The interaction between healthcare professionals is a crucial part of their daily work. While physicians and nurses usually work together, paramedics work mostly among themselves, and their interactions with other healthcare professionals are limited and occur at predefined moments, mainly in the pre-hospital setting and in emergency departments (EDs). This interaction includes physicians and nurses. These interactions are usually limited in their scope and it is not therefore clear whether other health professionals know what the paramedics scope of practice is, or even if they can distinguish paramedics from other EMTs. A literature review carried out prior to this study found no research examining how other healthcare professionals perceive paramedics and their clinical competency, and their attitude towards incorporating paramedics in the ED work force. This study set out to examine the ED staff knowledge and attitudes towards the paramedic profession in Israel.
Background
Paramedics interprofessional interactions
The paramedic profession developed in the 1960s in the USA as a need to address a growing number of injuries and critical patients who did not receive adequate treatment in the pre-hospital setting (Tintinalli et al, 2010).
Many countries (e.g. United Kingdom, Canada, Australia, and Israel) have utilised paramedics successfully in their EMS systems (Emergency Medical Services), turning paramedics into a dominant profession in pre-hospital emergency care. While initially paramedics where thought of as an auxiliary of the physician, who could not make clinical decisions on their own, and relied on limited protocols and telemedicine, today paramedics have a wider scope of practice, treat a variety of patients, and have considerable clinical judgement (Pozner et al, 2004).
Historically, the relationship between paramedics and the medical and nursing professions was that of a mentor and a student. Paramedics were initially taught by physicians, and worked under their guidance. As time went on, paramedics were trained predominantly by veteran paramedics.
In countries where paramedics are employed, physicians and nurses usually do not take an active clinical role in the EMS system, and the result is that paramedics do not treat patients jointly with other healthcare professionals, except EMTs.
Paramedics work alone, or with other paramedics and EMTs in pre-hospital settings, such as a patient's home or even on the road. This working environment is very different than the hospital environment, and paramedics have relatively limited tools to deal with emergencies in the field. Because of the nature of their work, paramedics need to have a variety of skills such as history taking, physical examination, performing life-saving procedures, and the ability to treat a variety of medical emergencies which are usually reserved for specialists in other clinical settings. This differentiates paramedics from other healthcare professionals, who usually treat emergencies in a multi-disciplinary highly specialised environment.
Paramedics usually meet other healthcare professionals in two distinct situations:
Paramedics in Israel
While the paramedic profession was established in the USA in the 1960s, Israel adopted the paramedic model in the late 1970s, thanks to Dr Nancy Caroline—an EMS pioneer who immigrated to Israel and became the medical director of MDA (Magen David Adom), the national EMS system (Baskett and Safar, 2003).
MDA was established during the British mandate in 1930 and since then developed considerably (Ellis and Sorene, 2008). Until the 1970s, the system included only BLS (Basic Life Support) units (Silverston, 1979). In the 1970s Physicians were introduced, and in 1979 Dr Caroline opened the first paramedic course in MDA. Since then other training frameworks have developed: a bachelor degree in emergency medicine, military training, and training for nursing students. A unique model developed in Israel—a MICU (Mobile Intensive Care Unit) that was staffed with a physician and a paramedic. In 1994, the first paramedic units without a physician were opened, and today the majority of MICUs are staffed by a paramedic without a physician.
To date 2 100 paramedics have been certified in Israel. Although it is difficult to assess the optimal number of paramedics needed in an EMS system, the number of paramedics in Israel per 100 000 is approximately 26, and in the USA, according to the Bureau of Labor Statistics, the number of paramedics per 100 000 is approximately 66. This does not take into account that the majority of paramedics in Israel and an unknown number in the USA are not active in the EMS or other clinical setting.
Currently, paramedics who are active (approximately 550) are employed almost exclusively in the national EMS system. Some paramedics work in private EMS and in the industry in an occupational health framework, but paramedics have not been introduced to hospitals or clinics. The turnover of paramedics in Israel is substantial (over 50% in three years) since paramedics cannot work outside EMS—paramedics who do not wish to work in the EMS setting lose their clinical abilities and experience due to lack of an alternative to EMS (Wacht, 2013). Another factor to consider is that in Israel there are no nurse practitioners, ECPs (emergency care practitioners) or PAs (physician assistants)—relatively new allied clinical professions that may, following additional training, provide an alternative to ambulance work for paramedics.
Methods
The study was a cross-sectional survey conducted among healthcare workers.
Research population, sample, and sampling method
Our research population included a convenience sample of physicians (about 150) and nurses (about 300) who work in the EDs of four level 1 hospitals in Israel: Soroka University Medical Center, Tel Aviv Sourasky Medical Center, Rabin Medical Center, and Rambam Health Care Campus. Procedure: the questionnaire was built using Qualtrics™ software. The procedure had two phases:
The questionnaire was distributed from November 2011 to February 2012. Of the150 emails sent, 124 questionnaires were answered. 68 additional questionnaires were filled in the four EDs. The final sample population includes 92 physicians (about 61% of the research population) and 102 nurses (about 34% of the research population).
Research tool
The questionnaire was composed of five parts: demographics, questions examining interactions with paramedics, knowledge about the paramedics’ work, evaluation of paramedics’ skills, and attitudes about expanding the paramedic's scope of practice.
The questionnaire content was validated by experts: two physicians and two nurses working in the ED, and three paramedics. A pilot study was conducted before the questionnaire was distributed. The questionnaires reliability was examined using Cronbach's alpha internal consistency (>0.7). Comparison between physicians and nurses was examined using χ2 or t test for independent samples according to the measured parameter.
Results
The sample population included 194 participants: 92 physicians and 102 nurses. 70.9% of the respondents were born in Israel, half of the physicians and a fifth of the nurses were male. The average age of the respondents was 36 years (SD=8.29) and was similar in both groups. The average work experience in the ED was 6.25 years (SD=5.11) 7.96 for nurses and 4.35 years for physicians (t=0.14, p<0.001).
Most of the nurses (92%) indicated the ED as their primary workplace, while only 17.4% of physicians work in the ED as their primary place of work (p<0.001). This can be explained by the high number of specialists who arrive in the ER only for consultations, and the large number of residents and interns.
Among the physicians, 39.1% were interns, 31.5% residents, 27.2% specialists, and 2.2% GPs. Among nurses, 88.2% had an academic degree, 34.3% had a master's degree. Four nurses had a paramedic certificate. 55.9% of the nurses had undergone advanced post-graduate training, mostly in emergency medicine and intensive care.
Interactions with paramedics
Only 5% of the participants in the survey (n=10) were ever treated as patients by paramedics, and all of them were satisfied with the treatment they received. 27% (n=52) indicated that a family member of theirs was treated by a paramedic and most of them (81%) were satisfied or very satisfied with the treatment.
Most of the physicians (92.5%; n=85) and nurses (80.4%; n=82) had been instructed by a paramedic (ACLS, PALS or other course).
About one fifth of the physicians (21.7%) encounter a paramedic on a daily basis, 22.8% a few times a week, 41.3% a few times a month, 12% rarely encounter a paramedic, and 2.2% do not encounter a paramedic in their daily work. Among the nurses, 87.3% encounter a paramedic on a daily basis, 9.8% encounter a paramedic a few times a week, and 2.9% a few times a month.
In Israel, paramedics and EMTs are distinguished by different colour markings on their uniforms, and there is no clear paramedic symbol or caption on the uniforms. We showed the respondents three pictures: a picture of an EMT-B, and EMT-I, and an EMT-P, and asked them to identify which one was a paramedic. 72% of the physicians and 77.5% of the nurses could recognise the paramedic in the pictures.
Only 14% of the respondents were familiar with the four different training frameworks for paramedics in Israel.
Only 31.5% of the physicians and 43.1% of the nurses knew that the majority of MICUs have no physician on board.
Table 1 describes physicians’ and nurses’ knowledge about procedures a paramedic is qualified to do in the pre-hospital setting in Israel:
| Procedure | Physicians (n=92) | Nurses (n=102) | Total (n=194 | χ2 | P |
|---|---|---|---|---|---|
| IV drugs | 94.6 | 96.1 | 95.4 | 0.25 | 0.617 |
| PO drugs | 94.6 | 95.1 | 94.8 | 0.03 | 0.867 |
| IO drugs | 83.7 | 80.4 | 82.0 | 0.36 | 0.550 |
| Anaesthesia | 75.0 | 77.5 | 76.3 | 0.16 | 0.689 |
| Defibrillation | 98.9 | 96.1 | 97.4 | 1.55 | 0.213 |
| NG tube | 77.2 | 74.5 | 75.8 | 0.19 | 0.665 |
| Intubation | 95.7 | 92.2 | 93.8 | 1.02 | 0.313 |
| Chest tube* | 67.4 | 59.8 | 63.4 | 1.20 | 0.273 |
| Terminating resuscitation | 15.2 | 32.4 | 24.2 | 7.74 | 0.005 |
| Not starting CPR | 26.1 | 36.3 | 31.4 | 2.33 | 0.127 |
| Leaving a patient at home after treatment* | 58.7 | 54.9 | 56.7 | 0.28 | 0.594 |
All of the above are part of the scope of practice of paramedics in Israel except inserting a chest tube and deciding to leave a patient at home after treatment
Evaluating the clinical work of paramedics
Table 2 summarises evaluation of clinical abilities of paramedics from physicians and nurses. The respondents were given a list of five statements, and were asked to grade their evaluation of paramedic skills on a Likert scale of 1 (very bad) to 5 (excellent).
| Statement | Group (n) | Average | SD | T | P |
|---|---|---|---|---|---|
| The treatment paramedics deliver to medically ill patients | Physicians (88) |
4.45 |
0.60 |
1.99 | 0.048 |
| The treatment paramedics deliver to injured patients | Physicians (87) |
4.68 |
0.49 |
0.73 | 0.464 |
| The technical skills of paramedics to perform procedures | Physicians (87) |
4.67 |
0.58 |
0.54 | 0.590 |
| The ability to take medical history and arrive at a correct diagnosis | Physicians (87) |
3.76 |
0.77 |
3.42 | 0.001 |
| The ability to work with the ED team | Physicians (87) |
4.32 |
40.78 |
0.30 | 0.767 |
| General evaluation | Physicians (90) |
4.38 |
0.47 |
1.70 | 0.091 |
We asked the respondents to rank from a list of professions (ED physician, paramedic, ED nurse, GP, EMT-B. paramedic, EMT-B, E.D physician, G.P) who they would like to treat a family member in case of an emergency in the pre-hospital setting. The scale was from 1 (most suitable) to 5 (least suitable). A lower average indicates a higher score.
Table 3 shows that the ED staff would prefer an ED physician first, then a paramedic, then an ED nurse, GP, and finally, an EMT-B. The rating was similar between nurses and physicians, except physicians rated paramedics second after an ED physician, while nurses rated themselves second and paramedics third.
| Profession | General score | Physicians score | Nurses score |
|---|---|---|---|
| ED physicians | 2.03 | 2.04 | 2.02 |
| Paramedic | 2.3 | 2.33 | 2.67 |
| ED nurse | 3 | 3.4 | 2.62 |
| GP | 3.42 | 3.18 | 3.64 |
| EMT-B | 3.87 | 3.76 | 3.97 |
The ED staff was given a list of four statements regarding their position on incorporating paramedics in new clinical fields. The rating was on a Likert scale of 1 (not at all) to 5 (very much so). The general opinion was calculated by the average of answers of each respondent, without taking into account those who voiced an indifference to who treated them.
Table 4 shows that there are differences between physicians and nurses regarding their opinions on integrating paramedics in the healthcare system. Physicians have a significantly more positive opinion regarding paramedics as PAs and paramedics in resuscitation teams.
| Statement | Group | n | Average | SD | T | p |
|---|---|---|---|---|---|---|
| It is possible to incorporate paramedics in hospitals as phlebotomists | Physicians |
89 |
3.79 |
1.35 |
1.27 | 0.205 |
| It is possible to incorporate paramedics in hospitals as physicians assistants | Physicians |
92 |
3.65 |
1.33 |
2.71 | 0.007 |
| It is possible to incorporate paramedics in hospitals as part of a resuscitation team | Physicians |
92 |
4.23 |
1.01 |
2.35 | 0.019 |
| It is possible to incorporate paramedics in HMOs in various clinical roles | Physicians |
85 |
3.26 |
1.34 |
0.87 | 0.387 |
| General opinion | Physicians |
92 |
3.74 |
0.98 |
2.41 | 0.017 |
The general position of physicians is more positive than nurses regarding paramedics integration in new clinical settings (on average 3.74 compared to 3.39; t=2.41 p<0.05)
Discussion
Although the paramedic profession is relatively new, most of pre-hospital emergency work in Israel is performed by paramedics. While physicians and nurses are considered the ‘classic’ healthcare professions, there is an ongoing debate whether the paramedic profession is becoming more widely accepted and recognised over the last years (O'Meara, 2012). While paramedics work primarily in ambulances in the pre-hospital setting in Israel, in the last few years paramedics’ scope of practice has expanded, and recently the Israeli ministry of health has advocated for paramedics to work in various clinical roles in hospitals (Israeli Ministry of Health, 2013).
While the majority of paramedics don't work in the pre-hospital setting with nurses and physicians, they transfer patients to the ED staff on a daily basis. Usually, this interaction of a paramedic with a healthcare professional in the hospital is with a nurse in the triage. The majority of nurses in our study work there as their primary workplace (92%), while less than one fifth of the physicians are permanent ED physicians (17.4%). This data is important, because if any interprofessional intervention or dialogue is to be done it seems that the nursing staff is the best place to start.
Our study found that while most of the staff knew the scope of paramedics practice, the majority did not know that paramedics can stop CPR or withhold CPR in certain situations. We assume the reason for the lack of knowledge in these specific fields is because patients who die in the pre hospital setting do not arrive in the E.D, and thus the E.D staff does not know that paramedics do not resuscitate certain patients.
The ED staff had a high regard for paramedics’ skills, such as treating sick and wounded patients, technical ability to perform procedures, history taking and diagnosis: on a scale of 1 (very bad) to 5 (excellent), the general evaluation by physicians was 4.38, and by nurses was 4.5. These evaluations show that the ED staff regard paramedics as skilled medical professionals.
Although nurses had a higher appreciation of the paramedic work in the pre-hospital setting, when asked about integrating paramedics in the hospital setting, the nurses were less inclined to incorporate paramedics in resuscitation teams (a role that is done by nurses today) and as PAs (a profession that does not exist in Israel). The general evaluation of nurses was lower than physicians, and on a scale of 1 (very bad) to 5 (excellent), the general evaluation of physicians was 3.74, and of nurses was 3.39 (t=2.41; p<0.05). Nurses might think that paramedics are less trained to treat patients in the hospital setting, yet nurses might also be more professionally threatened by paramedics taking some of their roles in the ED than physicians.
Although historically paramedics were instructed by physicians, today the majority of paramedic instruction is done by paramedics. Our research shows that today paramedics are training physicians and nurses in their field of specialty, and the majority of ED staff in our survey were previously instructed by paramedics in ACLS, PHTLS, PALS and similar courses. This important interaction can be used to further the understanding of the paramedic profession and as an initial interprofessional dialogue.
We suggest paramedics and nurses reinforce their professional ties. Studies on reinforcing interprofessional collaboration shows that although overall attitudes were favorable, initiatives towards changing the educational and working environment to promote interprofessionalism are not common (Braithwaite et al, 2013). This can be done in colleges and universities investing in interdisciplinary studies, interventions to promote interprofessional collaboration in the clinical setting, and by promoting a dialogue between professional associations. For paramedics to be accepted in the hospital setting in Israel, a constant discussion should be initiated between the professions, emphasising common goals and interests, and understanding together how paramedics can be integrated in hospitals, improving the working environment, and thus improving the Israeli healthcare system as a whole. It is important that a major change in the ‘classical role’ of paramedics as from pre-hospital healthcare professionals into a wider scope of practice will be done as a part of a dialogue between the professions and not just as a policy that is dictated from the ministry of health.
Limitations and conclusions
This research was conducted in four level 1 hospitals. Rural and small to mid-size hospitals were not sampled. No other allied health care professionals were included in the questionnaire. Further qualitative research should be conducted in order to better understand the differences found between physicians and nurses attitudes towards paramedics.