In Australia, paramedicine is undergoing significant regulatory change. This is a result of the expansion of the scope of practice of paramedics spanning the past ten years. What has ensued is the substantial change to the role of paramedics, from ambulance officers to emergency practitioners performing complex life-saving medical treatments. Paramedicine is self-regulated by each state government's ambulance service; however, this model has produced variances in standard professional care across the nation. Concerns about these variances have procured an intense nationwide debate among industry stakeholders on the registration, regulation and tertiary qualifications of paramedicine. In addition, a new generation of students is enrolled in paramedic degrees across Australia, replacing older style in-house training by ambulance services. The members of this cohort are in the initial stages of their education and remain isolated from existing paramedic culture. However, they provide an exciting opportunity to act as informed members of the public and speak into the debate on national registration. There is a variety of themes illuminated by the research with this cohort, which address the expectations of consumers of paramedical services in relation to registration and regulation. In addition, the perceptions of whether paramedics are registered and regulated in a synonymous manner to the broader health care industry. This paper will discuss the outcomes of this research and propose several unique points that industry stakeholders may wish to consider.
Literature review
In 2009, the Australia and New Zealand College of Paramedics (previously Ambulance College of Ambulance Professionals [ACAP]) provided a submission to St John Ambulance of Western Australia entitled ‘An agenda for change’ (ACAP, 2009). This document highlighted the need for a national approach to paramedicine, drawing on state and federal strategies for emergency healthcare and patient safety (ACAP, 2009). In 2012, industry stakeholders gathered with a vision of regulating paramedicine (Australian Health Ministers' Advisory Council Health Workforce Principle Committee, 2012). At various consultation forums, the council presented four options for paramedicine, three of which made minimal changes to existing regulation processes. Vigorous debates at the forums galvanised the fourth option which would allow the regulation of paramedicine, by means of a national registration and a tertiary education accreditation scheme. This mission presents the prospect to work towards a path to attaining the professional hallmarks that lead to the recognition of the industry.
The first step in analysing the hallmarks of a profession is to capture what it specifically represents. Professionalism often stems from industry culture, is implicit in industry and includes knowledge, skill, beliefs and attitude demonstrated by workplace behaviours (Woollard, 2009). The professional hallmarks of an industry can be explained as ‘a unique body of knowledge, authority, community sanctions, ethical codes and professional culture’ (Greenwood, 1957: 45). In addition, First et al (2012) identify that people can modify their behaviour to adhere to a professions requirements and may do so to protect its title.
The aforementioned professional hallmarks are notably present in other health disciplines such as medicine, nursing and physiotherapy, where a body of knowledge is attained via tertiary education and monitored by the presence of a professional authority. Mahoney (2003) identified that professional authorities have the power to accredit graduates, which is vital for quality assurance and legitimacy, as well as practitioner and consumer protection. Inertia for the mission of professionalisation also requires mandatory acquisition of a unique body of knowledge from the tertiary education sector (O'Meara, 2009) and that which Williams et al (2010) suggest is noticeably absent from paramedicine. The overarching aim of registration according to Woollard (2009) is to protect the public from harm. Conversely, the deficiency of these underpinning strategies leaves paramedicine and the consumer at risk of a perpetual cycle of reactive engagement to industry issues. A salient point made by First et al (2012) highlights that elevation of respect and knowledge may result if registration is implemented; however, it does not necessarily alter the conduct of a paramedic. In order to achieve this, reflexivity is required to ensure a proactive process which employs continuous improvement. If national registration and regulation of paramedics is implemented, it would potentially allow members of the public to report unprofessional behaviour; employees would have a duty of care to do so and the employers would be legally obliged to (Woollard, 2009).
The regulation of paramedicine via national registration could potentially improve patient safety ensuring that minimum standards of clinical ability are met. However, as matters stand, patients must accept the care of any given paramedic attending them (Boyle et al, 2003), despite the disparity of national standards in training across Australia. In the absence of a regulatory body, neither tertiary providers nor industry employers are compelled to achieve standardisation of education, and arguably that may influence the quality of clinical skills obtained by paramedics, and in turn affect patient safety (Joyce et al, 2009). An important opportunity exists to elicit a change in behaviour, through the influence of tertiary education and assist a new generation of paramedics to prepare them for operating within an industry striving for professionalism (First et al, 2012).
Such outcomes described are inevitably political. Indeed registration and regulation are enmeshed in a political debate, the extent of which the broader employees as paramedics are presently starting to appreciate. Although politics are often synonymous with negative connotations, they should be suspended from its innate intensions, as it primarily narrates the exercising or seeking of power (Mahoney, 2003). Traditionally, those who sway the politics of industry are often conspicuously male stakeholders of industry, who appear more prepared to engage such debates comparable to female stakeholders (Gardner and McCoppin 1995). Interestingly, a poignant realisation has evolved for paramedicine. Despite the statistical dominance of males within the paramedical industry, a historic abdication and subversion by paramedicine has resulted in their laggard status behind the female dominated profession of nursing. Furthermore, this lack of engagement in registration and the politics that encapsulate it appears to stem from an ‘inwardly focused attitude and complacency’ (Mahoney, 2003: 7). Potentially the rationale for this is that paramedicine has historically had the ability to partially gather their revenue from consumer service fees. Consequently, the paramedic industry has somewhat evaded full government control and therefore engagement with national registration and regulatory processes.
The aim of regulation should ideally act to allow for continuous improvement, and in doing so contain those who do not adhere to the expected standards (van der Gagg and Donaghy, 2013). Currently the self-regulatory status of paramedicine does not afford it the credibility synonymous with other healthcare professions, such as medicine and nursing. Furthermore, self-regulatory status is considered appropriate when: there is an absence of occupational licensing, registration laws and regulatory professional body; or if non-compliance will not result in catastrophic outcomes (Boyle et al, 2003). Given the high-risk nature of paramedicine, and the potentially fatal consequences for patients, ‘if the paramedic's clinical judgment supporting the intervention is wrong or if the execution of a dangerous procedure is poor’ it is difficult to comprehend that paramedical practices are performed in the absence of a mandatory national regulatory framework (Boyle et al, 2003: 5).
Research methodology
The Human Research Ethics Committee (HREC) for Social Sciences within the University of Tasmania has approved this research project.
Despite a range of literature on national registration and regulation of healthcare professionals, little exists that examines the public's perception of the regulation of paramedics. It may be that the public's perception is largely founded on that which they obtain from the scant media coverage of the topic and therefore what appears is the erroneous assumption that the industry is accredited as a registered profession.
As the inertia of national registration proliferates, this research study and its respondents may allow discernment of the consumers' position on registration and regulation of the paramedical industry. The research question that framed this study was entitled ‘Striving for professionalisation of Australian Paramedics: Student paramedics perception of the current national registration and professionalisation debate’. The respondents have been chosen due to their enrolment in the Bachelor of Paramedic Practice degree at the University of Tasmania (Rozelle campus, Sydney). In totality, 48 respondents voluntarily participated in the study. All respondents had no clinical placement experience in the out of hospital care arena and therefore have had little exposure to the cultural opinion on the national debate on the registration of paramedicine. The intent of this tightly framed study aimed to evaluate the knowledge of respondents and gain insight into what consumers' knowledge of national registration of paramedicine would represent. The respondent group was predominately from an Anglo-Saxon middle class background; ages ranged between 18–41 years; the majority of respondents had recently completed high-school; nine of the cohort had completed a tertiary degree; four respondents indicated they came from a trade background or had a Technical and Further Education Commission (TAFE) qualification; 50% of the respondents were female.
Key thematics
The research study utilised focus group interviews with up to eight respondents attending each of the six sessions. In addition, three purposive interviews, with two to three respondents attending each were conducted to allow thematics to be extrapolated and increase the robustness of the research enquiry. All interviews were video recorded to assist in the documentation of the conversations held to allow for later analysis.
Key thematic findings from focus group interviews
In order to sift through the qualitative data and find thematics, the digital recordings were viewed. The data were then transcribed by the researcher to allow for the illumination of the key thematics. This involved the collation via a chunking method to align similar information and enhance the clarity of study thematics which is recommended by Rowley (2012). The key thematics discovered from the focus group interviews were:
Key thematic findings from purposive interviews
Discussion
Who is responsible for national registration?
The respondents discussed the involvement of the government in the national registration process, though they acknowledged the Australian government would need to allocate funding to achieve this. This was viewed as a challenging political action and equivocal at the upper echelons of politics in Australia. O'Meara explains that in order to engage in the processes of national registration paramedicine will need to seek ‘a respected place at the table with government and other health professionals’ (2009: 2). However, respondents also identified paramedics as being responsible for the implementation of national registration; identifying its absence was due to the lack of declaration by the industry and ownership of the processes required. This evolution of professional identity within paramedicine and recognition as an emerging profession is identified as integral to its success (O'Meara, 2009). In addition, respondents believed that public support would be pivotal to gaining adequate momentum to pressurise its implementation by government bodies.
What does an informed public view say about professionalism?
The terms ‘standards’, ‘benchmark’ and ‘quality’ were frequently used during the focus group interviews. It was viewed that the purpose of implementing registration and gaining professional status would ensure equality in the expertise of paramedics. Woollard emphasises that it is requisite for professional bodies to ‘set the standards, and the registrant bodies enforce them’ (2009: 3). This was apparent to the respondents who identified that paramedics must adhere to the standards of being a profession and meet the criteria to practice safely.
Conversely, some respondents explicitly expressed the view that paramedics are already a profession, as they are professional in their performance of their practice. First et al (2012) define this term profession as ‘a practitioner who exhibits professionalism is essentially doing a good job in providing a social service that is valued and useful’ (378). Other respondents disagreed that paramedics are a profession, explaining that it is the lack of standardisation of tertiary education across the industry that prevents paramedics achieving professional status.
In relation to a comparison between nursing and paramedicine, the perceived difference was the practice of nurses occurs in conjunction with doctors and therefore a standardisation of skill and registration is an industry requirement due to their directly interrelated roles. In order for professionalisation to be achieved in paramedicine this standardisation requires professional guidance ‘as is the case with the Australian Nursing Council and the Australian Medical Council’ (Boyle et al, 2003: 2). It could be argued that paramedics do work directly with nursing and medical healthcare providers, in terms of patient handover and consultation of patient issues at hospital. However, as paramedics perform the majority of their work in the field, it was identified by the respondents that it was this lack of intimacy that lessened the impact on allied health care workers and perhaps leads to the lack of awareness of their non-registration status.
Increasing patient safety through tertiary education and continuing education
Tertiary qualifications and patient safety were considered synonymous by the respondents in order to promote consistency across paramedicine. In addition, it was expressed that the state ambulance services should be responsible for providing assistance to the workforce to achieve conversion of the existing paramedicine diploma to a tertiary degree. However, Boyle et al (2003) indicate that an employer bias exists, due to the tension between operational demand and best clinical practice. The respondents ideally envisioned the incorporation of study leave for employed paramedics, and were able to empathise with the enormity of tertiary study and full-time work.
Also iterated was the correlation of continuing education to ensure ‘balances and checks’ on paramedics' practice and this was appreciated as vital to ensuring quality of the industry as ‘credible’. Without continuing education, the respondents feared the process would become a payment of monies and management of data without any real impact on patient safety and recognition as a profession. In addition, national registration and credibility is highly reliant on continuing education of paramedics as it ‘goes hand in hand’ with the regulation of paramedics to ensure standards are met and patients are protected from harm. Notably, Joyce et al (2009) suggest that the Australian government is required to incorporate budget planning for the paramedic workforce in line with medicine and nursing that ensures funding levels are equally aligned.
Respondents expressed that a set standard of practice is imperative to ensure the industry achieves recognition of its niche within the health care sector. This niche is identified by Mahoney (2003) as one of the key strategies to success in achieving professional status. The respondents identified that the minimal academic literature specifically on paramedicine may have resulted in a ‘lack of backing’ of the industry, and therefore recognition as a profession. Williams et al (2010) identify a requisite for an emergence of a paramedic scholarship and enticing the future stakeholders of paramedicine into the evidence-based research via its inclusion in the undergraduate academic arena. The vast majority of respondents accepted that part of their future role as a paramedic was remaining conversant with industry challenges, such as improving the profile of paramedics through their own future contributions to the body of published literature.
Public perception and awareness
The erroneous assumption frequently arose that paramedicine is a registered, highly-regulated industry and is credited with professional status. This was a pivotal thematic within the research study, as it highlighted the limitation in information provided to the public via media coverage. A rigorous debate ensued within the research interviews of whether the public should remain unaware of the absence of professional hallmarks within paramedicine. Some respondents envisioned that this may lead to distrust within patient/practitioner relationships, as there may be questions asked of the quality of the paramedic attending them. It was acknowledged that patients or relatives may question the medical authority of paramedics during the performance of lifesaving treatment and this could potentially lead to adverse events. This reciprocal ‘trust’, notably, ‘trust in the regulatory system to operate transparent, consistent, proportionate and targeted processes for ensuring that standards are maintained’ (van der Gagg and Donaghy, 2013: 10), is imperative.
Conversely, some respondents believed utilising the ‘power of the people’ would assist the implementation of national registration and regulation of paramedicine. It is noted in the literature by Boyle et al (2003) that it is in fact ‘the time critical nature of crucial interventions that separates paramedic practice from most other acute health practitioners' (2003: 4). It would be interesting indeed if the public were made aware of the extended scope of practice of paramedics procured during life-threatening events in the absence of a regulatory body and adequate framework to ensure best clinical practice.
Limitations
The author acknowledges the limitation of the public perception to be contained within the university students' context and it may not represent a broad public perception across the nation. In addition, the interpretations of the research data were conducted solely by the chief investigator.
Conclusions
It was identified that there exists misassumptions from the respondents to the research study regarding the professionalisation of the paramedic industry. Existing literature focuses on the professional hallmarks of healthcare workers, patient safety issues, and the influence of politics and the self-regulation of the paramedic industry. However, little exists that assesses the expectations of the consumers of paramedicine. Student paramedics as a group of respondents have a valuable public perception of the national registration debate and this could be taken into consideration in the strategic planning and implementation of national registration. The key thematics highlighted within the research identify the Australian government, paramedics and ambulance services as the responsible parties for the implementation of national registration. In addition, tertiary education is one of the key hallmarks of a professional and its standardisation is required nationwide, with inclusion of continuing education as a definitive part of ensuring an increase in patient safety. Furthermore, public awareness may be a vital key to success, though does not exist without its own inherent conflicts. Finally, in order to achieve recognition of paramedicine as a profession, further research is required by key stakeholders of the industry. This will greatly assist the implementation of national registration and encourage ownership by paramedics of their industry's future.