model of paramedic training has been around for a long time. It has been developed, analyzed and redeveloped many times over the years and we have long considered it a good ‘bang for the buck’ in terms of producing job ready practitioners in a short amount of time. However, the pre-employment (or university) model is becoming the new standard in many countries, and while this is good for the profession, we need to be wary. Elsewhere, universities and technical schools have adapted by combining existing courses with traditional paramedic training. In many cases, existing courses such as microbiology, research, English and math may prepare learners for life after paramedicine but not adequately prepare an inexperienced learner for the job.

Higher education places great emphasis on developing graduates as critical thinkers, to question, challenge and research. So there is the potential for confusion when graduate paramedics enter a work environment that is steeped in the realm of ‘competences’, clinical practice guidelines and specific work instructions. As was the case in nursing, the post-employment model of paramedic training was very practically oriented by design and this could be seen as a strength of the model. The pre-employment model (university-based education), in contrast, provides less exposure to the clinical environment and thus clinical skills may be less well developed on graduation. (3)

This was studied in Australia and skills development was

found to be suboptimal for third year students. Less than 50 per cent of learnt skills were practised during clinical placements. These findings are similar to an evaluation completed on undergraduate surgical students where 70 per cent of students failed to complete a procedure that linked to their level of education. This raises the concern that students are not receiving adequate skills practice during clinical placement and a review of supplemental skills practice needs to be considered by the university and the ambulance services. This begs the question; does the problem lie with the university or the paramedic industry itself ? Is the university curriculum meeting the contemporary needs of the paramedic environment, or is the industry complicated by other issues such as industrial reforms and enterprise bargaining disputes?

These Australian paramedic students are now required

to complete a three-year bachelor degree before commencing paramedic employment. This model encompasses an extensive theoretical base. But in contrast to the post-employment model, students are provided with limited ‘on the job’ skill acquisition via clinical placements. Clinical placements form a fundamental component to under- graduate programs and provide students with a means of developing communication skills, professional socializa- tion, working in an interdisciplinary team environment, learning professional etiquette and practising psychomotor skills. (4)

Theses issues seem to come up in in each country that has moved to a university model and we see the same issues arise in our own ACP programs. Hospitals and ambulances have a limited capacity to train students on clinical placements and we must compete with nursing and other allied health care students. Also, the nature of the work dictates that there are a limited number of high acuity calls over a given time. While the general public no doubt appreciates this, it can be difficult to develop skills. In Canada we have the ability to use the experiences of other countries to inform our planning. I’m sure you agree that we must take the best from the old model and we must add the necessary education from universities to develop our degree program. If we meet the degree requirements by taking non-essential courses, we won’t graduate job ready practitioners. In other countries, this has led to increased levels of stress, burn out and a lack of retention. We need to support the next wave of paramedics in Canada as the job is already taking an increased toll on our practitioners’ mental health. Here, we have the ability to drive the change from within our profession and it seems that we are well on the way. My hope is that we will develop a career path that will take us from EMR through to PhD and provide opportunities at every level. Higher education will not only produce higher-level clinicians but improve the leadership and business aspects of EMS as well. In time, we will be able to guide our own practice and our patients will benefit. For more detailed information, you may find the following publications of interest.

 

REFERENCES

  1. http://aace.org.uk/wp-content/uploads/2011/11/Taking-Health- care-to-the-Patient-Transforming-NHS-Ambulance-Services.pdf
  2. http://aace.org.uk/wp-content/uploads/2011/11/Taking-Health- care-to-the-Patient-2-REPORT.pdf
  3. Lessons about work readiness from final year paramedic students in an Australian university Kylie O’Brien PhD1,2, Amber Moore BChinMed(Hons)2,3, Peter Hartley PhD2 , David Dawson MBA
  4. The bargaining of professionalism in emergency care practice: NHS paramedics and higher Assaf Givati, corre- sponding author Chris Markham, and Ken Street. Adv Health Sci Educ Theory Pract. 2018; 23(2): 353–369. Published online 2017 Nov 10. doi: 10.1007/s10459-017-9802-1
  5. An Australian story: Paramedic education and practice in transition Kylie O’Brien PhD1 , Amber Moore BChinMed- (Hons)1,2 , David Dawson MBA3 , Peter Hartley PhD
  6. An investigation of theory-practice gap in undergraduate paramedic education: Rebecca Michau, Samantha Roberts, Brett Williams, Malcolm Boyle BMC Med 2009; 9:23. Published online 2009 May 18. doi: 10.1186/1472-6920-9-23 PMCID: PMC2694182