Challenges and lessons learned in conducting international paramedic research: A scholarly perspective

Abstract

Over the past two decades, paramedicine research has expanded significantly. While much of this work has been conducted within individual countries, there is now a critical need to foster international collaboration to improve knowledge synthesis and dissemination. This perspective paper draws on the authors’ experience conducting a multi-country study involving Canada, the USA, the UK, and Australia to reflect critically on the structural, methodological, and ethical challenges of international research in paramedicine. Rather than positioning the project as the central focus, it serves as a lens to explore broader issues that impact cross-jurisdictional research, such as differences in ethical review processes, variability in academic and regulatory infrastructures, and the complexity of designing context-sensitive methodologies across systems. These reflections highlight both tensions and opportunities for advancing paramedic research on a global scale. The paper underscores the importance of early engagement with partner organisations, flexible planning when working with operational clinicians, and deliberate strategies to foster mutual understanding within interdisciplinary teams.

Introduction

Paramedic research generates discipline-specific knowledge that informs professional practice and strengthens the evidence base for a field that is rapidly evolving. As paramedics increasingly help to address health workforce shortages, particularly in rural and remote areas, their scope of practice continues to expand, along with expectations for advanced clinical reasoning and health system-level contributions. These shifts have created a dynamic learning and research environment, advancing the profession into sectors and settings beyond traditional emergency services, including integrated primary care, community paramedicine, and other emerging models of patient care. Engaging with international colleagues allows paramedicine to learn from alternative health systems, some that have been delivering care in these settings for longer, offering valuable insights into implementation, workforce development, and patient outcomes.

As the profession continues to evolve, these insights become increasingly relevant. Although paramedic scope of practice has expanded significantly over the past two decades, the rapid pace of change has intensified the existing challenges of conducting high-quality prehospital scientific enquiry. ¹ Paramedicine remains a rapidly evolving profession with a growing research culture, but many areas still lack robust evidence. ² While degree-level academically prepared paramedics are more common now globally, support from organisations for paramedic-led research remains limited, hindering engagement and development particularly at a doctorate level. ² A global register lists only 281 paramedics with or pursuing doctorates across 29 countries. ³ In Australia, just 18% (n = 29) of university-based paramedic academics have a doctorate. ⁴ With such a limited pool of experienced paramedic researchers, collaboration across multi-disciplinary and geographical boundaries becomes not only appealing but necessary. Building a robust evidence base depends on active research engagement, without it, the profession's capacity to generate, apply, and evolve evidence-informed practice remains constrained.

International research collaborations therefore present valuable opportunities for knowledge generation, system improvement, and innovation in paramedicine. Working across borders enables comparison of practice, identification of shared challenges, and the co-development of solutions that strengthen the profession globally. However, such collaborations also come with challenges. Variations in clinical practice, ethical frameworks, governance structures, and research cultures can create complexity and, at times, tension. While these differences can be enriching, they highlight the ongoing need to build academic capacity and research literacy within the profession. As paramedicine transitions from a historically practice-based vocation into a knowledge-producing discipline, international collaboration becomes essential.

This paper is informed by a research project examining the obstetric and neonatal experiences and educational needs of paramedics working in Canada and the USA. The research team included members from Canada, the USA, the UK, and Australia, selected for their expertise and to build on prior research conducted in Australia. ⁵ Using reflective memo notes from each researcher, this paper captures their collective experiences of conducting international paramedic research. Insights captured through memos informed the identification and framing of key themes discussed in this paper. Some examples of memo content are provided below:

It's fascinating to hear about how paramedic practice aligns and differs across our countries, but we will need to consider how best to ‘reach’ our colleagues in our distinct contexts and how our norms and values compare and to what extent we have professional equivalence. (Non-identified member of the research team)

With regards the content validity, it's important to consider this more…. here is some more info (links below) and I suppose my initial thoughts to the discussion was that we really need someone (people) independent (local to the country) to review the questions which is recommended too–this will help with any inherent bias we have unknowingly introduced. (Non-identified member of the research team)

Consensus on which individual, reflective points were of scholarly relevance, and how these would be incorporated in the iterative development of our key points, was achieved using a portion of our meetings for a focussed, reflexive discussion. Drawing from both these reflections and the broader literature, the paper explores challenges and enablers across collaboration and team dynamics, methodology, ethical approvals, and regulatory barriers.

Rather than serving as a process evaluation, this scholarly perspective relies on a post hoc ethnographic strategy to illustrate broader insights about the conditions under which international paramedic research can succeed. As a novel approach, we advocate for the use of a conceptual space that allows for the critical development of meaning across professional, cultural and system boundaries. By outlining key challenges and providing progressive recommendations, it aims to support others undertaking cross-jurisdictional research within globally diverse teams, and to position paramedicine more centrally within the international health research dialogue.

The value of international research collaboration

The benefits of international research collaboration are well recognised across disciplines and include opportunities for mobility, access to institutions and facilities abroad, and insight into different research structures and systems. ⁶ Furthermore, in a post-pandemic world, scientific globalism has been reinvigorated through the ubiquitous use of technology that supports collaboration and communication, removing the barriers and costs associated with in-person collaboration. ⁷ This facilitates connections with researchers who might otherwise be out of reach and promotes alignment of research priorities across disciplines and regions. ⁸

Advancing paramedicine through global partnerships

While each country approaches the broadening of paramedic roles differently, international research collaboration enables the co-creation of globally informed approaches to models of care, education, and system design. In addition to supporting innovation and improvement in practice, these global collaborations strengthen the academic and clinical impact of paramedicine research by extending the scope and influence on a wider audience. Evidence suggests that international research is more frequently cited, in part due to broader readership and perceived credibility tied to institutional and national reputations.^9,10 These partnerships provide valuable opportunities to draw on diverse knowledge and perspectives, facilitating resource sharing that can accelerate research. ¹¹ This was evident in this international team of paramedics and midwives, where open exchange supported constructive challenge of ideas and perspectives.

Opportunities and challenges of global collaboration

Such collaborations often enable the collection of more diverse datasets and support more nuanced analysis of complex issues through the integration of multidisciplinary expertise. They also allow researchers to identify and assess global trends, enhancing the relevance and applicability of findings across various settings. ¹² For countries where paramedicine is still developing its research capacity, international collaboration provides a critical pathway for mentorship and skills development, supporting the growth of local expertise through engagement with established researchers in the field. ¹³ In mixed-discipline research groups, members can also share insights into how research capacity and capability have been developed within their respective fields. However, these collaborations are not without cost. They often demand greater investment in coordination and communication, introduce logistical complications such as scheduling across multiple time zones, and require navigation of diverse administrative, technological, and epistemological systems.^9,10,14 The widespread reliance on English as a common language can restrict nuanced information exchange, particularly where language or professional jargon differs. ⁹ Mismatches in referencing management systems, institutional procedures, and ethical frameworks can also lead to inefficiencies and misunderstanding. ¹⁵

Communication, coordination, and team dynamics

Communication across distributed teams can also be problematic, sometimes resulting in participants withholding ideas or deferring to lead investigators, behaviours that may suppress creativity and limit genuine collaboration. ¹⁰ Additionally, international partnerships often form along lines of shared professional heritage, ¹⁰ particularly evident in paramedicine, where service models in Australia, Canada, the UK, and the USA share historical and structural similarities. While such alignment may assist collaboration, it also risks narrowing the diversity of perspectives engaged in the research and encourages assumptions about shared norms, values, or priorities that may not be true. This risk was partially mitigated within this research group with the inclusion of a non-paramedic clinician.

Enablers of effective collaboration

The literature on international research collaboration highlights several key enablers for success. These include the establishment of shared ethical and governance frameworks to streamline multi-jurisdictional approval processes, and the use of distributed leadership models that promote equitable participation across teams. ¹⁵ Studies also emphasise the importance of flexible communication structures and digital tools to manage time zone differences and reduce coordination burdens.^9,15 This includes an acceptance from the researchers involved that some communication and meetings will inevitably fall outside their normal working hours. Furthermore, there is growing recognition of the need to diversify partnerships beyond traditional Anglosphere alliances, and to embed reflexivity, cultural diversity, and inclusive epistemologies into global research practice. ¹⁰ As a fundamental activity in science, international research collaboration has continued to grow ⁹ driven partly by reliable technological solutions to support interconnected activity, as well the internationalisation agenda of many universities. ¹⁰ However, it is recognised that further work is required to fully understand the barriers, the motivation behind collaborations, and the factors that contribute to successful long-term partnerships. ¹⁶

Social and structural features of collaboration

An essential consideration for the initiation of any cross-country, interdisciplinary project is to establish an inclusive and encouraging research environment while recognising the logistical challenges of coordinating across three continents, including time zone and scheduling differences. Katz and Martin ¹⁷ conceptualised these considerations as the social and spatial features of collaboration. Interestingly, some studies have suggested that more successful collaborations involve female collaborators and where there are mentorship relationships. ¹⁸ Both points were present in this grouping, as 40% of the contributors were female, and opportunities for mentorship from experienced researchers available.

Leydesdorff and Wagner ¹⁹ advocate the need for the foundation of a core group for any research collaboration. While this assertion was based upon experience in scientific research, the principle is transferrable to any collaboration that requires the sharing of expertise in problem identification and problem-solving activities. ²⁰ The research team comprised field paramedics, clinicians, academics, educators, and policy professionals. It also included novice and experienced researchers with expertise in qualitative and quantitative methodologies, which fostered mentorship and a positive research culture across a multiprofessional group which is recognised as an enabler in multidisciplinary research. ⁴

Establishing effective communication and workflow

An agreement on the approach to communication within any team is required, driven by pragmatic decisions given the time differences, as well as cultural preferences to establish effective habits. ¹⁴ As clinical and academic professionals with broad experience of collaborative working, a combination of email, instant messaging and regular video conference calls were used for communication. Co-production using shared documents were used to circulate structured meeting summaries to maintain project momentum, and for the creation of core documents, including ethics applications, survey outlines and citation management. ¹⁵ While the cross-continent research afforded opportunity to work around the clock (the benefits of staggered time zones) this occasionally led to challenges inhibiting real-time communication.

A clear understanding of the purpose of collaboration, the intended outcomes of collaboration, and the process for collaboration is essential to share and maintain throughout any project. ²¹ Such foundational elements will provide a solid foundation for the collaboration of research design elements across a global research partnership.

Methodological challenges – Translation and conceptual equivalence

Adapting the knowledge, attitude and practice (KAP) survey

In this project, a KAP survey was selected as the primary methodology, based on its demonstrated value in identifying knowledge gaps and informing targeted health and education strategies. ²² Originally developed in the 1950s, well-designed KAP surveys have been widely used to support policy development and program planning across diverse healthcare contexts. ²³ We argue that this method offers significant potential for transforming assumptions into evidence, understanding what we think we know and what we actually know, and highlighting knowledge deficits and variations in practice. ²⁴ When applied rigorously, KAP surveys can provide meaningful insights into the preparedness and educational needs of paramedics in any jurisdiction, making them a powerful tool for international research efforts in the profession.

However, moving research focus from one geographical region to another, even where systems appear homogenous, can offer up some distinct challenges. Other disciplines have described the importance of survey question translation, conceptual equivalence and raise awareness of culturally specific connotations.^25,26 A timely methodological pause ²⁷ can therefore afford careful reflection, enabling a refinement of earlier approaches, but one now enriched and meaningfully challenged through a discursive lens by the cultural insights from cross-country partners. A KAP survey comprises a series of constructs that can be altered significantly when transferred across geographical/geopolitical/sociodemographic boundaries. As such, careful translation is essential in ensuring conceptual equivalence. Failure to do so will compromise the instruments validity and reliability ²⁸ otherwise such ‘methodological artefact’ may result in misinterpretation of results. ²⁹ Our study, replicating the Australian KAP survey, ⁵ within the USA and Canada required an iterative reflective/developmental approach to establish equivalence. Through our discursive approach three broad areas of contextual discourse emerged: professional/organisational, cultural/social and language. Each area will now be briefly discussed.

Professional/organisational equivalence

All countries included in this study deliver services through the Anglo-American model of prehospital care where care is chiefly delivered by Paramedics/Emergency Medical Technicians. ³⁰ Presumptions can be made that paramedicine is a homogenous profession as internationally the title has an apparent equivalence. However, the paramedic profession is evolving at different paces both globally and locally. ³¹ Organisations delivering out-of-hospital care are responding to variability in the healthcare needs of respective populations and organisational delivery models. These developments are often the catalyst to changes to scope of practice, education and licensure/certification required to support the safe and high-quality delivery of care. Such elements differ not only locally, but internationally and can therefore affect a survey instruments conceptual equivalence. Careful adaptation was required in describing differences in licensure, education levels/qualifications and role titles between countries.

Cultural and social considerations

Those employed as prehospital care providers will naturally reflect the cultural diversity of the geographical regions within which they operate. Collectively then, our profession remains relatively heterogeneous, while our intended outcomes have equivalence, the context, operationalisation and delivery of these may differ, of which must be acknowledged during survey translation. This was particularly evident during translation of the demographic questions where the range of response options was substantially extended (from the Australian study) to ensure cultural inclusivity. Notably, this was crucial in representing the diverse background within the Canadian indigenous context.

Language and conceptual equivalence

A central focus of survey translation is on language and within the context of conceptual equivalence. ³² On one level, namely language, articulation and, by extension, interpretation, it could be assumed that there would be a degree of homogeneity, given that all participating countries are English language speaking. However, communication styles differ regionally, and linguistic diversity must always be carefully considered. ³² Fitzgerald et al. ³³ identified a typology of error caused during survey translation citing simple translation mistakes, poor source questions or cultural probability issues as the root causes of measurement error. Early identification of these risks enables timely instrument refinement and improves the reliability of cross-cultural survey data.

And so, building on the spatial and social dimensions of collaboration inherently requires engagement with representatives from each respective country; this is essential to the success and integrity of any study. Our Canadian and US partners played a critical role in this element identifying linguistic disparity (dialects, structure), terminology semantic interpretation (how terms are understood, interpreted) and even simple spelling differences between the old and new survey instrument (paediatric vs. paediatric). The time required for such detailed analysis and consideration should not be underestimated nor should a pre-testing phase centred on identifying language, cultural differences and interpretation to mitigate systematic measurement error and therefore bias. ³² Caution is required however, as such iterations can lead to a lengthening of the survey instrument which can likely induce survey fatigue and negatively impact participation and completion. ³⁴

Methodological refinement across contexts

Alternative methodological approaches do not escape these challenges. For example, in qualitative research, topic guides will need careful translation to ensure conceptual equivalence and therefore validity, with similar care taken by those analysing and interpreting the data and ensuring a reflexive approach. ³⁵ Some discussion is evolving on the concept of ‘cross-language trustworthiness’ to improve methodological consistency in the undertaking and reporting of this essential process. ³⁶ The work addresses pragmatic elements such as ensuring bi-lingual facilitators where undertaking focus groups, and/or the inclusion of researchers from the country within which the research is being undertaken to ensure ‘cultural competence’. ³⁵ Alternatives are for researchers to immerse themselves in the culture and language within which they are undertaking the research, but this will be time-consuming. And notably, these challenges are not limited to multilingual or cross-country research; they can also arise in countries where English is the primary language such as the UK, where regional dialects may cause difficulties in translation and interpretation. ³⁷

Although quantitative paradigms often conceptualise translation as an objective or neutral process, care must be taken here too. A nuanced understanding of the cultural influences on care delivery is equally critical during intervention development and testing. For example, cultural-norms can significantly shape prehospital response to road traffic incidents in low- and middle-income countries. In some communities, attention of responders is directed towards those dead rather than tending to those injured thus potentially contributing to preventable deaths. ³⁸ While this may perhaps be viewed as an extreme example, it underscores the profound impact that cultural, systemic and religious factors can have on methodological design.

As such, regardless of methodology, a meticulous translation process grounded in an awareness of organisational, cultural and professional differences and augmented by authentic collaboration with regional experts will enhance the conceptual equivalence, validity and reliability of the survey instrument.

Ethical approval and regulatory barriers

Variations in ethical review processes

Conducting research across international borders presents well recognised complexities, particularly around ethical and regulatory approvals. ³⁹ Despite a shared foundation in core ethical principles such as those outlined in the Belmont Report, ⁴⁰ significant variation exists in how research ethics boards (REBs) or institutional review boards (IRBs) interpret and apply these principles across jurisdictions. These differences are shaped by regional norms, legal frameworks, and cultural histories, raising critical questions about whose standards define ethical practice in international research. ⁴¹ As our own experience illustrated, one institutional board required no justification for the inclusion of demographic items such as ethnicity and gender identity, while another recommended their omission. To use the language of our own reflections, this highlighted the struggle to ‘streamline ethics according to whose standards for ethical practice?’.

Conceptual tensions between universalism and cultural relativism are particularly prominent in cross-border research. ⁴² While universal ethical principles aim to ensure consistency, they can risk overlooking local realities and practices. As some scholars note, ‘universal’ is not necessarily synonymous with ‘global’, and ethical frameworks must be critically examined for embedded assumptions, especially when shaped predominantly by Northern, Euro-American norms. ⁴³ Rather than exclusively either universalist or relativist ethics, Evanoff ⁴⁴ proposes that researchers should engage in a pluralistic dialogue that recognises multiple moral frameworks and seeks consensus. For international interprofessional collaborations like ours, this model underscores the importance of seeing ethical review not as a compliance exercise but as an iterative, negotiated process shaped through conversations between culturally and institutionally diverse partners.

Demographic data and cultural sensitivities

The inclusion or restriction of demographic questions in research ethics applications, for instance, varies significantly between countries, often reflecting differing national attitudes toward race, identity, and marginalisation. ⁴¹ Where one country may support comprehensive demographic data collection to address disparities, another may limit such inquiries to avoid reinforcing harmful labels or breaching cultural sensitivities. For us, these negotiations became a site of ethical reflection, forcing us to consider how demographic categories carry both epistemic and moral weight.

To address these tensions, a constructivist approach to research ethics is recommended. This involves treating ethics as a dialogical and negotiated process, allowing space for diverse epistemologies and promoting culturally responsive methodologies. ⁴² For example, demographic terms such as Two-Spirit, used by some Indigenous North American communities, reflect cultural identity and tradition that may not be easily translatable or recognised across other national contexts. ⁴⁵ Engaging with such nuance requires more than procedural compliance, it demands cultural humility, reflexivity and what Fricker ⁴⁶ terms epistemic justice. This is being the ethical responsibility to ensure that marginalized knowers are recognised as credible contributors to the construction of knowledge.

Data sovereignty and legal constraints

Data sovereignty also emerges as a key concern in international collaboration. ⁴⁷ Legal restrictions on data storage, cross-border sharing, and the comparative analysis of international datasets can introduce logistical and ethical challenges. In our project, REBs on both Canada and the USA required local data storage within national servers, preventing combined analysis unless secondary agreements were established. Researchers must navigate overlapping and, at times, conflicting requirements while ensuring that all parties have equal access to their own data. These complexities align with Kukutai's Data Sovereignty Theory, which emphasizes that communities, specifically Indigenous and historically marginalized groups, have the right not only to control how their data are collected and used, but also to determine the narratives and interpretations derived from them. ⁴⁸ Broader conversations on data sovereignty extend beyond research into areas of digital governance and global economics, underscoring the importance of aligning research design with jurisdictional and cultural expectations.

Ethics within collaborative teams

Finally, the ethics of collaboration itself warrants attention. While ethical reciprocity is often framed as a participant–researcher concern, it also applies to relationships within research teams. ⁴⁹ Power differentials, academic hierarchies, and differing institutional expectations can influence decisions about roles, recognition, and authorship. Co-authorship, for instance, is not always based on contribution, and may instead reflect informal or political considerations. ⁵⁰ Reflective memos from our team highlighted the importance of continuous negotiation around authorship and recognition, ensuring early career or clinical researchers were not overshadowed by senior academics. To ensure fairness, transparent and ongoing dialogue about authorship criteria, role expectations, and mutual accountability is essential in any international research team.

Lessons learned

International paramedicine research is most productive when insider expertise and outsider perspective converge within a shared third space, adding both contextual depth and critical distance.^51,52 This conceptual space allows researchers to negotiate meaning across professional, cultural, and systemic boundaries, where local knowledge meets comparative insight, and where assumptions are surfaced, debated, and re-examined. In such a space, the ‘insider’ contributes grounded understanding of operational realities, patient needs, and contextual constraints, while the ‘outsider’ introduces fresh analytical frameworks, alternative methodologies, and critical detachment that can challenge embedded norms. ⁵³

This conceptual space of teaming insider and outsider perspectives has been identified in paramedicine research as enabling negotiation across professional and systemic boundaries. For example, Johnson et al. ⁵⁴ use collaborative and triangulated methods to understand decision making by paramedics, highlighting how operational (insider) knowledge is combined with research (outsider) perspectives.

Translating this conceptual balance into everyday collaboration requires deliberate systems and processes that support both structure and adaptability. Creating this space requires project management that is both structured and adaptable. Visual tools such as GANTT charts can provide a shared roadmap for the team, but flexibility, through contingency buffers and asynchronous communication platforms, are essential when collaborators, and participants are navigating rotating shifts across time zones.

Early and strategic planning around survey distribution is essential for improving response rates in international research. Timing the release to align with optimal windows, disseminating through trusted communication channels, and partnering with reputable organisations all contribute to stronger engagement. Surveys are more likely to be completed when they are mobile-friendly, clearly communicate their relevance and value, and are supported by short, timely reminders and modest, non-monetary incentives. ⁵⁵

Time constraints affect research teams as much as participants, particularly when clinicians and academics are balancing competing demands. Securing protected research time, adopting flexible meeting schedules, and structuring projects around individual project components can help maintain momentum across diverse teams. Equally important is building trust between researchers and ambulance services. Low research literacy, limited funding, and institutional data gatekeeping can create barriers to access and collaboration. ⁴ Transparent data sharing agreements and relationship building should therefore begin before ethics submissions.

Cross-jurisdictional research requires careful navigation of local consent procedures, privacy laws, and professional structures, that is, understanding who holds authority in clinical decision-making and how roles are defined within different health systems. Creating comparison tools, such as structured tables that map differences in education, terminology, and clinical guidelines, can help identify potential mismatches early. This proactive approach supports smoother collaboration and more meaningful knowledge exchange across diverse healthcare contexts.

Recommendations

The following key actions, drawn from the literature and reflective analysis, offer practical guidance for strengthening international collaboration in paramedicine research:

Future capability building. To sustain momentum, paramedicine must invest in workforce development strategies that support dual clinician-researcher roles, create clear academic pathways, and prioritise research literacy from undergraduate curricula through to continuing professional development.

Activate international networks. Use web-based repositories, conferences, and professional associations to forge multinational teams and share data.

Normalise constructive comparison. Reframe benchmarking as mutual learning to ease political sensitivities and foster disciplinary maturity, integrating socio-cognitive considerations. ⁵⁶

Equity and Inclusion. Equity, underpinned by justice theories,^57,58 should be a guiding principle, including resourcing participation from low- or middle-income countries, also ensuring shared authorship and ownership of research outcomes.

Structured ethical considerations. Develop template protocols and data use agreements that satisfy diverse regulators while safeguarding participants.

Foster a research ready culture. Challenge the lingering ‘blue collar’ stereotype by demonstrating how practice-based studies improve patient outcomes and workforce development.^59,60

Embed flexibility. Build contingency time, asynchronous collaboration, and mobile first tools into every project plan.

Showcase paramedicine scholarship. Leveraging motivational theories and techniques to ensure paramedics hold visible authorship and leadership roles, emphasising their capacity to shape primary, critical, and community care through evidence-informed practice. ⁶¹

Towards a Research-Ready Discipline: By embedding research within paramedic practice and systems, and fostering international dialogue, the profession can solidify its position as a leader in applied health research. This potential for transdisciplinary research may be augmented by establishing informal and formal Communities of Practice. ⁶²

These reflections demonstrate that successful international paramedicine research relies as much on relational and cultural understanding as it does on methodological rigour. As the profession becomes increasingly engaged in cross-jurisdictional health systems, there is a growing need to embed research into the everyday fabric of paramedic practice. Fostering a research-ready culture, strengthening international networks, and acknowledging the structural realities of operational workforces will be essential to advancing both the credibility and impact of paramedicine as a global health discipline.

Conclusion

Conducting international research in paramedicine presents a unique opportunity to collect data with greater generalizability from diverse populations and practice environments. Successful interprofessional research that crosses national boundaries and continents is not well described in the literature providing an opportunity for the author team to explore its unique challenges, including coordinating diverse teams, navigating ethical and methodological complexities, and addressing differences in education, practice, and healthcare systems. This reflective paper highlights key lessons learned in global research collaboration.

Research teams comprised of academics and clinical practitioners requires balancing the schedules of field clinicians and academics while accommodating multiple time zones for contemporaneous meeting planning and collaborative document drafting. Methodological challenges, such as aligning terminology and developing comparable survey instruments, require careful planning and flexibility. Ethical approval processes differ across countries, adding complexity for study administration that can lead to lengthy delays in launching a new project challenging research momentum.

Despite these challenges, international research collaboration offers significant returns enabling meaningful knowledge exchange, strengthening professional and institutional networks, and informing best practices across paramedic education and clinical care. The complexity of working across borders is outweighed by the depth of insight, cultural perspective, and shared learning that such collaborations produce. By sharing these experiences, we provide insights and recommendations for future global research teams, emphasising the importance of adaptability, clear communication, strong project management strategies and technology support, and strong partnerships in advancing paramedicine research.