Is the Australian paramedic discipline a profession? A national perspective


Background Over the past century the Australian paramedic discipline has gone through a dramatic evolution; moving from its origins of an ambulance driver to its current practitioner role as an integral member of the Australian health care system. However, at present the Australian paramedic discipline is not considered a full profession by the national or state governments. This begs the further question, how does the paramedic discipline within Australia view itself? Objectives This paper has two objectives: 1) To examine whether or not the Australian paramedic membership views itself as a profession, and 2) if it does not regard itself as such, whether the paramedic community wants to be considered a full profession within Australia. Methods 3800 questionnaires were posted to all Australian College of Ambulance Professionals (ACAP) members around Australia. An investigation of attitudes towards professionalisation were investigated using an 8-item paper-based self-report questionnaire using a 5-point Likert scale (1=Strongly Disagree to 5=strongly agree). Findings A total of 872 paramedics (23 % response rate) returned completed questionnaires. The responses indicated that, broadly speaking, the Australian paramedic membership does not consider itself a recognised profession, furthermore, the Australian membership indicated a desire for paramedics to be recognised as a profession. Conclusions Given that first, the paramedic discipline does not presently view itself as a full profession and second, the paramedic discipline wants to become recognised as a profession. The study identified a set of underpinnings of professional paramedic practice; including professional autonomy, national accreditation for paramedic education programmes, and the development of a unique body of knowledge.

The Australian paramedic discipline has undergone important transformations over the past 30 years in its education, training and health–care provision scope of practice, moving from its former vocational, education and training roots to the higher education sector. Significantly, these transformations have and are currently taking place when the health care system is searching for alternative service delivery models that are both more effective and more efficient.

Current health care reforms such as increased workforce mobility, greater emphasis on interprofessional collaboration, and a single national registration and accreditation governance structure (Productivity Commission, 2005), highlight that the Australian paramedic discipline is ‘professionally’ vulnerable given its current ‘semi-professional’ status.

Similar changes have also occurred in other countries such as Canada and the United Kingdom who both have long-standing professional paramedic systems. For example, a number of international studies have addressed the provision of paramedic service delivery and alignment with education and training and industry expectations (Kilner, 2004; Cooper, 2005; Campeau, 2008; Bowles, 2009). These areas, along with national registration have ensured that paramedics in Canada and United Kingdom are recognised as professions.

Moreover, other established professional groups are competing with paramedics by offering extended health care scope of practice duties (Mulholland et al, 2009), especially in rural and remote locations (O'Meara et al, 2006). Without formal recognition as a ‘fully-fledged health care profession’, and the national registration and accreditation scheme, such occupational encroachment places the paramedic discipline in a tenuous situation, with the erosion of disciplinary identity a real possibility. Currently, the Australian paramedic discipline is not one of the ten listed health care professions (which currently includes Medical Practitioners, Nurses and Midwives, Pharmacists, Physiotherapists, Psychologists, Osteopaths, Chiropractors, Optometrists, and Dentists) included in the national registration and accreditation scheme in July 2010. Furthermore, as recently announced, while Torres Strait Islander Health Practitioners, Chinese Medical Practitioners, Medical Radiation Practitioners and Occupational Therapists were invited to join in July 2012, paramedics, along with social workers, speech/language pathologists and dieticians/nutritionists, were again overlooked (Australian Health Practitioner Regulation Agency, 2010a). The disappointment at having to wait at least another four years was evident in the comments made by the National President of ACAP Ian Patrick who stated:

‘…it was an anomaly that paramedics had to date not been registered as health professionals, given that the everyday clinical practices of the profession and the administration of potentially dangerous medications and interventions pose exceptional risks to public health and safety’

Patrick, 2008a.

Any strategy to professionalise the discipline requires a sound theoretical underpinning. Professionalisation theories (Greenwood 1957; Freidson, 1970; Higgs et al, 1999) have consistently identified a number of professional traits that need to be demonstrated before a discipline will be recognised as a full profession.

The check-list of common professional traits includes: a unique body of knowledge, professional registration, autonomy, altruism and service to the public. Previous investigations into whether the Australian paramedic sector is considered a profession have argued that the paramedic discipline did not yet have professional authority (national registration) or possess a distinct body of knowledge (Reynolds, 2004; Williams et al, 2010).

To advance the discipline's development as a profession, the study seeks to answer two questions. First, does the Australian paramedic discipline consider itself to be a profession? Second, does the paramedic discipline in Australia actually want to be recognised as a profession? If the answers to those questions are respectively ‘no’ and ‘yes,’ further consideration will be given to the apparent barriers standing in the way of paramedics being recognised as a profession.

Method

Design

A non-probability convenience sampling approach was used for this study. This type of sampling is commonly used in exploratory studies such as this (Roberts and Taylor, 1998).

Participants

Participants who were invited to take part in this study were financial members of the Australian College of Ambulance Professionals (ACAP) (n=3800). The questionnaire was distributed by way of Response Magazine, which is the national paramedic magazine circulated to all ACAP members on a quarterly basis. The questionnaire was inserted inside the magazine along with a pre-paid reply envelope. The latest salaried-paramedic employment figures are quoted at 9 491 (Council of Ambulance Authorities, 2008) suggesting that approximately 40% of all Australian paramedic membership was sampled. Ethical approval was sought and received from the Monash University Standing Committee on Ethics in Research Involving Humans (SCERH).

Instrumentation

A paper-based questionnaire was designed to anonymously survey the views and beliefs about the professionalisation of the paramedic sector. Participants were asked to answer using a 5-point Likert Scale (1=strongly disagree to 5=strongly agree). Section 1 asked participants six demographic questions (age, gender, location, employment, current position, and length of time in that position) while section 2 asked participants eight questions about their views on the current and future standing of the professionalisation of the Australian discipline. The questionnaire was devised in consultation with input from a group of senior paramedics, field-tested on four respondents (two experienced paramedic practitioners and two paramedic educators) and revised based on their feedback. The questionnaire took around 10 minutes to complete.

Procedures

Participants were informed about the study via an explanatory letter that was attached to the questionnaire. There were no exclusion criteria. Participants were advised of the anonymous nature of the study and that they were under no obligation to consent to participate in the study, however, if consent was given, they could only withdraw from the study prior to submitting the questionnaire. No incentives were offered and one questionnaire format was used for all participants who agreed to take part. Questionnaires were returned by pre-paid reply envelopes addressed to the researcher.

Data analysis

Data processing included the entry of all results into Statistical Package for the Social Sciences (SPSS) Version 17.0. Descriptive statistics, t-test and one-way analysis of variance (ANOVA) test were used to compare the differences between gender, age group, occupation, residence and length of time in current position. The effect sizes were calculated to evaluate the findings, and results were considered statistically significant if the P value is < 0.05. All tests were 2-tailed unless stated otherwise.

Results

Participant demographics

The characteristics of the participants are described in relation to age, gender, employment status, current professional role, and length of current professional role. The response rate was 23 %. Of the 872 participants, almost 40 % were aged between 35–44 years, while only 5 % were less than 25 years of age. The ages of participants ranged from 18–75. The overall mean age was 40.71 years with a standard deviation of 9.92. As expected, the number of male participants was higher than their female counterparts, an obvious trait given the traditional male–dominated paramedic workforce. Over nearly three–quaters of participants, 74.5 %, were male (n=650 and 25.5 % (n=222) were female. The complete participant demographics are reported in Table 1.


Table 1: Participant demographics (n=872)
Table 1: Participant demographics (n=872)
Variable N %
Age group
<20 4 0.5
20–24 44 5
25–29 81 9.3
30–34 89 10.2
35–39 174 20.0
40–44 168 19.3
45–49 137 15.7
50–54 105 12
55–59 44 5
> 60 26 3
Total 872 100
Location
Victoria 160 18.3
Tasmania 32 3.7
New Zealand 1 0.1
Australian Capital Territory 26 3
Queensland 135 15.5
South Australia 87 10
Western Australia 72 8.3
New South Wales 342 39.2
Northern Territory 16 1.8
South Africa 1 0.1
Total 872 100
Current R=role
Paramedic 701 80.4
Paramedic Manager 45 5.2
Paramedic Clinical Educator 62 7.1
Academic 21 2.4
Student 32 3.7
Nursing 4 0.5
Other 7 0.8
Total 872 100
Length of employment
< 12 months 13 1.5
1–5 383 43.9
6–10 178 20.4
11–15 123 14.1
16–20 91 10.4
21–25 29 3.3
26–30 32 3.7
> 31 years 23 2.6
Total 872 100
Employment status
Ambulance Service 807 92.5
University 22 2.5
Hospital 7 0.8
University Student 24 2.8
Defence 8 0.9
Other 4 0.5
Total 872 100

The majority of participants lived in New South Wales (n=342; 39.2%), Victoria (n=160; 18.3 %) or Queensland (n=135; 15.5 %). Only two participants lived outside of Australia. All states and territories were represented in the study. The vast majority of participants worked for an ambulance service (n=807; 92.5 %), followed by university undergraduates (n=24; 2.8 %) and academic staff members (n=22; 2.5 %). The vast majority of participants were paramedics (n=701; 80.4 %), followed by paramedic clinical instructors (n=62; 7.1 %) and paramedic managers (n=45; 5.2 %). Participants were employed in their current professional role ranging from three months to 45 years with a mean of 9.41 years (SD=8.48).

Professionalisation

The majority of participants indicated that they strongly believed that the paramedic discipline would benefit from being recognised as a full profession (M=4.75, SD=0.54) and that the higher education sector has an important part to play in this process. Further, the moderate mean score of 3.83 (SD=0.94) on the corresponding item indicated that the respondents believed that the sector already exhibits the traits of a professional body. On the other hand, the majority of participants believed that national registration would not occur within the next two years (M=2.90, SD=1.03). In response to the question of whether the discipline should align itself with nursing or medicine to improve its chances of becoming a profession, participants preferred an alliance with medicine (M=3.31, SD=1.16) rather than one with nursing (M=2.37, SD=1.17). Further distribution of scores is reported in Table 2.


Table 2. The professionalisation of paramedics
Table 2. The professionalisation of paramedics
Professionalisation of Paramedics Mean SD
The Australian Paramedic sector will benefit from becoming recognised as a profession. 4.75 0.54
The Australian Paramedic sector already exhibits the characteristics of a profession. 3.83 0.94
The Australian Paramedic sector already possesses its own unique body of knowledge. 3.95 0.85
The Australian Paramedic sector already has a high degree of clinical autonomy in the provision of emergency health care. 3.78 0.96
The Australian Paramedic sector will have national registration within the next 2 years. 2.90 1.03
The Australian Paramedic sector should align itself with Nursing to enhance its chances of becoming a profession. 2.37 1.17
The Australian Paramedic sector should align itself with Medicine to enhance its chances of becoming a profession. 3.31 1.16
The Australian Paramedic sector depends upon Higher Education to enhance its chances of becoming a profession. 3.98 0.96

The professionalisation of paramedics (n=872)

Demographic comparison

An independent-samples t-test was also completed on each of the items in section 2 for participants from the paramedic industry and tertiary institutions. The item suggesting the ‘paramedic sector should align itself with Nursing to enhance its chances of becoming a profession’ was statistically significant for academics (M=2.95, SD=1.13) and paramedic staff (M=2.35, SD=1.18 t (827)=−3.09, P=0.002). The magnitude of the differences in the means (mean difference =−0.604, 95 % CI: −1.10 – −0.101) was large (n2=0.25). Cohen (1988, as cited in Baker, 2006) defines 0.2–0.49 as a small effect size, 0.50–0.79 as a moderate effect size, and 0.80+ as a large effect size (Baker, 2006).

The item suggesting the ‘paramedic sector depends upon higher education to enhance its chances of becoming a profession’ was statistically significant for academics (M=4.41, SD=1.09) and paramedic staff (M=3.96, SD=0.95; t (827)=−2.44, P=0.01). The magnitude of the differences in the means (mean difference=−0.448, 95 % CI−0.856–−0.039) was large (n2=0.21).

Reponses from participants from the 25–29, 35–39, 40–44, 45–49, and 50–54 year age groups produced a significant effect regarding the notion that the paramedic sector depends on higher education to achieve professional status, F (9, 862) = 3.84, P < 0.0001 n2=0.03. Post-hoc comparisons using Tukey HSD indicated that the mean score for 25–29 year age group (M=4.10, SD=0.93), 35–39 year age group (M=4.20, SD=0.89), 40–44 year age group (M=4.05, SD=0.85), and was significantly different from 50–54 year age group (M=3.59, SD=1.13).

Participants also generated a significant effect regarding whether the ‘paramedic sector would achieve national registration within the next two years’ F (6852)=7.60, P=0.00, n2=0.05. Post-hoc comparisons using Tukey HSD indicated that the mean score for participants employed between 1–5 years (M=3.14, SD=0.98) was significantly different from those employed between 6–10 years (M=2.74, SD=.99), 11–15 years, (M=2.74, SD=1.10), 16–20 years (M=2.57, SD=0.96), 21–25 years (M=2.48, SD=0.68). Although statistical significance was reached the effect size was small.

Discussion

Results from the professionalisation section of the survey provide important information regarding what current (and past) ACAP members consider the present professional status of the paramedic discipline. Since the view of the Australian membership is that the discipline is not currently viewed as a full profession, these findings also importantly provide information on which professional characteristics or governance structures are still required in order for the paramedic discipline to achieve full professional status.

While the results suggest the paramedic discipline is not recognised by the members as a profession, findings also demonstrate that being recognised as a profession is something the ACAP membership does want to achieve. Interestingly, other results suggest the paramedic discipline believes it is currently moving towards exhibiting professional traits such as possessing a unique body of knowledge (M=3.95), and working autonomously (M=3.78). External evidence supporting both items has been demonstrated by the recent industrial campaigns and outcomes from Fair Work Australia in South Australia (Lennox, 2010) and Australian Capital Territory (ACT), where paramedics (intensive care level) have been recognised as health professionals and received professional rates of pay (Australian College of Ambulance Professionals, 2010a).

Currently, ACAP members are pessimistic regarding paramedics achieving national registration within the next two years (M=2.90, SD=1.03). While this negativity is perhaps based on a lack of public debate, the past 12 months has seen an emerging voice from two national paramedic peak/governing bodies: ACAP, and the Council of Ambulance Authorities (CAA). The ACAP is a national body representing over 4 000 paramedic members involved in the provision of pre-hospital patient care. On the other hand, the CAA is a peak body and corporate identity for the paramedic discipline and individual ambulance service organisations, employing over 18 000 members in either paid or volunteer capacities (The Council of Ambulance Authorities, 2008b).

The CAA do not support the notion of national registration for paramedics (The Council of Ambulance Authorities, 2008b), while conversely ACAP endorses its implementation (Australian College of Ambulance Professionals, 2008; Australian College of Ambulance Professionals, 2009a, 2009b). The disagreement over national registration has led to several public confrontations highlighted in Response Magazine (Hotchin, 2008) and at a pre-conference seminar meeting held in Auckland, September 2009 organised by the CAA. The main point of contention between the ACAP and CAA rests with the perceived conflict of interest, and perceived loss of ‘organisational control’ that currently exists with CAA. This is illustrated by the following remarks made by both parties. CAA (The Council of Ambulance Authorities, 2008b) states:

‘There is no demonstrable need to advance registration at the current time in the interests of patient safety as systems and procedures are in place in every jurisdiction to safeguard patient safety in what is already a highly regulated field of the health service delivery.’

In opposition, the ACAP (Australian College of Ambulance Professionals, 2008) notes that:

‘ACAP does not agree with the CAA's view that there is currently no demonstrable need to advance the cause of registration in Australia and the apparent desire to maintain the status quo for the funding and administration of out of hospital EMS [Emergency Medical Services]. The CAA position is perceived by ACAP to be contrary to the community's desire to achieve improved health care outcomes in the broad public interest as articulated by the Australian government and the general thrust of the underlying principles for health care outlined by the NHHRC [National Health and Hospitals Reform Commission]’.

The discourse created by these ideological differences between the ACAP and CAA, is the debate the discipline urgently needs to have, particularly given the changes and proposed reforms taking place in the Australian health–care system (Productivity Commission, 2005). This leads to the broader question, which organisation best represents the views of individual paramedics working in the Australian health care system, is it ACAP or CAA? CAA appears to have an inherent conflict of interest in this context.

Given the many proposed reforms, it is likely many industrial issues will also be dealt with, hence, it is no surprise that in recent times, the newly created National Council of Ambulance Unions (NCAU) have formed public partnerships with the ACAP regarding their committed stance on paramedic registration (Australian College of Ambulance Professionals, 2010b). The following statement demonstrates the positioning of both groups opposing the CAA:

‘ACAP and NCAU representatives noted the widespread support from practitioners and the growing endorsement by various jurisdictions for the registration of paramedics and the inclusion of EMS within national healthcare policy. ACAP and NCAU are disappointed that so far the Council of Ambulance Authorities (CAA) has not embraced the principle of national registration which we see as fundamentally important for the profession and in the interests of public safety. ACAP and NCAU believe it is time for the CAA and Ambulance Services nationally to take positive steps to work collaboratively with all stakeholders to ensure the early implementation of national registration.’

(Australian College of Ambulance Professionals, 2010b).

The ACAP and NCAU appear to be at loggerheads with the CAA. What is important to note is that professional registration as mandated by the Commonwealth government is for the protection of the general public from unqualified or poorly–performing health–care providers while at the same time ensuring that health–care professionals remain current in their abilities, knowledge and skills. It is only an indirect benefit to the professions themselves that they will be more visibly recognised by members of the public as being ‘fully professional’. The ACAP and NCAU likely have differing vested interests compared to the CAA. In other words, ACAP and NCAU represent the views of the Australian paramedic discipline who have reported that they want the paramedic field to move towards full professional status.

The transition of paramedic training programmes to the higher education sector was seen as an important part of the professionalisation process (M=3.98, SD=0.96). While the mean score suggests widespread support of the move of paramedic training programmes to the higher education environment, there still appears some uncertainty among the paramedic membership in general. Based on a growing body of anecdotal evidence gathered by paramedic staff, it seems that there are perceptions that graduates from the ‘newer’ non-vocational system do not possess the life experience skills and are too young or immature to adequately meet the demands of paramedic employment. For example, several descriptive studies (Waxman and Williams, 2006; Boyle et al, 2007) examining paramedic students' pre-employment experiences while on clinical placements, found that a proportion of the membership still have reservations concerning the move from vocational education (for example, apprentice-like, TAFE-level) to higher education (for example, university undergraduate and graduate-entry level).

This view is illustrated in a recent interview with an experienced paramedic (Mann, 2010) who states:

‘That's the one thing that's changed over the years that I don't really agree with [transition to higher education]. Being a paramedic is a very intensive job and a three-year training course really equipped us well because it included a high level of practical experience. These days the graduates start a lot younger and can be on the road within 12 months and although some are more than capable, I prefer the ‘old school’ methods of teaching.’

The item that the discipline ‘depends on higher education to enhance its chances of becoming a profession’ produced significant differences between Victoria/Queensland and South Australia/Western Australia based respondents, though effect sizes were small.

One plausible explanation for these regional differences might be the historical origins and contemporary nature of programmes in Victoria and Queensland, compared with South Australia and Western Australia. For example, Victoria has five universities providing either undergraduate or postgraduate entry-level qualifications, while Queensland now has three, one of which specialises in remote paramedic practice. These compare with one university in South Australia and one in Western Australia that uses a hybrid model of part-vocational and part-bachelor level of education. These comparisons suggest base paramedic qualifications at the bachelor level are generally considered the ‘standard’ in Victoria and Queensland, while this is not the case in Western Australia which has still yet to convert to a standard bachelor degree. Another interesting finding was that statistical significance was not reached among the New South Wales cohort. The result may have been expected in the light of the New South Wales Ambulance service still running a major vocational education programme for the training of its paramedics. As the NSW cohort is the largest (accounting for some 39 % of the respondents), its responses are likely to have played a significant role in the overall outcome.

Perhaps not surprising, statistically significant differences were produced between academics (M=4.41, SD=1.09) and paramedic staff (M=3.96, SD=0.95) on the item ‘depending on higher education’. These differences produced a large effect size, and suggest that the transition to and current education and training arrangements in formal higher education settings is still not necessarily supported by front-line paramedic staff. This uncertainly could be reflected by the rapidly increasing number of universities now offering paramedic programmes, and the diverse standards exhibited in newly–graduated students. In other words, since formal accreditation processes and standardisation of curricula has yet to be achieved nationally, consistent clinical and pedagogical standards cannot be guaranteed between one university and another.

The end–products are graduates lacking consistency, or who may or may not meet paramedic members' competency standards (Council of Ambulance Authorities, 2010) or standards set by ambulance services. That is not to say that all curricula should be the same however, but rather that core attributes such as critical thinking, the ability to work in teams, required psychomotor abilities, good written, verbal, and numeracy communication skills, and approaching patients in a focused, non-discriminatory manner, should be evident at agreed-upon minimum standards of achievement in every university curricula as common and reliable paramedic graduate attributes.

Limitations and future research

The current study has limitations. The use of convenience sampling limits the generalisability of the study findings. This method, while easier to recruit participants, is less likely to recruit a representative sample. Those participants who do volunteer to respond may bias the results, particularly given their membership to a professional college that fundamentally promotes professionalism. Furthermore, non-response bias also limits study generalisations. Despite these limitations, the results between different groups have raised some interesting questions, and opportunities for further research. Another notable limitation was the use of a non-standardised questionnaire to elicit participants' attitudes about professionalisation. However, efforts were made to ensure preliminary face and content validity of the scale.

The use of qualitative methods (such as key informant interviews or focus groups) could also provide a richer data source, particularly relating to items involved in the professionalisation section. Moreover, further research could include the use of alternative theoretical models to professional trait theory in characterising and defining professional paramedic practice (Ewing and Smith, 2001)

Conclusions

The findings from the survey suggest two points in relation to paramedic professionalisation. First, the paramedic discipline in Australia is not currently recognised as a full profession by either the government or the membership. Second, the paramedic discipline wants to become recognised as a full profession.

To this end, this paper has identified a set of defining characteristics of paramedics as a professional and highlighted which of these are yet to be realised in practice. Included are such requirements as national registration, and the establishment of a unique body of knowledge. Further, the manifestation of these characteristics will also ensure the definition of the discipline's ‘un-encroachable’ area of professional expertise and authority. In the first instance however, further research in these areas are urgently required if the paramedic discipline wants to become recognised as a profession by its members, the national and state governments of Australia and the general public.

Key points

  • The Australian paramedic discipline does not presently view itself as a full profession.
  • The Australian paramedic membership wants to be recognised as a fully fledged health care profession.
  • The Australian paramedic discipline is currently considered a semi-profession based on traditional trait theory (unique body of knowledge, altruism, autonomy etc).
  • The establishment of national registration is considered an important part of the Australian paramedic professionalisation process.