Interprofessional graduate programme for nursing-paramedicine degree graduates: work outcomes and participant experience

Aim

The aim of this study was to examine the employment outcomes and participant experience of the first cohort of 10 IPG participants following completion of IPG.

Methods

Results

There were 10 IPG participants, nine of whom completed all three surveys and nine of whom agreed to be interviewed. The participant who did not complete the surveys was a different person from the participant who declined the interview.

Two were males, the other eight were female, and all participants were born in Australia. The average age of all participants at the commencement of the IPG was 23.7 years (SD=1.3). Two participants spoke second languages: one spoke Greek and the other Norwegian. Prior to joining IPG, two participants had no previous experience in health care, three participants worked as paid carers, two participants worked as enrolled (diploma prepared) nurses, and two participants worked in clerical positions in hospitals.

Discussion

This study had four major findings. First, all IPG participants in this cohort selected careers in paramedicine and all were working full-time as paramedics and about half were working casual shifts in nursing. The tendency to move towards full-time paramedic employment has a number of possible explanations. At the conclusion of this first IPG, full-time or casual employment were the only employment options in paramedicine, but there were opportunities to work full-time, part time or casual in nursing, and specifically in emergency nursing. There was uncertainty among IPG participants about their capacity to work as a casual paramedic and later reinstate full-time paramedic employment in a location of their choice. There was also concern about restricted access to casual shifts, thereby limiting the ability to continue consolidation of paramedicine skills. These concerns are also reflected in the WES where perceptions of involvement, the extent to which employees are concerned about and committed to their jobs, decreased significantly over the time studied.

The other driver of employment choices may be the difference in employment conditions and pay structures. At the time of IPG completion, Victorian paramedics generally worked a rotating roster comprising two 10-hour day shifts, two 14-hour night shifts and four days off, and have 10 weeks leave per annum. They also had an annualised salary whereby shift penalties are distributed across the year making for a constant fortnight-to-fortnight salary. In contrast, nurses work a rotating roster allocated on a preference basis that is available 6 weeks in advance. Nurses are paid shift penalties according to the shifts actually worked so have variable fortnight-to-fortnight salaries.

Perceptions of increased freedom and independence were cited as a reason for choosing paramedicine as their dominant profession. However, there were no significant changes in the WES personal growth dimensions of autonomy, task orientation and work pressure. One possible explanation for this finding is that IPG participants had not progressed to a level of autonomy in emergency nursing, which is typically the domain of postgraduate qualified emergency nurses. A postgraduate university qualification in emergency nursing is requisite in most EDs to undertake the roles of resuscitation and triage, where high risk autonomous decisions are common place. Exposure to high-end independent decision-making such as managing mechanical ventilation, titrating inotropes, analgesia and sedation, and prioritising care of a full waiting room of undiagnosed patients may alter this view.

In conflict with statements about increased freedom and independence, there was a significant increase in perceptions of manager control on the WES from above average at T1 to considerably well above average at T3 (p<0.018). Managerial control is related to how much management use rules and procedures to keep employees under control (Moos and Insel, 1994). The reasons for this increase are unclear but it may reflect the hierarchal (Regehr and Millar, 2007) and protocolled nature of paramedic clinical practice (Ambulance Victoria, 2013). It may also be that participants had increased perceptions of freedom and independence in daily practice when they were on road and only answerable to their partner, but found less freedom and independence when navigating issues at an organisational level.

Second, participants expressed a view that emergency nursing and paramedicine were both areas of practice in emergency health care. As evidenced in the theme ‘best of emergency health care’, IPG participants were able to continue the ideal that drove them to undertake a double degree in nursing and paramedicine. Undertaking the entirety of graduate nursing experience in emergency nursing was reported by participants as a favourable attribute of IPG and raises questions about the traditional structure of graduate programmes, particularly in nursing. Nurse educators were concerned that IPG participants would not establish basic nursing skills without a medical or surgical ward placement; however, it was clear from IPG participants they did not want to work in these practice settings either as graduate or registered nurses. Given the significant recruitment and retention issues in nursing, the merit of designing graduate programmes with end career in mind must be given urgent consideration.

Nurse engagement is a critical component of safety and quality of health care (Simpson, 2009; Gokenbach and Drenkard, 2011) and is a top predictor of variation in mortality rates across hospitals (Blizzard, 2005). Forcing graduates to practice in areas they are not interested in not has a negative impact on the graduate's experience and likelihood to remain in the profession, but also on patient safety.

The themes ‘knowledge and experience’ and ‘understanding and respect’ suggested that participants had a positive learning experience that led them to a deep understanding of the distinct differences and similarities of both disciplines. Further, participants seemed to appreciate the unique contributions of paramedics and emergency nurses to the patient journey but also understood how they were inter-related for the good of the patient. Many respondents also reported that their experience and knowledge in the two disciplines informed and enhanced their clinical practice in both areas of health care. There are no published studies detailing truly integrated practice by clinicians holding qualifications as paramedics and registered nurses. To date, published literature related to nursing and paramedic roles has focused on movement of nurses to paramedicine (Hickey et al, 2010; Williams, 2012), use of paramedics to staff emergency departments (Oglesby, 2007), and use of nurses in pre-hospital care (Machen et al, 2007). Many of these studies focus on the assessment and triage skills and procedural capability of clinicians, with little attention to the discipline-specific skills and knowledge required by expert paramedics and emergency nurses though specific educational preparation and experiential learning (Machen et al, 2007; Oglesby, 2007; Whetzel and Wagner, 2008).

There have also been a number of publications, predominantly from the United Kingdom, detailing the emergency care practitioner role (Mason et al, 2006). Emergency care practitioners are autonomous practitioners with a blend of nursing and paramedic skills and are a major strategy to meet increasing demands for patient-centred health care by extending the existing clinical skills of the health workforce, maximising the effective use of resources, and improving the efficiency of health services delivery (Mason et al, 2006). Benefits of the emergency care practitioner include less referrals to other health professionals, lower use of emergency transport, reduced emergency department attendance and reduced acute care admissions (Cooper et al, 2004; Mason et al, 2006; Cooper et al, 2007). While programmes such as IPG may form the basis for graduates to progress to roles such as emergency care practitioner, graduates will still require experiential learning and postgraduate education in order to achieve the clinical skills and decision-making required of the emergency care practitioner role. Currently, in Australia there are limited opportunities for integrated nursing and paramedicine experiential learning, and postgraduate education is still siloed in traditional nursing or paramedicine models.

There are, however, a number of studies highlighting the benefits of inter-professional education and integration of knowledge from different health disciplines (Underdahl et al, 2013). Specific advantages are increased collaboration and teamwork, well developed communication skills and a workforce prepared to work within health care as a system, not a place (Underdahl et al, 2013).

Participants' positive view of the IPG was supported by the constantly high levels of co-worker cohesion. Co-worker cohesion was limited by ceiling effect but this is not a surprising finding. All IPG participants were from the same university therefore they had established relationships before entering the IPG. As the first IPG participants, they were employed as a large group with two subgroups. When their subgroup was in the ED, they attended study days and worked clinically together, alongside registered nurses undertaking transition to emergency nursing practice via the supported transition to emergency practice (STEP) programme. The relationships that peer groups form is supported in the literature related to transition to practice programmes in emergency nursing and team-based learning as an education methodology (Rider and Brashers, 2006; Morphet et al, 2008; Sibley and Parmalee, 2008; Sweet and Pelton-Sweet, 2008; Shacklock et al, 2014).

A contradictory finding to the positive reports of knowledge and experience was that supervisor support was below and well below average for the duration of the study. The reason for this finding is unclear. One possible explanation may be that all participants completed their T3 surveys while employed as paramedics. The nature of work as a paramedic can be isolated and the ‘supervisor support’ for graduate paramedics is provided by clinical instructors, but this support decreases following completion of the graduate ambulance paramedic programme. Whether there would be stronger perceptions of supervisor support in the ED environment, where unit management are present most days during hours so have regular contact with staff, is unknown.

Finally, the major negative experience reported by participants was the constant rotation between emergency nursing and paramedicine. The theme ‘Chopping and changing’ showed many respondents reported that the rotations between ambulance and emergency nursing, while necessary to the IPG, were challenging. The challenging nature of rotating between two disciplines and two organisations is supported by the constantly below average WES ratings for clarity. Clarity is the degree to which employees know what to expect in their daily routine and how explicitly rules and policies are communicated remained constant (Moos and Insel, 1994), and was below average for the duration of the programme.

These findings are not surprising given the ambitious nature of the IPG in trying to meld two roles across two very different organisations, each with different roster patterns, remuneration, and superannuation arrangements (Considine et al, 2015). Adding to the complexity of IPG was the blending of one registered profession (nursing) with an unregistered profession (paramedicine), each with different codes of conduct and practice standards, and regulatory requirements (Considine et al, 2015. Participants were also required to reframe their scope of practice according to the capacity in which they were working. For example, a major difference in scope of practice was how each profession was governed under the Drugs, Poisons and Scheduled Substances Act and Regulations (Parliament of Victoria, 2006). When IPG participants were practicing as registered nurses, they could administer intravenous morphine for pain relief under prescription from a medical officer or nurse practitioner. When practising as a paramedic, they could administer intravenous morphine for pain relief guided by clinical practice guidelines approved by the Ambulance Victoria Medical Advisory Committee (Considine et al, 2015).

The challenges of rotations may, in part, also be associated with non-significant decrease in innovation scores over the duration of the study. Innovation is related to variety, change and new approaches (Moos and Insel, 1994). This is a counter-intuitive finding given paramedics and emergency nurses do not know how their working day will evolve and both areas of practice require the management of patients across all age groups and with varying degrees of illness and injury severity. Further, participants willingly and enthusiastically signed up for IPG knowing it was the first programme of its kind to be attempted in Australia. It may be possible that participants entered IPG with an ideal that did not reflect the reality of full-time work as an emergency nurse or paramedic. Further, the decrease in innovation scores may be a reflection of participants' perceptions of high levels of managerial control. Further, the appeal of unpredictability of work as an emergency nurse or paramedic may be tempered by protocolled care and standardisation of work practices.

Limitations

There are a number of limitations that should be considered when interpreting the study findings. Notably, the study participants were a small cohort from one pilot programme involving one ambulance service and one health service. There are no like programmes with which to compare these results so the generalisability of these findings is unknown. Second, all participants were working in paramedicine as their dominant profession at T3 and at the time the interviews were conducted. Whether the study findings would be different if there was greater nursing representation is unknown. Finally, the small sample size may explain why some changes in the WES dimensions did not reach statistical significance.

Conclusions

Participants' experience of the IPG were largely positive; however, if further programmes of this nature are to be pursued, alternative strategies for managing rotations and better integrating practice in two disciplines need to be considered. At 18 months post IPG completion co-worker cohesion was high; however, there were reported shortfalls in key elements of practice such as role clarity, innovation and supervisor support. Addressing these issues warrants attention in employing organisations and both undergraduate and graduate programs for double degree students. Careers in emergency health care in its broadest sense are still under-developed and traditional professional and industrial structures still prevent double degree graduates using their skills and knowledge to their utmost capability.

Key Points

Conflict of interest: none declared