Paramedicine: An evolving identity

Paramedicine's identity is evolving. As paramedicine strives for professional recognition, part of this process must involve defining and understanding the boundaries of the profession which will in turn inform its identity. ‘Boundary work’ – a concept used by sociologists – describes how professional bodies distinguish themselves from other professions by elucidating their field of practice.^1,2 This process is an important part of establishing a group as a profession as it clarifies what resources are needed, from whom, and which should be prioritised for this group.^1,2 There is a growing body of research attempting to explore what paramedicine is as a profession; however, this work may be somewhat futile while the industry expands into other healthcare domains without defining or considering its boundaries. This diversification of paramedicine into non-traditional roles has not been driven with an understanding of its professional boundaries and field of practice, but rather through a range of other drivers that are not coordinated and without clear goals about the future identity of paramedicine. As a result, there is an increasing lack of clarity about what it is that paramedics do. This confusion can be seen at governmental levels, within paramedicine education and within emergency medical services (EMSs) (otherwise known as ambulance services or paramedic/paramedicine services) themselves.

A recent Canadian study identified a shift from paramedicine being considered a public safety service towards a public health service. ³ A good example of this exists in Australia where some EMS systems operate under the governmental jurisdiction of the Department of Health and Human Services and are represented by a Health Minister, while others are part of the Department of Justice and are represented by an Emergency Services Minister. These differing identities directly impact resourcing. As part of the healthcare system, EMS, like other healthcare organisations, are expected to wade through the large workload and do their best to meet this demand. However, if operating within the boundaries of being an emergency service, it is likely there would be a greater focus on sufficient resourcing to ensure ambulances are available and able to respond to emergencies as they arise.

The lack of clear boundaries also means we have not identified who should be delivering our education and what scope of practice should be covered. Whilst it is common now for paramedicine education to occur in tertiary institutions, the faculty or department in which paramedicine programs are situated and governed varies widely, and include paramedicine, nursing, biology, health and society, and even sport, health and engineering. Furthermore, much of the content of many paramedicine courses continues to revolve around the traditional model of emergency response to critically unwell patients, most if not all of whom require medical intervention in the prehospital setting. Beyond the pathophysiology and pharmacology being taught, paramedicine education includes major emergency or disaster response and logistics in dynamic situations, ⁴ all contributing to the identity of being responders within an emergency medical response system.

A study conducted over 10 years ago by Wankhade described cultures relating to paramedics, dispatchers, and senior managers. ⁵ In describing these three groups a discordance emerged. Paramedics were described as responding to emergencies and providing life-saving interventions. The dispatchers were also described using emergency situations as a lens through their use of an array of technology to triage, dispatch, and communicate with crews in the setting of time pressures and limited resources. However, when describing their vision for their ambulance service, the UK senior managers stated their goal was to be seen as part of the National Health Service (NHS) rather than an emergency service. ⁵ They described cooperation and sharing of resources across the health services, and pressures to grow service delivery. ⁵ Whether this description of the views of the senior managers was driven at the time by increasing low-acuity demand and community need, or whether it has in fact, driven increasing low-acuity demand is not known. What was seen in the years leading up to this study was the emergence and establishment of non-urgent paramedic roles within and outside of ambulance services. ⁶

Whether provided directly or indirectly by contract, the various entities that provide EMS across Australia, New Zealand, Canada, and the United Kingdom (UK) all prioritise emergency response as the primary function.^7–10 Yet, in the UK, for example, only 8% of EMS calls are to life-threatening health emergencies, ¹¹ a statistic reflected in many EMS systems internationally who report an increasing low-acuity workload. ¹² Contributing to this are failures of other aspects of the healthcare system to meet demand which has seen the paramedicine workload increasingly shift towards non-emergency community-based health and some care services.^13–16 This begs the question then: What are the field of practice boundaries for paramedicine?

The various non-urgent paramedic roles (e.g. extended care paramedic, community paramedic, and paramedic practitioner) appear to have evolved out of failures of access to traditional healthcare services, particularly in rural and regional areas. ¹³ Latent capacity is a term used to describe unused resources within an organisation that could produce more products or services. ¹⁷ The discovery that machinery, people, or systems within an organisation could be capable of producing something new or different is exciting. Senior leaders typically explore latent capacity with a degree of enthusiasm, and this may be an underlying driver in Wankhade's paper when senior managers were thinking of paramedicine differently to increase capacity and services. ⁵

Expanding the scope of practice of healthcare practitioners has become public health's supposed panacea for increasing capacity and resources. However, role substitution – not role duplication – is the key to improving the patient experience, patient outcomes, and system productivity. ¹¹ Too often, role duplication and not role substitution is what has occurred, and without careful planning and consideration, paramedicine may not be distinguishing itself from other professions, and instead simply duplicating their field of practice. While some efforts have been well designed and liberate expert clinicians such as general practitioners from routine clinical tasks, such initiatives have not been consistent or universally welcomed.^11,13,18 One contributor to this, is that the role (the boundaries around field of practice) of non-urgent paramedics is not clearly defined and varies from setting to setting. ¹³ These roles have largely been developed without any specific consideration for what the paramedicine boundaries may, or should be, and without reflection upon existing non-urgent paramedic roles thereby feeding this confusion. In complex systems, roles become extremely important,^19,20 and within healthcare teams, role clarity is directly linked to improved patient outcomes. ²¹ At an individual level, role clarity is closely tied to stress and satisfaction.^22,23 Between individuals (peers, other professionals, or patients) role clarity speeds the process of communication: it instantly defines behaviours and expectations. At an organisational level, role clarity (or clear boundaries) directs who receives what training, what equipment is needed, and how tasks should be allocated and how performance is measured.^1,2,19,23 Therefore, considerable work needs to be done, not only to define paramedicine boundaries, which in turn inform roles, but also to identify what factors, for example, system or patient needs, will contribute to shifting these boundaries.

Another aspect to consider is the reasons underlying the expansion in the paramedicine role over the past two decades. Perhaps this expansion is not about more efficient use of resources, capitalising on latent capacity or improving patient outcomes. Maybe it is about paramedicine establishing itself as a profession and trying to occupy more of the healthcare landscape. Again, this is reflected in the senior manager's views in Wankhade's paper with the pressure to grow within the NHS. ⁵ But if having a larger footprint in the healthcare landscape is the goal, we must ask the question of why? Without understanding these drivers, the boundaries of paramedicine cannot be established, and the resources required for paramedicine, as a single profession, cannot be well articulated.

The use of the ‘expansion of scope’ methodology over the past two decades to fill the gaps in primary health care has taken the role of paramedic from being tightly defined and understood to one that is vague and varies widely. A review of studies looking at the role of paramedics in primary health care highlighted that currently, paramedics in non-urgent roles can find themselves in no-man's land, where their purpose, responsibility, and range of skills in these new roles has not been defined, and they are no longer part of the traditional EMS. ¹¹

There are a range of non-urgent paramedic models that now exist, including those that work within, and outside of ambulance services. ²⁴ Nearly all of these models aim to address low-acuity workload to reduce the burden on another part of the healthcare system, whether it be EMS, emergency departments, general practitioners, or other services. The impact on patient outcomes and productivity gains is difficult to identify primarily due to the diversity in non-urgent paramedic roles. ²³ Furthermore, many evaluation studies only report on patient/provider satisfaction, temporal variables, or transportation rates rather than appropriate patient outcomes or direct cost savings (as opposed to speculative cost savings).^24,25 Moreover, the methodological quality of many of the studies identified in the two reviews was found to be low overall.^24,25 We may learn, with additional high-quality research that some of these roles (and their influence on our identity), whilst worthy, are simply not worthwhile.

As this field of paramedicine continues to develop and new career pathways for paramedics evolve, it is important that these roles are studied, and that our research community makes a meaningful and measurable contribution to identifying what the boundaries of paramedicine are (or should be) and whether these new roles should alter these boundaries. There is no question that attempting to fill gaps in the healthcare system is worthy, and that attempts to find capacity are useful. However, additional research is needed to determine how or what current non-urgent paramedic roles or other activities in their myriad of forms mean for paramedicine. In other words, while some of these roles may be worthy, are they worthwhile when considering our current limited understanding of the identity of paramedicine and the uncertainty regarding the impact of these roles on healthcare broadly? Because there are so many different service delivery and community paramedic models, and in turn roles for paramedics, broad research methodologies, paradigms, and theoretical frameworks are needed to guide this academic and practical discussion. We look forward to supporting and engaging our authors and readers as we further explore our identity and profession.