The role of the paramedic in the UK has changed over the past few decades (Smith, 2017). A once protocol-driven vocation, associated with limited clinical decision-making and responsibility, paramedicine has emerged as an autonomous profession involving an expanding scope of practice (National Institute for Health and Care Excellence (NICE), 2017). In part, this may have been driven by the shifting focus on models of care delivery, with increased attention paid to alternatives to hospital admission (Pollock, 2019).
Paramedics are required to demonstrate a higher level of clinical decision-making and judgement than was historically required (Simpson et al, 2017). While emergency care remains a fundamental part of the paramedic role, calls to less urgent or acute conditions have become a growing aspect of their job (NICE, 2017). New approaches to healthcare delivery, with more treatment being provided away from acute hospitals and closer to home, require different ways of working (Miller et al, 2016).
Making decisions around the most appropriate place of treatment for patients to ensure they receive effective care is complex and involves the use of intricate clinical decision-making skills and judgement (Simpson et al, 2017).
The perceptions of the paramedic role, both within and outside their profession, have predominantly concerned their importance as emergency care providers who transport acutely unwell patients to hospital (Crowe et al, 2016; Wankhade, 2016). This outdated and stereotypical perspective of paramedics' role may result in their clinical decision-making abilities being undervalued and creates a significant mismatch between perception and reality (Simpson et al, 2017).
In practice, paramedics regularly have to make time-dependent clinical decisions in emotionally charged environments. The often-limited local support services further restrict the options available to them (Crowe et al, 2016) and factors such as patient and carer knowledge and expectations add to the complexity (Nixon, 2013). These decisions are then played out in a constantly changing and highly politicised environment where targets have become markers of quality (Collen, 2007). Little is known about how student paramedics manage these competing demands given the focus on supporting the delivery of care closer to home.
This study aims to explore how student paramedics undertaking a part-time diploma in paramedic science experience this shifting healthcare landscape. The findings feed into the broader discussion around the role of paramedics, the changes in healthcare delivery and managing public expectations.
Methods
A qualitative methodology with a phenomenological enquiry was employed, with three focus groups. The focus groups, guided by an interview schedule, were facilitated by academics from the university's school of nursing who were not known to participants. The one-off interviews took place at the university, lasted approximately 90 minutes each and were audio-recorded and transcribed verbatim. Bias was minimised by framing open-ended questions and two members of the research team facilitated the interviews (Stake, 2010).
Setting and population
The study was conducted with 15 student paramedics undertaking a diploma in higher education to explore contemporary views and lived experiences.
The students had, on average, 8 years of experience in the ambulance service before starting on the diploma programme and were in their first and second years. They were all employed by ambulance services and supported by trusts to complete their academic programmes. There were equal numbers of men and women in each of the three focus groups.
Data analysis
Data analysis was informed by the descriptive nature of the research and based on the transcripts alone (Samuelson et al, 2012).
The inductive process began by the four members of the research team reading and re-reading transcripts, followed by the use of a thematic map (National Voices, 2012) to develop emergent themes with the use of notes, comments, descriptions and potential meanings linked by extracts from the transcripts (Glaser and Strauss, 1967). Member checking and data saturation were not considered appropriate.
Analysis from the three focus group interviews resulted in the identification of two main themes plus related subthemes, representing the experience of participants. Each theme will be discussed in detail.
Ethical approval was granted by Liverpool John Moores University (UREC 18/NAH/028). Data were stored on a password-protected university computer.
Findings
Impact of the immediate context
Highly emotional situations
It was apparent that the types of cases that participants have to deal with while studying part-time for their diploma in paramedicine are very demanding, even when taking into account their previous experience in the service.
The emotional responses from carers, in often volatile situations, appeared to test their decision-making ability:
‘I know what I'm doing but you've got the family member screaming in your face—that's when you're trying to keep your cool.’
‘They're swearing at you, they're threatening you and stuff, so you're trying to make a clinical judgment and thinking: what am I going to do next? Am I going to do this? They could hit me any second but I need to stay nice and calm, while they're swearing at me.’
The difficulties experienced in maintaining focus, when managing distraught family members as well as the patient, was evident:
‘It's an emotional, stressful situation. It's pitch black, you're trying to keep your concentration even though you're knackered. You've got family members sobbing and crying around you.’
This was especially relevant when participants were caring for a child:
‘An adult, you're not going to attempt resuscitation because they're past resuscitation. But if you went to a kid, you're not going to say to the parents, “no”.’
Managing expectations
Where the needs of the patient and expectations of the family were conflicting, participants indicated that they sought compromise by offering care that was not supported by knowledge they had acquired at university. This ensured they maintained control over the environment, enabling them to manage the situation more effectively as student paramedics:
‘The patient's family member was just pushing us and we thought, well, if it's going to make this patient's family feel better as well, it sometimes has a kind of placebo effect.’
The patients themselves were key to influencing actions taken by the student paramedics, particularly in relation to whether they were transferred to hospital.
One participant gave an example where their clinical decision-making was invalidated by patient demands and expectations:
‘When a patient says they've got a pain score of 10 and they're sat on their phone and exhibiting behaviours that kind of makes [sic] you think that might not quite be true, but we go along with that.’
It was suggested that the easy access patients had to information online undermined the participants' ability to make the make appropriate clinical decisions:
‘You lose count of the amount of times you walk in and you can see the screen on the PC blinking away in the corner with Wikipedia on and straight away you know you're on to a loser.’
Furthermore, there was a clear impression that patients associated the arrival of a paramedic with the need to go to hospital. Little could be done to dissuade some patients, even when alternatives were offered, reinforcing the expectations of the patient and their family and how they influenced participants' actions and decisions:
‘They insisted that they go to hospital so everything will be normal [as normally expected] and they could go to a walk-in, could go to the GP and you mention that to them and they don't like it. They want to go to A&E even if you're telling them about the pressures and the waiting times—they will still insist.’
Frustration was expressed by one participant, who felt these cases undermined their clinical judgment, leaving them powerless to act in what they perceived to be in the patient's best interests.
‘This is an ongoing problem they've had for 2 years but they've not seen their GP. But 4 o'clock in the morning they decide, “well I want to go to hospital now”. Has it changed? Is it any worse? No, everything is still the same. They like to phone you and for you to say we'll take you to hospital now.’
Impact of the broader context
Perceptions of colleagues
The narrative of the participants suggests there is a sense of being professionally undervalued. This made decision-making in relation to hospital transfers difficult, where external pressures, organisational targets and public expectations resulted in transporting patients to hospital even when the decision is against clinical opinion:
‘There's been a massive increase in the management wanting you to leave people at home, and there's people in a management position who just base what they do purely on statistics. We've been approached, say, by a paramedic or a boss and told our figures for leaving people at home aren't good enough.’
While theoretically the participants felt such demands should not affect their decision-making, they admitted they were impossible to ignore:
‘You're not going to listen to that—you're going to base your decisions purely on the patient in front of you. But some people might take that as pressure, and it starts affecting how they're making clinical decisions.’
In addition, participants noted that their actions were restricted by how other colleagues reacted to their suggestions:
‘You're constrained sometimes by other people's responses to your requests for what you'd recommend.’
Support services
A lack of wider support networks added to the complexity of situations as participants described the impact of not having support services available during certain times.
‘After hours, social services are not there and then we take them to A&E as a place of safety. That's clogging up A&E.’
‘It's a 24-hour city, it's a 24-hour service. However, not everything works 24 hours. So the people you need to speak to at certain times finish at 5 o'clock.’
Dissatisfaction was expressed by participants who explained that, because of the lack of support services, often the only option for triage services was to request the paramedic service.
‘They just go to the default of “I'll send an ambulance”.’
Accessing out-of-hours mental health support services was perceived as particularly problematic.
‘So at 3 o'clock in the morning when you need a community psychiatric nurse to speak to, to try and get a patient a respite bed, nobody there.’
‘I spent 3 hours in a woman's bedroom. The crisis team wouldn't go so they sent us.’
However, the importance of working with other agencies was evident as participants recognised the need for a collaborative approach.
‘It's about working with other agencies, or what's right for everyone who's involved.’
‘You could call up urgent care, can't you, if you really need some back up.’
Discussion
The NHS in England is the largest publicly funded healthcare system in the world, with healthcare reform and ambitious goals over the last decade resulting in continuous change and transformation (Department of Health and Social Care, 2019). Given the ambitious aspirations of reform and promises of improved standards, less variation in practice and access to excellent care, transformational change depends on new ways of working across multiprofessional groups (Thomas et al, 2014).
The context in which paramedics function is complex. There needs to be a shift in the public perception of paramedics so they are seen as having an extended scope of practice and providing patient-centred, individualised care in the prehospital setting, and that they work not in isolation but closely with other health professionals to deliver care in the most appropriate setting (Eckert et al, 2014).
In this study, participants on occasion felt pressurised to take patients to acute hospital services to placate individuals and manage expectations. They often felt let down by other health professionals, particularly in relation to dealing with patients with mental health issues, rather than experiencing effective teamworking and cross-professional activity, which evidence suggests lead to better patient outcomes (Ramanuj and Pincus, 2019).
Participants expressed concerns about patients having unrealistic expectations, which resulted in high levels of anxiety for all those involved. This is consistent with Robertson et al's (2018) description of patients experiencing heightened anxiety where there is uncertainty. Additionally, when support from family and friends may be absent, for some patients, the media increasingly appears to be a fundamental source of emotional support or guidance, and this was evidenced within the theme, ‘Managing Expectations’, where patients were seen to turn to sources such as Wikipedia.
Participants indicated that the public and other health services did not fully appreciate paramedics' role, skills or ability to make clinical decisions, nor their contribution to the wider functioning of emergency, out-of-hospital services. Where they had autonomy, they seemed to flourish and were able to demonstrate their extended scope of practice.
Participants were able to give examples of effective teamwork and autonomous decision-making. There were positive examples of when they were guided by their supervisors and other health professionals to help with clinical decision-making, particularly when reflecting on stressful or emotionally charged situations they had experienced. This adds strength to the importance of teamwork and shared decision-making processes for paramedics—something considered essential for safe, effective, integrated care provision (Higgs et al, 2018).
In England, urgent and emergency care consists of a range of services including out-of-hours GP services, walk-in centres and minor injury units as well as accident and emergency departments. Although there are some commonalities between these services, their development has changed the NHS landscape with little evidence of what influences patients’ choice in their use of each service (Booker et al, 2014). Findings from the literature suggest a public misconception of what non-paramedic services can offer, even though it appears that members of the public can make clear justifications for requesting an ambulance even when this is considered inappropriate by paramedics given the symptoms involved (Richards et al, 2011). This resonates with the findings of the present study, where there appears to be a disparity between how the paramedic service was viewed and used, suggesting that different perspectives exist on what paramedic services should be used for.
Increased patient contact, rising expectations from the public and a shifting NHS landscape have intensified the demands placed on clinicians including paramedics, which is evident in this study. NHS healthcare services comprise complex systems of decision-making processes and multidisciplinary teams, often with competing pressures, opposing mandates and dynamic professional relationships (McLaughlin and Olsen, 2017), as the current study illustrates.
However, teamwork, supportive relationships and the effective use of health services will bring together the skills and knowledge of various disciplines, including those of paramedics, and provide the linchpin of seamless service provision (Eckert et al, 2014).
In this study, participants reported that they felt the public perceived the service they were meant to provide as the largely traditional one of transport to hospital, which is a significant barrier if the profession is to embrace new models of care.
‘Unplanned’ or ‘urgent’ are ill-defined phrases applied to care, but are used in discussions of transformation of emergency services in England. This lack of clarity may affect whether paramedic services are used appropriately, particularly when other support services are absent.
Limitations
Limitations to this study include that the findings are based on a small number of interviews. The participants were students undertaking a part-time diploma in paramedic science while employed by an NHS trust and some of their reflections may not be based solely on their experiences as a student paramedic. The study does not aim to promote generalisability in terms of representing all those studying paramedic practice, including those studying full time for a BSc, but it does provide valuable context for those preparing student paramedics for the role.
Conclusion
Demand for health and social care is rising because of an increase in the number of people with long-term conditions and an ageing population. Paramedics are an integral part of the wider, multidisciplinary team but participants in this study suggested that the ambulance service and paramedics are viewed largely as having a traditional role as a service to transport patients to acute services. This view appears to influence their clinical decision-making and, ultimately, on whether people are transferred to hospital.
Managing people at home should become the standard approach for paramedic services when appropriate and the expansion of their roles and the extension of their skills will enable this to happen. This can only be achieved if those working with and coming into contact with paramedics, including patients, carers and other services, recognise the significance of their role and their contributions.
Furthermore, this study has illustrated the need for a deeper understanding of how the public and other services perceive the role of the emergency care paramedic.