There has been a significant shift in the scope of practice in Australian paramedics. For example, the scope of emergency care now includes advanced medical techniques and interventions (such as rapid sequence intubation) (Council of Ambulance Authorities (CAA), 2009). Paramedics also provide non-emergency low acuity out-of-hospital and pre-hospital care and capacity building for emergencies with potential service provision that can act to support more traditional ambulance services, as well as transport of the ill or injured (CAA, 2009; Edwards, 2011). Lucas et al (2013) report that there is likely to be a sustained increase in demand for ambulance services in Australia, largely due to an ageing population, which is likely to impact on paramedic practice, and that it will be critical that paramedic students are prepared to work effectively in a changing environment and have the competencies required of a 21st century healthcare system.
Paramedic education has by necessity changed from minimal educational requirements (e.g. first aid certificate), to exclusively in-house training (‘post-employment model’) provided by state and territory-based ambulance services providers. This educational model was based on an apprenticeship style approach and required students to be employed by ambulance services, as student paramedics completed on the job training inclusive of block classes, delivered by vocational education providers via regional training offices registered within the employing organisation. These students graduated with a diploma/associate diploma level qualification (Willis et al, 2009; Edwards, 2011). In recent years, there has been a transition to the current ‘pre-employment’ model where students complete a three-year university bachelor degree course, then an internship of 1–2 years (Dawson, 2008; Willis et al, 2009; CAA, 2010a). In a rapidly changing global environment where national healthcare needs in 10–20 years time are not entirely certain (though some predictions may be made in relation to, for example, an ageing population), it would seem logical that paramedics need to be equipped with not only discipline-specific skill sets but also generic or employability skills such as communication skills, critical thinking, clinical decision making and problem solving. Indeed, the literature suggests strongly that employers value and want graduates with generic skills (Wagner, 2008). Higher education institutions nationally and internationally are stressing the development of generic graduate capabilities, with evidence of these in graduate learning outcomes and mission statements of most universities (O'Brien and Oliver, unpublished observations). The relevance of ‘soft skills’ within the paramedic profession has been raised in the Australian Learning and Teaching Council report by Willis et al (2009): Paramedic education: developing depth through networks and evidence-based research.
The influence of employers of paramedics (state and territory-based members of the CAA) on education is strong. The Council of Ambulance Authorities, the key body representing the ambulance industry in Australia and New Zealand, together with Paramedics Australasia (PA) as the peak national professional body representing practitioners, have established an accreditation process for tertiary entry-level paramedic courses and have also published national competency standards (CAA, 2010b; PA, 2011). Such competency standards set out those expected competencies required to enter the profession. How well prepared paramedic graduates are actually perceived from the employers’ perspectives has not been investigated in a formal sense in Australia. In addition, it is not known how important generic skills (in addition to discipline-specific skills and knowledge) are to paramedic employers? While pre-employment factors and concerns of paramedic students and academics have been investigated (Waxman and Williams, 2006; Dawson, 2008; McCall et al, 2009; O'Brien et al, 2013), little is actually known about what capabilities employers seek in paramedic graduates. In Australia, paramedics are employed by state and territory-based providers of ambulance services, which are members of the Council of Ambulance Authorities (CAA). There are eight such ambulance services in Australia.
Given the changing nature of practice of paramedics, and the changing nature of paramedic education in Australia, we decided to investigate the perceptions of the major employers of paramedics in Australia on the work readiness of paramedic graduates. We were particularly interested in whether there were any perceived strengths or weaknesses of recent graduates by employers, what their expectations were in terms of work readiness, and whether generic capabilities (typically emphasised in university education) are recognisable in graduates and relevant to paramedic work.
Objectives
The aim of the study was to investigate the perceptions of employers from the state and territories’ ambulance services as the key employers of paramedics in Australia, on workplace readiness of graduates from Australian paramedic education programmes. In particular, we sought to understand what skills and knowledge are required by employers from a graduate paramedic, in order to inform educators and improve the work readiness capabilities of graduates of Australia paramedic education programmes.
Methods
The intervention was composed of in-depth, one-on-one, semi-structured, recorded interviews with representatives from employers of paramedic degree graduates, both from an operational and educational perspective. Using a qualitative methodology with in-depth interviews allowed the researchers to invite at least one representative from the eight state and territory-based paramedic employers (the main employers of paramedic graduates) to participate. Given the homogenous nature of the participants, a recommended minimum number of participants to achieve data saturation was 6–8 interviews for a homogeneous sample (Kuzel, 1992). Ethics approval was received from the Faculty of Health, Engineering and Science Human Research Ethics Committee.
Participants
Chief Executive Officers of the state and territory branches of the CAA were asked to nominate two members of their organisation: a senior level manager of operations and a senior level manager of education, who were invited to participate in the study. Of the nations eight states and territory-based services, seven responded to this request and participated in this study.
Interviews
The semi-structured qualitative interviews took place either on-site (at a location convenient to the participant) or over the telephone. Each interview lasted between thirty minutes to one hour, and was conducted by the same researcher (Ms Amber Moore). There were six question areas for the semi-structured interview (see Table 1). Interviews were tape recorded and transcribed into written form using a transcription service.
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Data analysis
Using NVivo 8 qualitative software, transcription data was analysed using the qualitative technique of thematic analysis, which is now well-accepted within social and health sciences research (Liamputtong, 2009). Qualitative thematic analysis of the first three interviews was performed separately by three of the researchers and then key emerging themes were compared, discussed and agreed upon to ensure internal consistency and rigour. The remaining data analysis of the transcripts was then performed by one of the researchers (AM). Data credibility is supported by participant validation of the interview transcripts post-interview, and peer-review of the transcripts and coding by the research team, in order to ensure reliability and rigour in line with accepted qualitative research methods (Liamputtong, 2009).
Results
Eleven semi-structured interviews were undertaken with the nominated representatives of the state and territory-based ambulance service employers. This section summarises the key findings in relation to the six key question areas asked.
Where do services obtain graduates from?
All of the ambulance services had, or were in the process of obtaining, new recruits that had graduated from a university programme, although there was one service who was finishing up running an employer-based VET program. There was only one employer who reported providing a current VET intake for new recruits. All employer representatives reported that the changing supply and demand around individual state requirements for paramedics was a distinct factor in their recruitment strategy. All participants expressed a close and ongoing relationship with universities in the provision of employees to their services. Two of the services also reported being currently engaged in directly developing university paramedic programmes in order to better meet their service recruitment needs and the requirements of the CAA/PA accreditation. The theme of the paramedic profession being in a state of significant change and professionalisation, with ambulances services reflecting various stages within this theme, emerged repeatedly throughout this study. An example of this theme was expressed as such:
‘Well our ambulance services are going through phenomenal change to meet increasing demand, changing pressures with the health system, increasing complexity, so those things will come into play, and so we need to have a graduate who is adaptable’ (PES_002).
The need for graduates to be adaptable is an important point made here.
Differences between university and post-employment employees
Most interviewees reported observable differences between the university-trained employees and employees who entered their employment via an employer-VET programme. A strong theme was that graduates of universities were highly-skilled and had a very high level of theoretic knowledge, but did not always know how to best apply that knowledge in paramedic practice. As one participant stated:
‘And look, the fundamental difference is that, and this is just an observation, you've now got people who come with a great deal of knowledge and so the first day that they set foot in the organisation, and the first day that they sit in an ambulance, you've got one person whose got a great deal of theory knowledge, and the only practical knowledge that they got is what they picked up in clinical placements which is hugely variable, and what we provided at orientation. And a VET sector person, comes mostly with no background information whatsoever, and they get a little bit of theory in their introduction and the same amount of practical as the uni graduate, on the day when they first sit in an ambulance. So yes, there is very significant difference, and that's in terms of their background knowledge, and in terms of their confidence levels’ (PES_011).
The ambulance services expressed an understanding and appreciation for this lack of clinical experience, and were seen to be adapting to this in various ways. For example:
‘…I think that ones that come in with a degree have the knowledge, they just don't have the hands on experience. Whereas we provide that hands on experience as part of the process’ (PES_008).
One employer reported going back to the main university provider of graduates in their state and working with them to develop more coherent and thorough clinical placement assessments, in an attempt to re-align this gap, and reduce the variation of student experiences in their clinical placements at university.
University graduates were recognised to be overall much younger in age with less life and work experience. This created some challenges for the employers, who reported addressing this change in organisational culture through adjustments to their recruitment and ongoing support programmes. One interviewee summed up this difference:
‘A lot of them come from a pure, straight from high school, and so having not had a work ethic or a worklife, and so some of that is still evolving. But overall vocationally, and we certainly treat them that way, they are vocationally equivalent to someone at the end of the programme but have a lot more knowledge. And in our experience are more adaptable to a changing environment’ (PES_002).
Another expressed it as such, in relation to university graduates:
‘So they certainly have as graduates, well they have to and they do, have a much better understanding of paramedic practice and what it means in the general sense. They've got a good anatomy and physiology, pathophysiology, they've done law and ethics, so they got all this stuff. So they've got a theoretical knowledge of practice but they don't have a working expert knowledge of practice. And you can see that, you can see that they're going to need time and support in order to develop as a practitioner, which is the same for any profession’ (PES_001).
In general, it was recognised that university graduates represented the future of the ambulance service, and adjustments were in the process of being made in organisational induction and support programmes, as well as addressing cultural differences within the service. Universities were seen to be ‘co-producers’ of paramedics, working with ambulance services on a continuum of paramedic professional development and training. Overall, participants saw the employment of university-trained graduates as positive for the profession.
Employer expectations of new graduates regarding work readiness
Interviewees expected university graduates to have a high level of knowledge, but did not expect them to be ready for unsupervised work within their organisation. Participants clearly stated:
‘Well the technical skills have been taught and learnt, the idea of the internship is not to reteach them, the idea of the internship is firstly to make sure that they are inducted into our particular practice environment, inducted into using the equipment, and our cultural way of working, which includes our clinical guidelines and protocols etc.’ (PES_001).
‘I don't think we have an expectation on them to be work ready. I think we recognise that that's our role. That's the reason why we have an internship, and it's the reason why we've continued to persist with a true internship type model, rather than a pre-employment or direct employment type model. So, we don't have a huge expectation on their work readiness, what we have is an expectation that they will come in with the appropriate theoretical knowledge so that we can convert that to the practical application’ (PES_010).
Employers saw it as their role, through an internship process, to prepare the paramedic graduate for on-road, independent practice, using the clinical practice guidelines, equipment and practices specific to their organisation, which were understood to differ between employers.
Employer perceptions of graduate work readiness and preparedness
Overall, graduates were perceived to be work ready for supervised paramedic practice, in line with CAA competency standards. The CAA definition of a work-ready graduate was often stated, and was explained by employers as making a distinction between work ready for supervised practice, and work ready for independent practice.
‘Yes, so I think they are well prepared for what I expect them to be prepared for and that is not road ready or as fully competent paramedics. They lack experience but you know experience can only come with time and the graduate programme that we run here for graduates is all about experience and giving them experience’ (PES_003).
‘What we've found with the new group is […..] they have greater knowledge, they have good understanding of the skills that are required and the equipment they are using. So from that perspective, yes they are work ready. Right, but from actually dealing with situations…. no they are not work ready to deal with situations. That comes with time, and basically as long as they are well mentored, well supported, they are fine’ (PES_007).
The need for appropriate and ongoing role-modelling, peer-support and mentoring within the ambulance services arose repeatedly. All of the interviewees spoke about various structures of this nature, and emphasised their importance in transitioning university graduates into the workplace successfully.
Strengths and deficiencies of recent paramedic graduates
As previously stated, graduates of paramedic programmes were seen to have a very strong knowledge base, but they did not always understand how to apply that knowledge clinically or practically. A number of examples of this were given:
‘I think maybe that's part of the issue, they are coming out with their heads full of all this technical information, and trying to apply that in practice and the ability to differentiate between what's serious and what's not is lacking because they are thinking the worst all the time’ (PES_008).
The expectation of university students that ambulance practice was all ‘lights and sirens’ was perceived as a challenge to be addressed by employers and universities. Several participants reported that university graduates have very good technical skills; however, the reality of paramedic work is that much of it is not related to accidents and emergencies, but rather management of chronic conditions and non-urgent work.
The issue of lack of life experience of university graduates and its impact on being able to communicate with a variety of people (patients and more experienced and/or older peers) was raised. This is exemplified in the comment of one participant:
‘And the job, you know, getting ready to put cannulas in people upside down in cars with a torch in their mouth. And that portion of the work is really only 1% of what we do. So the ability to talk down a psych patient, or to communicate with someone who's a hundred years old, and have that discussion about boiled lollies and their grandchildren. They somewhat, have missed that experience. So they come out, and we're working, we're working out now how to get them to become better communicators quicker, because they come out without that body of knowledge from the battle scars from years of life experience’ (PES_006)’
Identification of generic capabilities in university graduates by employers
A key finding was that employers regard generic capabilities as highly desirable, in line with the values of the ambulance service, and that these are observed in graduates. New recruits were seen to be able to research and keep up-to-date with new research findings, and are eager to implement them within the organisation.
‘While the new graduates, university graduates I should say, have been challenged through their academic process to think about change, to be adaptive to evidence-based medicine, to look at driving the changes in their own practice, so in essence in my experience a lot of them are pushing the changes and talking about the changes, that we should be driving from a professional sense, when previously that wasn't necessarily the case. So they are more adaptable to changing environments. So when there is a new bout of research that comes in saying this is a new clinical practice and these are the rationales for introducing it they will jump at that opportunity, they will be a part of, often they will submit the research proposal to change the practice’ (PES_002).
Other capabilities that were highly valued included the ability to work in a team, communication skills and problem solving. In particular, the capability of critical thinking was seen to be of particular relevance to paramedic practice. When asked about graduate attributes, one participant responded:
‘Yes, yes, that's exactly what we're looking for. Look I've been in this line of work for X [number deleted] years or some ridiculous amount of time, and there are still individual things that I have not seen, a case of this or that, or something like that, and so you can be in the job for a long, long time and not see certain things, but on the day that you go and you find that particular problem, you've got to have a skill set that allows you to adapt everything you do know to that problem. And that's what we are trying to develop in people, that's what we want them prepared in. And I think one of the things that does happen with universities, and clearly this would be an attribute of any university programme in any discipline is they are supposed to turn out critical thinkers. And I think on balance, most people are, like there will always be individuals that aren't, but I think the programmes for the most part are doing that, and that's the starting point for this. They do two things, they provide people with a background level of knowledge, in some certain skills and behaviours, but then the thing that's harder to measure, is that they should provide people with that skill of problem solving and critical thinking’ (PES_011).
Although these capabilities were appreciated by employers, there was still some adjustment occurring within the ambulance services. They recognised these skills as necessary for the future workforce, that the new leaders of the services were emerging equipped with these skills, and that there is a need to further nurture and support the ongoing development of these capabilities.
Discussion
How to prepare graduates for the workforce is of prime concern to educators, students and employers. Against a background of extensive changes to the scope of practice of paramedics over many years, Australian paramedic education is in a state of transition from a post-employment model to a pre-employment model that incorporates an internship with the ambulance service for new university graduates. This pre-employment model is different to one in which graduates are expected to have the requisite skills to begin practice on graduation (for example, optometry, physiotherapy, Chinese medicine to name a few of the regulated health professions in Australia).
This is the first study of employers of paramedic graduates within Australia, focused in particular on perceptions of how work ready graduates are, their strengths and weaknesses, and whether generic skills are valued by ambulance services and demonstrated by graduates. Results indicate that participants felt graduates to be work ready in the sense that they were ready to enter the internship phase, but not ready for unsupervised work. Participants felt that graduates had very good clinical skills and a good knowledge base, though they did not always know how to apply the knowledge in a practical sense. Interviewees recognised the role of the ambulance service in providing the support and frameworks to transition new graduates, including the need for appropriate and ongoing role-modelling, peer-support and mentoring.
The development of generic or employability skills is a focus of higher education institutions nationally and internationally (O'Brien and Oliver, unpublished observations). Results indicate that generic skills are valued by ambulance services, in particular critical thinking, problem solving, teamwork and communication. There was acknowledgement of the strengths of graduates in critical thinking, problem solving and applying an evidence-based approach to practice, and that these capabilities are necessary for the development of the profession. Interviewees recognised also that many graduates of university courses are young and lack important life experiences that can equip them with the skills to communicate effectively with a variety of people of different ages and cultural backgrounds. The perceived gap between expectations of the daily work of a paramedic, that of emergencies (‘lights and sirens’) and the realities of dealing with more mundane, chronic care issues is something that should be heeded by educators and careers counsellors. Prospective students need to be appraised realistically of the day-to-day realities of the work of a paramedic and this should continue to be emphasised in order to manage expectations.
How work ready final year students perceive themselves to be was investigated in a small study of final year paramedic students at Victoria University (O'Brien et al, 2013). The study found that the majority of survey respondents felt themselves to ‘somewhat prepared’ or ‘adequately prepared’ with respect to nine key dimensions of paramedic practice. Students highlighted some of the strengths of their course which included clinical placements, though a common theme emerging was a desire for more clinical placements and greater variety in terms of experiences, within hospitals and the healthcare system (O'Brien et al, 2013). This is consistent with studies in other healthcare disciplines including Chinese medicine (Moore et al, 2010) and nurse practitioners (Hart and Macnee, 2007) that also found that students wanted more placements experiences (including more rigorous and relevant experiences). Though the internship years will provide greater opportunities for practical experience, whether greater clinical experience could be provided in university courses by, for example, extending the three years to four years, and whether this is desirable, bears some consideration by key stakeholders. The commendable, close relationship between ambulance service providers and education institutions conducting bachelor degree courses provides the ideal climate for future dialogue.
Conclusions
This was the first study to investigate aspects of work readiness in university graduates, from the employer perspective in Australia, at a time when paramedic education is transitioning into the higher education sector. Whilst a previous study investigated student perceptions of work readiness, this study has closed the loop in looking at this issue from the perspective of the employer. The study found that from the perspective of senior officers within state and territory-based ambulance organisations, graduates are ready for supervised practice, though not independent practice, and that the state and territory ambulance services expected to be involved in transitioning graduates to independent practice. The adaptability of new graduates, armed with solid theoretical knowledge, good clinical skills and good employability skills including the ability to think critically and problem solve, appear to be strengths of university-based training. A weakness indicated is that graduates are not always able to apply the knowledge in a practical sense. It is hoped that the information provided in this study will be of use in ongoing dialogue between paramedic educators and ambulance service providers as they, together, shape the future of paramedic education in Australia.