The Intermediate Ambulance Care (IAC) course is a 30-week ambulance training programme offered in Penang, Malaysia. It was designed to improve the clinical education of ambulance practitioners and forms part of many different training opportunities of varying quality in the region. The question that this research aims to address is: what is the impact of the IAC on the emerging professionalisation of pre-hospital care in Penang, Malaysia?
Using a focused ethnographic approach, this research considered the programme's contribution to professional development, enabling comment on how such programmes could improve future service provision.
Background
Pre-hospital care is an interprofessional and intersectorial service that transects many areas of health care. Emergency health care has not been well-regarded, nor considered a distinct specialty in its own right in many countries; yet in some systems, it is an integral part of primary, secondary and, in some cases, tertiary health models (Tippett et al, 2008). While this may be the case in some healthcare systems considered developed by the World Health Organization (WHO) (2018), the same cannot be said for others, let alone those that are still considered to be developing.
In developed healthcare systems, such as those in Australia, New Zealand (NZ) and the United Kingdom (UK), paramedics are pre-hospital care providers and act as autonomous practitioners. They often treat people in their own homes without the need to transport them to hospital (Raven et al, 2006). Evidence-based, independent practice means that pre-hospital care practitioners can develop their own scope of care in order to deliver solutions to public health issues. These activities have the support and recognition of peak professional bodies in Australia and NZ among other areas, as advancing the professional status of paramedics (Paramedics Australasia, 2015).
This is contrasted in Malaysia, where a number of different occupations contribute to the provision of pre-hospital care practice (Hisamuddin et al, 2007). Those practitioners are referred to by a number of different titles, such as paramedic or medic. Some belong to other professional groups, such as nurses, medical assistants or even medical practitioners. Literature describing the international comparison of pre-hospital care roles, titles and occupation or professional grouping is largely absent. Therefore, this article will refer to those who undertake pre-hospital care in Penang as pre-hospital care providers. Furthermore, the term ‘paramedic’ is used to refer to those who practice this role in a more clearly defined manner, such as those in the UK or Australia.
Paramedic professional development in the UK, Australia and other developed countries has, by and large, occurred when education has shifted from a vocation model to pre-employment tertiary education. Education, and associated research activities, can assist in creating a distinct body of knowledge and the ability to critically reflect on current practices in pre-hospital care (Greenwood, 1984). This change of practice benefits the community by improving service delivery for both urgent care and public health.
Evolving and expanding scope of care beyond traditional service delivery models means that the current unmet needs or major incidents can be addressed. Raven et al (2006) discuss the non-traditional roles of paramedics throughout the UK and Australia where 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; Mason et al, 2007; O'Meara and Grbich 2009). As a measure of system responsiveness and development, the ability to respond to major incidents, such as pandemics, is now seen as a key feature of a developed pre-hospital care system (Tippett et al, 2008).
Since the 1990s, paramedic education has shifted its delivery from vocationally-based to the higher education sector in many countries in the developed world, such as the UK and Australia (Hou et al, 2013; Townsend and Eburn, 2014; Paramedics Australasia, 2015; Brooks et al, 2016). However, there remains little information on how education informs or assists with professionalisation. There is even less known when the setting is in a developing country.
A systematic search of the literature from September 2014–September 2015 revealed 33 related articles that appeared to focus on answering the research question. The search terms included: (‘Ambulance’ or pre*hospital care or paramedic or EMT or technician or ambulance officer) AND (‘Malaysia’ or ‘developing country’). These terms were searched in PubMed, Ovid, Academic Search Complete, Embase and ERIC databases, with the process supported by a subject librarian from the University of Adelaide.
None of the 33 articles directly related to the research question and all focused on emergency medical system design rather than providing a theoretical basis for practice or education. Owing to the paucity of literature, the researchers were unable to conduct a traditional literature review. Indeed, the absence of high-quality research in this area highlights the need for this study.
Establishing the context
While fully integrated pre-hospital care systems may be taken for granted in many developed countries, those in the focus of this study in Penang, Malaysia, have only recently emerged. In response to the developing needs of primary care, the Malaysian Ministry of Health recognised the field of emergency medicine in 2009 (Fadhli et al, 2010). What has evolved since this time is a systematic upskilling of Malaysian medical skills via education and sponsorship links with the UK and other countries, such as Australia, throughout the 1990s (Jaafar et al, 2013).
However, this upskilling does not appear to have been extended to pre-hospital care in the same way. Currently, Malaysian pre-hospital care systems are made up of a complex mix of government, quasi-government and non-government agencies with individual training and competency standards, and are best described as developing (Hisamuddin et al, 2007). Government clinics and hospitals (such as the one in Penang, Hospital Pulau Pinang (HPP)) are the main ambulance service providers. Red Crescent (RC), St John Ambulance of Malaysia (SJAM) and the quasi-government Malaysian services such as the Malaysia Civil Defense Department (MCCD) provide an ever-increasing share of emergency medical services.
The education and training of pre-hospital care providers in Malaysia has been ad hoc. Like the pre-hospital care systems, there is a blend of roles and in education provided for both ambulance pre-hospital care providers and hospital-based assistant medical officers (AMOs) who work as pre-hospital care providers when required (Hisamuddin et al, 2007). The AMOs are tertiary-trained while other pre-hospital care providers often receive no more than extended basic or advanced first aid training. This results in a workforce comprised of varying competencies, professions and perspectives. Those differing perspectives have potential to result in competing interests and therefore impede the development of pre-hospital care.
In 2011, the IAC was offered to ambulance practitioners based in Penang by SJAM in order to address the need to provide an improved education base for pre-hospital responders. The course was offered to all government and non-government organisations (NGOs) such as Red Crescent (RC), Bomba (Fire Services), MCCD and hospital emergency department staff. The majority of students have come from SJAM; however, all of the other providers have been represented at times and the course aims, in part, to bring together varying perspectives to aid development.
There remains tension in the literature as to how pre-hospital care education leads to improvements in patient care (Spaite et al, 2000; Giddens et al, 2012). This increasingly divergent debate centres on which model of service provision is advantageous for developing ambulance services. Furthermore, few studies have considered the impact of non-tertiary training courses in terms of professional development in a developing system. To address the paucity of literature, the present study explores the perceptions of those involved in the IAC with regards to the impact of professional learning and development on clinical service delivery.
Methods
Study design
The current study used a qualitative method—focused ethnography—to describe the impact and subsequent professional development of those pre-hospital care providers and medical personnel associated with the IAC. To ensure trustworthiness, authenticity and transferability, important concepts to ensure rigour in qualitative research (Guba and Lincoln, 2005; Lincoln et al, 2011), and verification criteria as described by Morse et al (2008), were considered.
Methodological coherence (between the research question and method); appropriate sampling (as demonstrated by saturation and replication); collecting and analysing data concurrently; theoretical thinking; and theory development all formed part of the consideration of the methodology and execution of the study.
Focused ethnography
Focused ethnography was selected as it has previously been described as a context-specific, time-limited study focused on situations within groups (Knoblauch, 2005). Under this methodology, the researcher is able to obtain a sharper focus of a particular aspect of the lived experience of participants. As professional development is a concept that exists in the minds of participants and interested parties (as a ‘constructed reality’ rather than something that can be quantified and measured), focused ethnography was deemed by the authors as appropriate to ‘observe’ this reality by way of interviews.
Ethics and rigour
Ethics approval was sought and obtained through the University of Adelaide Human Research Ethics Committee (H-2014-276), where the lead researcher was based. This was accepted as evidence of adherence to appropriate ethical standards by the Penang-based authorities. Rigour was ensured through methodological triangulation (using participant observation and thematic analysis of interviews). The thematic analysis was externally validated with external researchers who oversaw the de-identified data and review process.
Sample
A purposive sample was used to enrol participants who were able to comment directly on the impact of the IAC on professional development. Ambulance practitioners (either employed or volunteer), emergency physicians, IAC graduates and AMOs were targeted for recruitment into the study. Of the 11 participants, some held dual or multiple roles (n=9). For example, as can be seen in Table 1, a participant may have been employed as a medical professional and volunteer in an ambulance role via an NGO and attend the IAC. All participants were employed either by an NGO or HPP.
| Participant | Age range | Role | ||||
|---|---|---|---|---|---|---|
| HPP | NGO | Medical profession | Ambulance role | IAC-trained | ||
| Leigh | 30–39 | √ | √ | √ | ||
| Nicky | 30–39 | √ | √ | √ | ||
| Reilley | 20–29 | √ | √ | √ | ||
| Joyce | 30–39 | √ | √ | √ | ||
| Greer | 20–29 | √ | √ | |||
| Dell | 20–29 | √ | √ | |||
| Reegan | 40–49 | √ | √ | √ | √ | √ |
| Shannon | 40–49 | √ | √ | √ | ||
| Kelsey | 30–39 | √ | √ | |||
| Devin | 20–29 | √ | ||||
| Val | 30–39 | √ | √ | |||
Data collection
Data were collected through interviews, observation and participation of ambulance and medical staff who were involved directly or indirectly with the IAC. Eleven semi-structured interviews of the five females and six males, aged 21–43, were undertaken. They were audio-recorded and transcribed verbatim before being offered back to the participant for verification. Table 1 describes the participants' role in EMS service provision. Observations were based in the main public hospital and at various NGOs with paid and volunteer staff. Observations focused on the process of handovers between ambulance crews and emergency department staff—both those who were IAC-trained and non-IAC. During these observations, the researcher participated in ambulance activities, such as patient care and general administrative duties.
Results
Data analysis drew on the 6-stage process as described by Braun and Clarke (2006) with four themes extracted from the data:
Table 2 shows the development of these themes.
| Theme (Phase 3) | Sub-Theme from data (Phase 2) | Concepts from data (Phase 1) |
|---|---|---|
| Quality of training and quality of care go hand-in-hand | When higher quality of care is seen, it is perceived to relate to higher quality of training | Training standards vary and are set by each provider. There is no central control of training content or standards. Those organisations that are perceived as providing a comparatively higher level of care are also those with a comparatively higher standard of training |
| Quality of training varies depending on the service provider | Quality of care is not necessarily associated with resources; however those with mainly volunteer resources may have lower training available. Some of the NGOs that have greater financial resources are regarded as having lower standards of care. Having government funding does not always result in higher perceived practice standards | |
| Pre-hospital care in Penang is at a crossroads | Penang lacks standardisation in both service delivery and training. This is seen as a key way to improve patient care | Similar to how change might be managed, the NGOs need to display leadership in this area. Pre-hospital care in Penang is under developed. The current system is outdated and not as effective as it could be. Even given the limitations of a developing nation, Penang can and should do better. Change can occur from the top (government) down or from the practitioners up. In both instances, there needs to be specific people with both the authority and the knowledge to effect change |
| Training is one of the key ways that standardisation may be achieved | The IAC is seen as one way of achieving standard training; however it would need the cooperation of the NGOs | |
| The IAC is one course that has assisted in the development of prehospital care | The course assists in improving practice through education | Education standards are variable among the NGOs and there is no specific pre-hospital care programme for AMOs. The IAC provided a course that fills a gap in the education market. It is not the only course, but it is accessible |
| Perception of quality of care and professional development have been improved as a result of the course | Those who have completed the course are now perceived as being more professional in their approach to pre-hospital care | |
| Focusing how NGOs lead change | Change is required for the system to improve. Change can happen if people are willing | The NGOs and the practitioners within them are well-placed to achieve change. If practitioners wait for ‘top down’ change, they may be waiting a long time |
| NGOs are able to set their own agenda | NGOs are seen as not being as restricted by government policy and bureaucracy. In the absence of regulatory bodies (authorities), NGOs are able to set their training agenda as individuals or in collaboration | |
| The pre-hospital care system currently relies on NGOs and now cannot exist without them | A move to a single government-run system would be unlikely as the current system is an integral part of the pre-hospital care response. The government service does not have the funding to change practice |
Quality of training and care
There is a distinct difference between each of the ambulance service providers in the quality of training and care that is delivered. This was attributed to each service having different operating systems and training methods, with attempts to standardise some aspects of the patient experience and practice largely depending on each individual agency. Clinical care and education were seen as linked. One participant summed up the current state of clinical care within Penang's EMS system, saying:
‘I don't think it's very [well] organised yet … most [ambulance practitioners] are Medical Assistants [AMOs] and the other main NGO will be St John. The rest of the NGOs are not very well trained. So in terms of attending the patient, how they are going to manage the patient, it's very much primitive still. I don't think care is very well managed here.’
The quality of patient care was viewed as often equating to the quality of the training provided. Quality of care is difficult to empirically assess in pre-hospital care and, in the absence of local guidelines, there is nothing to compare service providers against. Where there are standards, they relate only to availability and response times—not clinical outcomes. It is unclear the exact standard that participants individually chose to use as a guide to their ranking of service providers.
In the absence of standards or measurement guidelines, the opinions of the medical professionals who received patients, along with other practitioners working within the industry, were seen as a valuable source of data. Those opinions consistently ranked the AMOs and SJAM Penang staff as the top two, followed by RC and MCCD. While some participants were eager to point out that there are other factors at play, such as the volunteering nature of people in the poorer performing organisations, they agree that most of the difference lies within education and training standards.
It was observed that medical staff were able to form informed and professional opinions on the presentation of patients. Once such participant, stated that the AMOs and SJAM are adequately trained and ‘the rest of the NGOs are not very well trained.’ Another commented that the training given to the AMOs and SJAM enabled them to distinguish between a critically ill patient and one who was not. When asked about the other organisations (namely MCCD and RC), they commented that the training was insufficient to allow members of those organisations to perform at this level. The improved level of training was reflective of the way in which patients were treated and handed over to the emergency department staff at HPP.
How NGOs lead change
Having introduced the IAC, improving patient care was viewed as a reasonable and attainable goal. However, the delivery of this care is dependent on its organisation. According to participants, the current standards within all EMS services should be at least Basic Ambulance Care (BAC) level—a 6-day course internally run by SJAM Penang. While this was viewed as minimum, one participant commented that it is not well-enforced with some crews only able to deliver ‘basic first aid’:
‘It depends on your luck where you have your medical emergency at… So, if you happen to be in a central part in Penang, if you call 999, 999 would have dispatch nearest ambulance which is Penang General Hospital. Let's say if you are in the southern part of Penang, if you are unlucky, you might get not so well-trained ambulance to respond to you … Pre-hospital care in Penang is not standardised. It varies from organisation to organisation, from person to person.’
When asked about their ‘ideal’ system of pre-hospital care, each participant stated that there was a need to standardise training and service provision. In contrast, hospital employee participants all commented that a single ambulance service based at the hospital was their preferred ‘best practice’ model. Participants who have roles within NGOs were split on this issue with some preferring standardised education across existing services and others preferring one service. Interestingly, one participant with multiple roles commented that:
‘If funding is not a problem I would think definitely a single emergency [system] would be better in controlling their management and all that. But the model we are using now in Penang with multiple agencies working together seems to be working as well.’
At a crossroads in pre-hospital care
Pre-hospital care in Penang is at a crossroads, owing in part to the availability of staff to attend to ambulance calls, as well as increasing demand. This situation seems to have driven the increased reliance on NGOs to provide additional services within Penang. A participant commented on the ability of the government systems to cope and the place of NGOs within the pre-hospital care system.
‘In Penang, as in the rest of Malaysia, actually we are very scarce on the number of ambulances that we have, which are belonging to what we call the Ministry of Health. So, we have tried to expand the number of ambulance we have by actually incorporating them into multiple non-governmental agencies into this pre-hospital care system.’
One participant supported the idea that NGOs are not only integral to the pre-hospital care system in Penang, but the system would likely fail without them:
‘If we were to do it all on our own, we wouldn't have the resources. It still needs to have the community … to be able to cover the numbers of cases that we see. For example, … I think we see about 14 000 ambulance calls a year, so compared to maybe 6 years ago, it was probably 6000 calls. So the number of calls have been increasing, so the demand is also increasing. So although [HPP] still manage the majority of all the ambulance calls, if we do not have extra help from the other organizations, we are also not going to be able to cope.’
Similarly, some viewed the involvement of NGOs in pre-hospital care as an inevitable consequence of a lack of resources. However, participants made the additional comment that resourcing is linked with the values of the community:
‘In this part of the world people don't see health as something that they need to actually invest a lot. For example, someone can go to a barber shop have their hair cut for RM50, wait there for 2 or 3 hours and they are very happy with the hair do. But if people go to a private GP practice, they pay the RM20 consultation fees, doctor say ‘Oh ok, you don't need any medications, consultation fee is RM20’ they will be screaming. That's how it is, so money probably is there, but it's not channeled to the needs. But basically the majority of them are still think ambulance is a form of emergency taxi, just come and pick up the patient and go.’
Economic affordability is linked to community acceptance of what is an essential service. The perceived lack of value placed on health care (and by association, pre-hospital care) can translate into a lack of recognition of those who provide that care.
The IAC is assisting development care
The IAC was perceived by those with knowledge of the course as being a positive driving factor in professional development. For those without direct knowledge of the IAC, the idea of having a course with specific pre-hospital care knowledge is seen as essential to improved ambulance practice.
Participants reported that ambulance practice requires knowledge that cannot be found in other disciplines and simply being medically trained is not sufficient. In particular, one participant found that being involved in an ambulance response without any specific training is a harrowing experience; on one ambulance run, she was treating an elderly lady for a gastrointestinal bleed outside of the hospital:
‘She was like bleeding frank blood on my shoes, I was like, ‘Aunty please survive’ and I couldn't get a line in … So it's tough for me. I would say because I'm not fully trained to go out on calls. I mean if it's in the Hospital, it's easier for me because there's help around.’
While medical knowledge is important, pre-hospital care knowledge is perceived as broader than just medical knowledge.
Observations within the NGOs support the description of the wider impact of the IAC above. Participants of the IAC were viewed by colleagues as clinical leaders within their organisations. While some were in leadership positions prior to the course, others have taken on roles with new staff and were observed providing guidance during ambulance responses. The description given of the IAC by participants familiar with it describe it as ‘more advanced knowledge set to shape [the] ambulance crew to be more professional.’
Discussion
The IAC has enabled the emergence of practitioners who are able to demonstrate a systematic application of their new knowledge, skills and attitudes towards how they delivered what they perceive to be quality and professional patient care. In this way, a body of knowledge specific to pre-hospital care appears to be emerging from the IAC.
Also evident is an increased level of respect for IAC participants by emergency medical hospital staff, enabling improved authority to practice. This was revealed when they more readily accepted the handover; IAC graduates were perceived to have the authority to practice as pre-hospital care providers, and their clinical knowledge and skills were deemed to be appropriate for their practice.
The developing culture and individual professional identity of ambulance workers as a cohesive group was strengthened by the IAC. The course gave a focal point for the development of the role and, therefore, a sense of identity.
As pre-hospital care services in Penang are delivered by various organisations, there is no systematic way to define and gain a common understanding of the role or to form a clear identity. This study has identified that the development of a common identity is limited by the slow uptake of the course by providers other than SJAM and, in order to develop further, a common training programme should be sought.
Given that Penang lies within a country that had been described as struggling with economic development (Hauswald and Yeoh 1997; Jaafar et al, 2013; United Nations, 2014), the affordability of a single state-run service is questionable. Ambulance services based on the current models in developed countries tend to be unaffordable within developing healthcare systems (Hauswald and Yeoh 1997; Altintas et al, 1999).
Limitations
There two key issues that need to be addressed when considering the limitations of the present study. These arise from the nature of the research question, researcher influence, and the transferability of the outcomes.
Guba and Lincoln (2005) comment that values cannot be extracted from any research process and the researcher being part of the system within which they are researching is not uncommon within ethnographic and indeed qualitative enquiry (Minichiello 2004; Knoblauch 2005; Liamputtong 2013). While it would not be accurate to describe the researcher as independent, it was not the intention of this research to seek such independence. The researcher simply remained critically aware of his possible influences as the research developed.
This research set out to describe the ways in which the IAC, being a specific educational programme, may have influenced the development of professional ambulance practice in Penang, Malaysia. While there may well be wider implications for other, similar settings, it is important to note that in much the same way as the impact of the course cannot be completely described within these pages, the variations in practice and policy in settings outside of that described in this study cannot be fully captured.
The pre-hospital care system within Penang is developing and constantly changing, just as any system will continually change. The views gathered over the course of this investigation relate to a specific time within the lived experiences of the participants.
Conclusion
The IAC has impacted on the emerging occupation of pre-hospital care in Penang by offering up a context-specific educational opportunity. Participants in this study have come from varied backgrounds and a number of other health professionals are represented; yet they express similar beliefs and hold similar values about the provision of pre-hospital care services in Penang. While the IAC cannot be solely credited with developing this commonality, this research shows that it has assisted. Future research may focus on the wider community acceptance of this newfound common understanding of the role of pre-hospital care providers.
The findings of the current study show how an educational programme can manifest in a change in the values and beliefs that are guiding one particular occupation, pre-hospital care providers, towards professionalism, rather than the clinical base of the education packages themselves.
This may have implications in the way in which future training is developed to concentrate more on professional knowledge specifically. While we may be a significant distance from the professionalisation of paramedics in developed systems, the present study nonetheless represents a significant step in that direction.
This article contributes to the growing body of evidence relating to the impact of education on the professionalisation of pre-hospital care providers. It contributes further to an emerging body of knowledge on the role of pre-hospital care in developing healthcare settings. Professional development is a process that may well take considerable time and cannot be achieved through a single educational programme; however, it is important to consider the contribution the IAC has made to this journey.