Community perceptions of the professional status of the paramedic discipline

Method

Two focus groups were undertaken in this pilot study. Participant responses underwent thematic analysis (Bender and Ewbank, 1994) by three independent investigators with experience in qualitative research methods. The results were then compared between data sets. The use of multiple coding approaches are intended to increase the objectivity and validity of qualitative research (Barbour, 2001). The focus groups were held in metropolitan and regional parts of Melbourne, Australia with 4–6 participants each in May 2010. Focus groups were facilitated by (BW and AM) and lasted approximately 60–90 minutes in duration.

Key issues discussed included: community perception of the professional status of the paramedic discipline and nomenclature used to describe an out-of-hospital employee, e.g. paramedic, or ambulance officer. Study participants were also asked to write down the attributes and traits they valued as the most important for paramedics to possess, and these were then discussed by the group.

Ethics

Ethics approval was granted from Monash University Human Research Ethics Committee. Members of the public willing to voluntarily participate in the study were recruited via community groups. All participants were provided with an explanatory statement, consent form and they were given a chance to clarify any issues with the researchers prior to focus group commencement. Each focus group was audiotaped with all responses transcribed verbatim.

Results

Study participants ranged from 21–62-years-old with a mean age of 42.5 years. A total of 10 participants were involved in both focus groups, including five males and five females. A sample of typical responses is shown below under the key topic areas during the focus groups.

Discussion

There is a dearth of research pertaining to community perceptions of the paramedic discipline. Currently, the Australian paramedic discipline is considered a semi-profession (Williams et al, 2010). Several traits are considered important in achieving professional status: altruism, self-regulation, code of ethics, and a unique body of knowledge (Reynolds, 2004). In addition to these, it is also recognised that public perceptions are important in the process of becoming a profession (Freidson, 1986). Specialised research, knowledge and skills are required to expand beyond the traditional ‘ambulance driver’ image, and to strive towards a standalone profession that is autonomous and integrated within the healthcare system. The dissemination of evidence-based clinical practice, complemented with technological advancement and community support will continue to shape the foundations of the progressive pre-hospital industry towards professional status (Tippett et al, 2003).

Freidson suggested that the term profession was based on independent practice, self-auditing processes, expert knowledge and special value in its work, monopoly and service to the public (Freidson, 1986). Others such as Greenwood (1957) summarise five key requirements to gain professional recognition:

However, contemporary definitions of professionalism have shifted from traditional models (trait theories) and adopted a more modern approach (e.g. Ewing and Smith, 2001), that promotes quality of life within the existing changing world and maintaining proficient personal interactions (Higgs and Hunt, 1999). Higgs and Hunt identify similar professional characteristics to Greenwood (1957) by recognising the importance of adapting with the changing practice, including the capacity to demonstrate responsibility in serving and enhancing society. Professions by nature have definable, achievable goals and expectations of practitioners (Berglund, 2007). A code of conduct provides guidance for the morality and integrity of professions which is reflective within ethical standards (Cruess et al, 2002). Clinical skills based on evidence-based medicine, complemented with altruistic services, is forefront to the professional nature of the paramedic discipline (Cruess et al, 2002). Ongoing student mentoring, research and professional affiliations enhance the arguments for professional status recognition.

To support these concepts, professional training entitles members to acquire privileged knowledge and technical skills exclusive to the paramedic discipline. Professions, in most cases, usually have a professional association(s). In the example of Australian paramedics, the discipline has Paramedics Australasia (formerly Australian College of Ambulance Professionals), which acknowledges the best interests of its members, accountability, patient care, self-regulation and advocacy (Australian College of Ambulance Professionals, 2009). Theoretical knowledge and a sound technical skill base complemented with strong ethical foundations and professional behaviour (Berglund, 2007), will assist to improve societal attitudes towards the paramedic profession. Professional responsibilities include improving and maintaining theoretical knowledge and technical/clinical skills. To be recognised as a profession, paramedics must be competent, moral, idealistic and altruistic to maintain community respect and trust (Cruess et al, 2002). Positive outcomes of these approaches ensures the highest level of professional services and patient care (Berglund, 2007). Likewise, research from Locke et al (2007) concludes that professionalism among health care members has the capacity to have an effect on the experience of patients. Williams et al (2010) examined paramedic perceptions concerning the professional registration of the paramedic discipline. A majority of the paramedic membership reported the paramedic discipline would benefit from being recognised as a full profession within Australia (Williams et al, 2010). Complementary to these findings, research from Mahoney (2003) acknowledged that paramedics have a good justification for their bid to gain professional status.

Results from the focus groups indicate the community have high expectations regarding the standards of clinical care. However, unlike academic definitions and theories about professionalism, it was assumed by focus group respondents that paramedics are nationally registered for a variety of reasons including: ‘they perform lifesaving skills, wear a uniform and are highly skilled and educated.’ It was also assumed paramedics have to conform to a high standard of care based on their level of responsibility and if breached their registration would be revoked, impeding their ability to work as a paramedic. This is despite the fact that the Council of Ambulance Authorities has provided guidelines for paramedic practice and the assessment and accreditation of entry level education programmes to meet perceived employer needs. Professional registration provides societal guarantee of professional competence, safety, and accountability (Cruess et al, 2002); therefore, the question must be asked, even though community perceptions of the paramedic discipline deem the industry as a professional registered domain, their justifications for this summation utilise lay terminology. Community perceptions which were consistent with Greenwood criteria to be a recognised profession include ‘sanction of the community’ (Higgs and Hunt, 1999), which was identified by the remark ‘[paramedics’] public support is enormous.’ Additionally, a ‘professional core focus’ (Higgs and Hunt, 1999) is implied with the paramedic ‘uniform’, as identified in the focus group where paramedics were considered ‘very professional’, and that a ‘professional culture’ could be implied by the assumption that paramedics maintain a competent level of clinical knowledge (Reynolds, 2004).

In order for paramedics to provide an optimal level of care and service community needs, the focus group participants identified education and training as fundamental elements. Traditional vocational ambulance training has been replaced with higher degree tertiary courses and qualifications in most states and territories in Australia (Williams et al, 2010). However, the standards and course content are not uniform, therefore there is the potential for students to graduate with inadequate or inconsistent levels of skills and knowledge. Higgs and Hunt state that universities should equip students to strive for the highest level of professional responsibility and accountability to deal with the changing professional context (Waxman and Williams, 2006); however, without a national educational requirement this is a difficult task. Continuing education is a key driving force to achieve recognition as a standalone profession within out-of-hospital health care. Universities are required to broaden their existing syllabus beyond professional competencies, such as clinical skills, that reflect contemporary employability and industry needs (Lord, 2002). Understanding the professional demands of society and the global context within pre-hospital health, and an expanded knowledge and skills matrix can be utilised to produce autonomous competent professionals (Higgs and Hunt, 1999).

Nomenclature: paramedic versus ‘ambo’

Traditionally the terms ambulance officer and ambulance driver have been the Australian nomenclature within the paramedic discipline. Williams et al (2010) raise the question: Does the general public refer to emergency out-of-hospital care providers as ‘paramedics’ or ‘ambulance drivers’? Authors from this study pose the question that the term paramedic is not universally understood according to focus group results. There was an assumption the term paramedic is ‘American’ and ambulance officer and ambulance driver is ‘Australian’. Some participants from the focus groups were unfamiliar with the term paramedic and were unsure of its meaning. Paramedics Australasia defines the term paramedic as: ‘A healthcare professional providing treatment and care in the out-of-hospital environment’ and provides transport solutions and options to definitive care (Australian College of Ambulance Professionals, 2009). According to the focus group participants, they collectively agreed the inconsistencies of term on ambulance vehicles, e.g. ‘ambulance’, ‘paramedic’ and ‘MICA paramedic’ exacerbates their confusion. Over time, the term ambulance officer has been abbreviated to ‘ambo’ as Australian slang, which was recognised by focus group participants as the most commonly used term to describe emergency medical service providers in Australia. This preliminary result indicates an opportunity for further research.

Attributes and traits recognised as desirable for paramedics

There is limited research that analyses consumer perspectives of the attributes of healthcare workers (Oermann and Templin, 2000). Attributes derived from literature on healing and health professionals have been conceptualised into healer, e.g. caring, compassionate, open, whereas examples of professional attributes include autonomy, self-regulation and team work. The overlapping of attributes for healer and professional include: competence, altruism, trustworthiness and honesty (Freidson, 1986). Additionally, Kilner used a Delphi study among paramedic staff in the United Kingdom to analyse the most desirable attributes of ambulance technicians, paramedics and clinical supervisors (Kilner, 2004). The Delphi results indicated the most desirable paramedic attributes in rank order were honesty, professionalism, followed by clinical skills (Kilner, 2004). Community perceptions from the two focus groups indentified paramedics being ‘caring and reassuring’ (46%) as the most desirable attribute and traits. Similar to the Delphi study, ‘professional and ethical standards’ (30%) were ranked second and it was collectively agreed paramedics ‘always conduct themselves professionally’. Furthermore, communication skills (17%), highly skilled, and educated (17%) were also identified as significant. However, in comparison to other research findings regarding healthcare attributes, the community perceived as fundamental, such as with nurses in a hospital setting, maintaining up-to-date qualifications, education and excellent communication skills were identified as most important (Oermann and Templin, 2000). Contrary to the focus group results of this study which indicated ‘caring’ as most important for nurses in the hospital settings, ‘caring’ was the lowest rated item.

This research strives to enhance the continual improvement of paramedic practice by underpinning the basis of professionalism through continuing formal education and training (Locke et al, 2007). Paramedics’ experience, knowledge and theoretical qualifications builds the credibility of paramedics as a standalone and recognised profession. The pre-hospital care industry has been encouraged to drive changes throughout the industry as opposed to responding to change from within the medical profession (Kilner, 2004). Emergency medical service approaches to out-of-hospital care build future foundations and embrace fundamental challenges, while embedding critical reflective practices and encapsulating diversity. These approaches strengthen the out-of-hospital industry by optimising health outcomes for health workers and the wider community. Findings from this pilot study may be utilised to recognise and eliminate community misconceptions about the role of paramedics, assist in advancing the momentum towards professionalism in the paramedic discipline, and contribute to defining future research agendas (Campeau, 2008).

This study is limited by the preliminary nature of data collection, indicated by a small sample size. This limitation is mitigated by the use of multiple qualitative data analysts when examining the transcripts, and there are plans for result validation in future larger scale studies in the future.

Conclusions

This pilot study conducted two focus groups to gain an understanding of community perceptions of the paramedic discipline. The general community recognises paramedics as professionals. Interestingly, the term paramedic is still not synonymous among community members, suggesting further role clarification and public education is required. The majority of participants assumed that paramedics were nationally registered, similar to medicine, physiotherapy or law. The public perceptions of the paramedic role and the desirable attributes of a paramedic provide important information and an extra dimension regarding curriculum development, core competencies, and establishment of a standardised curriculum. Further examination of community perceptions is required, particularly as the discipline progresses toward national standards, registration, accreditation, and professional identity.