Thinking beyond and through innovation and reform in paramedicine

Introduction

Across health professions, including paramedicine, professionalisation is rarely a simple story of maturation. Rather, professions seek out legitimacy through contested and uneven projects shaped by struggles over jurisdiction, scope, title, education, regulation and access to work.^1–3 It unfolds within the profession itself, and in relation to other professions, employers, government and funder interests, and changing models of care. ⁴ In that sense, professionalisation does not describe how a professional group achieves a collection of attributes, but rather it is a complex process of occupational change occurring in a particular sociopolitical context.

Accordingly, professionalisation is in reference to a key sociological concept defined by Larson, Abbott and others, which describes the ongoing process through which an occupation seeks to organise, legitimate, defend and reshape its work, knowledge, boundaries and authority in relation to other professions, the state and wider health system.^1–3 Processes of professionalisation are consequential as professions navigate who gets to define problems, who can claim a domain of practice and whose work remains subordinate, delegated or only partially recognised. As Bourgeault and Chamberland-Rowe (2023) argue, professionalisation is a continuous process whereby the division of labour, scope of practice, regulation and models of care are formed and remade. ⁵

For professionally engaged practitioners, policy-makers concerned with professionalisation and in particular, paramedicine researchers, this broader conceptual and theoretical framing of professional change matters. Paramedicine is often studied through service delivery, clinical outcomes, education, system reform and innovation. These are indispensable lines of inquiry. But they are also, in many cases, sites in which professionalisation is being pursued, negotiated or resisted. Underlying some of these inquiries are questions about how work is organised and defended, how new forms of practice become legitimate, and how professions position themselves within a changing health care context. Paramedicine research is more often focused on the intervention under study, rather than on what that intervention means for professionalisation or the profession itself. To study paramedicine in this way is not to move away from or replace practical questions; it is to ask what those practical developments are doing (or not): what they authorise, what they redistribute, how they exist next to other health professions, what they normalise or perpetuate and what they reveal about how the profession is being shaped.

Attention to professionalisation

This focus on professionalisation is not an abstract gap. A small body of international literature has adopted a sociological lens to examine paramedic professionalisation in the UK, Australia and Canada,^6–10 collectively revealing and contextualising the nuanced, socio-political and at times disjointed pathways of professional change in paramedicine. This sociological framing is not entirely new to paramedicine. Work by McCann and colleagues in the UK has already shown that paramedic professionalisation is a contested process of occupational change shaped by the organisation of work, status claims and evolving professional identity.^6,7

Additional papers published in Paramedicine point directly towards these issues. For example, a scoping review of the topic argues that self-regulation has intensified discussion of professional identity and standards, but also that professionalisation remain poorly defined and would benefit from broader theoretical engagement. ⁹ A recent commentary on paramedicine's evolving identity similarly argues that professional recognition depends on defining and understanding the profession's boundaries. ¹¹ Another editorial in the journal presses for stronger use of theory, theoretical frameworks and conceptual frameworks, ¹² while a recent special issue describes the field as being at an ‘inflection point’ marked by expanding scope, deeper health-system integration and the need for more coherent professional attention. ¹³ These contributions suggest that the journal is already circling questions of identity, boundary work and professional formation, even if not yet consistently framed as questions under the broad umbrella of the sociology of professions.

Sociology of professions and paramedicine

A sociology of professions lens helps to bring into focus how professions emerge in crowded fields already structured by professional hierarchy, government regulation, labour market pressures, public expectations and local socio-political conditions. For instance, the allied health literature shows how many professions developed under conditions of medical dominance, often through recurrent patterns of subordination, limitation or exclusion.^14–16 More recent sociology of professions scholarship conceptualises how professionalisation is shaped not only by interprofessional hierarchy, but by the state, policy and organisational reforms that enable, constrain or redirect professional projects.^4,14,17 Some occupations are permitted various degrees of autonomy, but only within tightly bounded jurisdictions. Others still struggle to secure legitimacy for their knowledge claims. These are not simply historical curiosities. They show that professionalisation is relational and politically mediated from the outset: one profession's advancement is often conditioned not only by other professions, but by the institutional and regulatory environments in which those struggles unfold.^1,18

Descriptions of interventions in paramedicine, broadly defined, are necessary, but insufficient. Regulatory reform, educational upgrading, new clinical frameworks, expanded care models, research agendas and service innovations may improve knowledge and practice, but they also shape jurisdiction, legitimacy, authority and identity. ¹⁹ These developments are not external to professionalisation; they are among the mechanisms through which professions are constituted, yet seldom studied in this way within paramedicine. They rarely unfold through professional agency alone, instead, emerging through compromise, political opportunity, organisational need and the regulatory and policy environments that permit some professional projects while limiting others.^2,4,14,20 Sociological perspectives make it possible to see growth not simply as implementation or improvement, but as a process of power, negotiation and partial achievement. A sociological perspective, therefore, helps distinguish between growth as implementation and growth as a negotiated, partial and politically mediated process, including the paths that are durable, deferred, constrained or abandoned.

Many developments in paramedicine can be read not only as reforms or innovations, but as activities in the profession's own making. For example, the ‘Principles to guide the future of paramedicine in Canada’, framed as a conceptual guide for the profession's future, can also be read as an intervention in professionalisation, one that articulates desired forms of autonomy, integration, accountability and evidence-informed practice, while identifying policy, regulation and legislation as enabling conditions for professional change. ²¹ Innovations and advancements are not merely technical, clinical, pedagogical or policy responses. They are also attempts to re-define the boundaries of what paramedicine is, what it should become, where it should sit in relation to other professions and the wider health system, and what kinds of work, knowledge and authority should belong to paramedics. Additional examples include:

Makrides and colleagues’ (2022) study on delegation models is useful as an analytical example. The authors suggest that Anglo-American paramedicine is not a singular professional form, but that it comprises at least two distinct sub-models with different relationships to delegated medical authority, professional autonomy, education, regulation and system integration. ²² From a sociological perspective, it provides a stimulus for examining how different organisational and regulatory arrangements shape professional authority, dependency and system location. As a result, it does more than classify systems. It creates an opportunity for studying how certain forms of professionalisation unfold differently across jurisdictions. Comparison matters here because those differences reveal that professionalisation is contingent, politically shaped and institutionally uneven rather than universal.

Community paramedicine is similarly instructive. It can be studied as a service innovation or health system response, but it is also an intentional or unintentional intervention in professionalisation. ¹⁰ Shannon and colleagues’ (2023) international Delphi study defines community paramedicine as a globally evolving model of care and shows that international consensus work is itself part of stabilising a new jurisdiction, including its qualifications, education, regulation and role boundaries. ²³ That is, international consensus work is not only definitional; it forms cohesion across the profession and is part of the work of making a role portable, legible and professionally credible across settings.

Education provides a third example. Corman and colleagues (2025) have argued that the future of paramedic education should be examined in relation to changing professional activities and demands. ²⁴ Others argue that education is increasingly implicated in professionalisation efforts, system innovation and wider health professions education research. ²⁵ Read sociologically, these are not only pedagogical debates. They are debates about who is authorised to enter the profession, what kind of knowledge counts, how legitimacy is secured and how the profession seeks to differentiate itself while remaining intelligible within wider health systems.

These are not trivial implementation details. They point to jurisdictional expansion, new boundary negotiations and new claims to legitimacy in spaces traditionally held by others. The point is not simply that paramedicine is changing, but that different kinds of change have different implications for the profession's authority, and jurisdiction, and the broader field of healthcare work. From a sociology-of-professions perspective, the issue is not only what claims are being made, but to whom they are being addressed: regulators, funders, other professions, employers, and the public all matter in determining whether (and which of) those claims become credible and durable. At stake in these processes are also questions of intraprofessional unity. ¹⁰ Professionalisation projects do not necessarily reflect collective action, or a shared professional interest. A sociological inquiry, therefore, asks who within the profession is able to define its future, whose voices are elevated or excluded, and which segments of the workforce stand to benefit from particular reforms.

One further reason to study professionalisation sociologically is that contemporary professional change may no longer be adequately understood only in terms of closure, title and autonomy. The literature on postprofessionalism points to an environment in which roles are increasingly re-engineered, tasks disaggregated, competencies codified and work redistributed across interprofessional and transdisciplinary arrangements, with implications for professional power or authority.^26,27 Professional legitimacy may depend less on owning an exclusive body of knowledge than on demonstrating transferability, standardisation and organisational or state usefulness. For paramedicine, this raises important questions about whether contemporary role expansion represents straightforward professional growth, a new form of hybridisation, or something closer to postprofessional workforce redesign.

Questions for the field

For paramedicine, this suggests a productive research agenda grounded in a sociological understanding of professional growth and change. Contemporary developments present a complex picture. The field would benefit from further studies of jurisdictional disputes, scope expansion, regulation, specialisation, labour mobility, educational reform, role development and interprofessional boundary work. It would benefit equally from more work that treats frameworks, reforms and innovations as interventions in the profession's own making. Such studies might take the form of comparative analyses of scope expansion, historical accounts of reforms that succeeded or stalled, policy studies of registration and regulatory change, or qualitative research examining how claims to legitimacy are negotiated among paramedics, governments, employers and other professions. They should also attend to what professional narratives often leave out: dependence as well as autonomy, exclusion as well as recognition and government shaping as well as occupational agency. The sociology of professions provides a rich set of resources for this work, including approaches attentive to equity, stratification and gender. ²⁸

Rather than asking only whether an intervention works, or even why, researchers might also ask: through what mechanisms, in which jurisdictions, under what conditions, and with what residual dependencies is paramedicine professionalising? To whom are these arguments addressed, and whose interests do they serve? Why are some reforms pursued while others are resisted? What kinds of professional futures are imagined in these initiatives? How are new jurisdictions being opened or closed? How are advanced and specialist roles altering internal dynamics? When scope expands, what kinds of work are being claimed, and what kinds remain contingent on medical authorisation, legislative amendment or organisational tolerance? Under what conditions do new competencies translate into durable authority rather than temporary role extension?

This seems an especially productive moment for Paramedicine to encourage scholarship that treats professionalisation as an open empirical and theoretical problem. If the field studies only innovation, reform and effectiveness, it risks mistaking activity for profession advancement. The pressing question is how, for whom and at what cost particular forms of change are taking place. A sociology of professions perspective brings those stakes and sharpens what the field is able to discuss and claim about its own development.