Paramedics have progressed in many developed nations—from primarily making up a medical transportation service to becoming the independent pre-hospital practitioners we often see today. This development has led to some unique solutions to various issues in public healthcare policy. For example, managing increasing emergency department (ED) demand has given rise to the establishment of specialist roles in non-traditional practice settings (Raven et al, 2006). However, healthcare systems differ between countries. Those countries considered by the World Health Organization (WHO) as having a ‘developing’ healthcare system (WHO, 2018) should not be directly compared with those with developed systems such as the UK.
The current article highlights challenges in contextualising recent professional developments that might allow for the interpretation of research for use in nations considered by the WHO (2018) as ‘developing’. The authors will demonstrate how recent professional developments might be contextualised, and made applicable for developing pre-hospital health services. Establishing the context of research will make it more transferable between settings. Furthermore, there are several difficulties in establishing internationally relevant research for paramedic practice.
Ambulance services
Ambulance services play a unique role in any healthcare system, but the services will differ from country to country. As we know it in the UK, ambulances serve the dual roles of providing both emergency and primary care. Traditionally, the role was limited to providing a transport medium to allow sick or injured people to get to a hospital for treatment. However, in the late 1960s, ambulance practice began its transformation into a profession in its own right (O'Meara and Grbich, 2009).
Recognition of the paramedic profession remains an important but contentious issue. Some commentators maintain that it has yet to attain professional status, and that paramedics therefore exist as a ‘semi-profession’ (Eburn and Bendall, 2014; Townsend and Eburn, 2014; Paramedics Australasia, 2015). It is unclear what impact the search for professionalisation in developed nations has on those nations which have yet to implement basic pre-hospital care. Questions also remain about the applicability of research conducted in often vastly different contexts.
The emergence of professional paramedic practice has occurred at different rates in different countries, and has been adapted to suit the healthcare system in which it operates. The process of achieving that professional status has varied from country to country as a result of the different models of practice and education. Through continuing research, it is possible to recognise when a unique body of knowledge relating to pre-hospital practice and care develops (Sheather, 2009; Perry, 2016). It is that emergence of a unique body of knowledge which then assists in identifying those attributes unique to the profession (Williams et al, 2009; Scalea et al, 2012; Williams et al, 2012). Allowing this body of knowledge to inform the future direction of education and practice remains a challenge in what can be a difficult profession to define.
Inter-sectorial service
Pre-hospital care is an inter-professional and inter-sectorial service that crosses many aspects of care. Once an often-forgotten phase of emergency healthcare provision, paramedicine has now developed into an integral part of primary, secondary and, in some cases, tertiary healthcare models (Raven et al, 2006). This expansion may assist in explaining some of the differences in practice across healthcare systems.
In Australia, New Zealand and the UK, paramedics practice as autonomous health professionals—often treating people in their own homes without the need to transport them to hospital (Tippett et al, 2008). New and unique ways of managing public health concerns outside of traditional medical practices have been developed, partially as a result of paramedic practitioners helping to meet societal needs (Raven et al, 2006).
This move to evidence-based independent practice means that pre-hospital care practitioners are now beginning to determine the scope of their own practice, and develop unique solutions to public health issues. Paramedics Australasia (the peak professional body for paramedics in Australia and New Zealand) recognises this as one part of the advancement towards professional status (Paramedics Australasia, 2015).
Alongside this development towards professionalism, changes have taken place in the way in which pre-hospital care services are delivered. Raven et al (2006) discuss the non-traditional roles for paramedic practitioners throughout the UK and Australia, which have the ability to significantly contribute to public health outcomes. Community paramedic and extended care paramedic roles have transformed the profession into one that delivers wider public health outcomes (Mason, et al, 2003; O'Meara, 2003; O'Meara and Grbich, 2009).
Not only does the delivery of pre-hospital care attend to urgent incidents; the often-neglected aspect of paramedicine is also able to respond to public health issues (such as those mentioned in the current article) and ease the burden on EDs. Responding to major incidents, such as pandemics, is now seen as a key feature of a well-established pre-hospital care system (Tippett et al, 2008).
There are also significant cost savings to be found in treating people in their own homes by employing professional pre-hospital care practitioners (advanced paramedics) (Ruest et al, 2012; Evan et al, 2013; Pearson et al, 2014; Varney et al, 2014). By using these practitioners in ways traditionally reserved for doctors, a reduction in the overall costs of public health care could be achieved across many countries (Raven et al, 2006)—although there have been few updated economic studies since the introduction of this role in some settings.
Nations classified by WHO as ‘developing’ have limited resources to devote to increasing healthcare demands. Encouraging the creation of alternate, safe and less expensive means of meeting public health demands is therefore often a priority.
Role of education
Professional development in Australia, the UK and other countries has, by and large, occurred through tertiary education. It is via the creation of a knowledge base through evidence-based research (Raven et al, 2006), and subsequent delivery in the tertiary setting, that pre-hospital care practice has advanced towards becoming a profession (Sheather, 2009; Williams et al, 2009; 2010).
However, the role of paramedics may be influenced by the variability in pre-hospital care education provided across different countries. This, in turn, may limit the type of services provided, and ultimately result in delayed progression in the improvement of health outcomes during emergencies.
Literature critique
Literature that has not had the benefit of peer review and publications such as government-commissioned reports have provided useful insights in the absence of peer-reviewed literature. Such ‘grey’ literature, such as annual reports and publicly available internal performance data are used throughout the current article. There are various reasons for the relative scarcity of the literature examining pre-hospital care roles; for example, the lack of consistent terminology for ambulance practitioners globally, and the wide variation in roles. There is also difficulty with defining ambulance practice in terms of the primary, secondary and tertiary healthcare models. Any experienced and qualified researchers are in their infancy; and perhaps most importantly—there is a lack of a cohesive occupational identity in many nations with developing pre-hospital care.
A systematic literature search was carried out between September 2014 and September 2015 in support of a study into the impact of a pre-hospital care education programme in Malaysia (Perry, 2016). PubMed; Academic Search Complete; Ovid; Embase; and Eric databases were searched using the terms ‘ambulance’ and ‘Malaysia’. The authors also replaced ‘Malaysia’ with various country names, as well as ‘paramedic’ with ‘EMT’, ‘technician’, ‘ambulance officer’ and other terms as described in Table 1. Once duplicates were removed, there were 220 results across the five databases.
| Country | Brief course (up to 1 week) | Short course (up to 6 months) | Degree or diploma (2–3 years) | Postgraduate or internal training post degree/diploma | |
|---|---|---|---|---|---|
| Australia | Available as part of the state run EMS system | ✓ | ✓ | ✓ | ✓ |
| Roles | Community 1st Responder (some states) | Patient transfer | Emergency ambulance | Emergency ambulance helicopter retrieval primary care roles and hospital avoidance. | |
| Name | Community responder first aider | Ambulance officer | Paramedic (some states have differing levels) | Intensive care paramedic, rescue paramedic, retrieval paramedic or extended care paramedic | |
| Professionally registered | × | × | × | × | |
| United Kingdom | Available as part of the state-run EMS system | ✓ | ✓ | ✓ | ✓ |
| Roles | Private first aid only | Patient transfer, assisting in emergency ambulance | Emergency ambulance | Emergency ambulance home care, hospital avoidance and primary care roles | |
| Name | First aider | Paramedic assistant, emergency care assistant, EMT-B (term not often used) | Paramedic | Paramedic practitioner, advanced care paramedic | |
| Professionally registered | × | × | ✓ | ✓ | |
| Singapore | Available as part of the state-run EMS system | × | ✓ | ✓ | × |
| Roles | Private first aid only | Patient transfer | Emergency ambulance patient transfer | × | |
| Name | First aider | EMT-B | EMT-I, EMT-paramedic | × | |
| Professionally registered | × | ✓ | ✓ | × | |
| Malaysia | Available as part of the state-run EMS system | ✓ | ✓ | ✓ | × |
| Roles | Emergency ambulance, patient transfer | Emergency ambulance, patient transfer | Emergency ambulance, patient transfer | × | |
| Name | EMT, paramedic, medic | EMT-B, paramedic, medic | EMT, paramedic, medic | × | |
| Professionally registered | × | × | × | × | |
Note: This table is illustrative of the role differences and does not seek to represent a comprehensive picture of all aspects of the systems presented. Information sourced from the following: Roudsari et al, 2007; South Australian Ambulance Service, 2008; Ong et al, 2013; Paramedics Australasia, 2014; St John Ambulance of Malaysia, 2014; South Australian Ambulance Service, 2015; Perry, 2016.
Those articles were assessed for their relevance to ambulance practice and professional development within the developing world, leaving 33 articles. The articles deemed irrelevant had limited reference to ambulance practice as distinct from hospital practice, or were describing limited studies focused on clinical practice. It is reasonable to assume that one explanation for this is the lack of a professional identity for ambulance practitioners throughout the region and the world, resulting in a lack of consistent role titles, and limited involvement in original research.
Practice models and terminology
The difficulty encountered by the authors in searching the literature is compounded by the inconsistencies in practice standards; models of emergency medical service (EMS) provision; and terminology internationally. As models of practice differ around the world, so too do the terms used to describe those who undertake pre-hospital or ambulance care.
In the UK, Australia and New Zealand, the term ‘paramedic’ has been reserved for those who can be described as professional or semi-professional; and ‘ambulance officer’ has been used to describe the role generally. Other terms available and used elsewhere are ‘emergency medical technician’, ‘ambulance practitioner’, and ‘medic’. Table 1 highlights the complexities of international comparisons of ambulance systems, based on the terminology and education level of those involved with the provision of pre-hospital care.
Comparisons of skill sets may be even more complex and few have sought to describe this in the literature. One possible reason behind the differences between countries with developed and less developed pre-hospital care, at least in part, is historical and government policy relating to health system design. A common denominator across all four examples in Table 1 is the charitable organisation, St John—or more correctly, the Most Venerable Order of the Hospital of St John of Jerusalem (Howie-Willis, 1983). At the time of British colonisation of Asia Pacific regions, St John re-emerged in late 1880s England after the suppression of religious orders by Henry VIII (Howie-Willis, 1983).
Other regional and geo-political influences which have shaped healthcare system design include universal health care, such as those systems introduced by the UK (National Health Service) and later Australia (Medicare). While in Malaysia and Singapore, religious and ethnic influences need to be considered in the development of their mixed healthcare system design, which includes a civil defence service as ambulance providers. In the mixed public-private Australian system, the regional differences in each state-based system provide additional challenges for comparison.
Even in areas where similar terms are used, they may have different meanings, and this complicates the interpretation of research output. Terms such as ‘paramedic’ could refer to a university-educated professional with a post-graduation year of supervised practice in parts of Australia; and in Malaysia, someone who has had a few hours of training. Likewise, models of pre-hospital care practice can differ between physician-led (such as in the United States (US) and Norway), or paramedic-led (such as in New Zealand and Australia).
Professionalism and education
Professionalism and education are uniquely interwoven. There is no universally accepted definition of what makes a profession, nor what contributes to the professionalisation of an industry. Definitions by Greenwood (1984), van Mook et al (2009) and Townsend and Luck (2013) provide a brief comparison of the attributes of a profession.
Greenwood (1984) offers a succinct definition of a profession, which includes a systematic body of theory and authority; while van Mook et al (2009) suggest that expertise in a particular area contributes to professionalism. Townsend and Luck (2013) discuss the mastery of complex tasks and skills in a context of knowledge of some department of science or learning. Consistent with most definitions of professionalism is the understanding that a specific body of knowledge and authority exists, often in the form of recognition around that knowledge.
There is some evidence that education can lead to improvements in patient care in healthcare services considered by WHO to be ‘developed’ (Spaite et al, 2000; Giddens et al, 2012; Andrew et al, 2015). However, advocates for the use of medically controlled treatment protocols, rather than an educated professional workforce base, continue (Halter et al, 2011). This increasingly divergent debate within this emerging profession has been the subject of continuing research; however, it is unclear from the literature if any one model of service provision has particular advantages for ambulance services seeking further development. Furthermore, few, if any, studies have considered the impact of non-tertiary training courses in terms of professional development.
The existence of a body of knowledge without the acceptance of associated professions (in particular the medical profession, which currently controls pre-hospital care in many parts of the world) would be unlikely to lead to the same innovations as seen in a truly professional and independent pre-hospital care practice. It is anticipated and expected that the outcome of the associated improvement in education standards is the ability of ambulance practitioners to move from systematic treatment protocols, previously controlled by medical staff.
Evidence for non-medical professionals’ involvement in emergency care and expanded out-of-hospital medical care is mounting, but is not overwhelming. Despite this, some countries, such as Germany and the US, remain largely convinced that pre-hospital care should be physician-led (Roudsari et al, 2007).
Professionalism and research
Professionalism depends on both education and research. Research in practice produces evidence for practice, and allows paramedics to claim rationality for clinical decision-making. Following medical orders or even clinical protocols does not create conditions for autonomous practice. Even when paramedics themselves establish clinical protocols, paramedics cannot claim professionalism without evidence to support these protocols.
The research literature to date has little to say about how paramedics make emergency clinical decisions in pre-hospital care; a recent systematic review found only four studies relating specifically to this topic (Sheffield et al, 2016). According to this review, clinical decision-making requires the following:
To date, paramedic research has used mainly quantitative methodologies to explore the functions and efficacy of various treatments in pre-hospital care. While these studies have provided useful information in describing the context and functions of an ambulance service, they do not necessarily reflect the future potential of professional paramedics working in pre-hospital care. While there have been ‘generic’ qualitative studies to gain this information, more sophisticated qualitative designs must be used (Cooper et al, 2009). In addition, few studies have been led by paramedics and may have been guided by researchers using very different frames of reference.
Clearly, paramedic practice would benefit from forms of qualitative research in ways that would demonstrate to the public and to other professional groups that professional practice is underpinned by evidence. Paramedics themselves must carry out pre-hospital research rather than rely on viewpoints from other professional groups. In this way, paramedic science can develop and paramedic practice can be acknowledged as a profession and a discipline in its own right.
Conclusion
As paramedic professional development has occurred in different healthcare systems at different times, and at a different pace internationally, educational programmes and paramedic practice vary substantially.
In the UK, Australia and some other countries, paramedic education is keeping pace with other allied healthcare professional education, such as nursing; however, the research output does not appear to be. Paramedics need both higher education and research output in order to be established as a credible profession. Once established on this pathway, it is clear that a significant contribution to public health care can be achieved within the global community.
Establishing internationally relevant research in an emerging profession with varying definitions and developmental phases across the globe has specific challenges. These challenges can only be overcome by understanding the context in which research is conducted, and more attention should be paid to describing such differences.