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From frontline to forefront: paramedics as healthcare leaders within the NHS
Abstract
The NHS in the UK faces numerous challenges, including increasing demand for services, financial constraints and the need for effective leadership. Paramedics are exceptional healthcare leaders within the NHS in the UK, possessing unique skill sets and experiences that make them invaluable in leadership roles. Their clinical expertise, decisive decision-making abilities, and adaptability, honed in challenging frontline environments, are crucial assets in healthcare leadership. Transformational and situational leadership theories align seamlessly with paramedic practice, showcasing their ability to inspire teams and effectively navigate diverse healthcare scenarios. Evidence demonstrates paramedics' significant positive impact on patient care, organisational performance, and healthcare innovation when in leadership positions. Despite their capabilities, challenges persist, including historical professional hierarchies and underrepresentation of certain groups in leadership. A new framework for developing paramedic leaders addresses these issues, emphasising targeted training, interprofessional collaboration, and inclusive practices. Recommendations include implementing comprehensive leadership development programmes, enhancing incident scene management training, and addressing psychological factors affecting leadership effectiveness. By fully recognising and nurturing paramedic leadership, the NHS can leverage their unique perspectives to create a more resilient, efficient, and patient-centred healthcare system to meet current and future challenges.
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Objectives
Patient assessment is a fundamental feature of community paramedicine, but the absence of a recognized standard for assessment practices contributes to uncertainty about what drives care planning and treatment decisions. Our objective was to summarize the content of assessment instruments and describe the state of current practice in community paramedicine home visit programs.
Methods
We performed an environmental scan of all community paramedicine programs in Ontario, Canada, and used content analysis to describe current assessment practices in home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy.
Results
A total of 43 of 52 paramedic services in Ontario, Canada, participated in the environmental scan with 24 being eligible for further investigation through content analysis of intake assessment forms. Among the 24 services, 16 met inclusion criteria for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Most assessments included some content from each of the domains outlined in the ICF. At the subdomain level, only assessment of impairments of the functions of the cardiovascular, hematological, immunological, and respiratory systems appeared in all assessments.
Conclusion
Although community paramedicine home visit programs may differ in design and aim, all complete multi-domain assessments as part of patient intake. If community paramedicine home visit programs share similar characteristics but assess patients differently, it is difficult to expect that the resulting referrals, care planning, treatments, or interventions will be similar.
This short essay supports the growing role of paramedics in the clinical and academic workforce. We present a commentary of recent draft consultations by the National Institute for Health and Care Excellence in England that set out how the role of paramedics may be evolving to assist with the changing demands on the clinical workforce. Using these consultations as a basis, we extend their recommendations and suggest that the profession should also lead the academically driven evaluation of these new roles.
Over the past 2 decades, as part of reforms to the National Health Service and with it organizational changes to ambulance work in the UK, paramedic education has undergone a process of academisation and a shift from in-house, apprenticeship weeks-long occupational training, to university-based undergraduate programs. While the professional regulation and standardization of Allied Health Professionals’ education in high-income countries has captured scholarly attention, the study of paramedic practice is still in its infancy and there is a need to explore its evolvement in relation to the fluid societal–political circumstances affecting its provision and demand. Based on interviews with front-line paramedics, paramedic educators and paramedic science students in the South of England, this article examines how the reforms to paramedic education have impacted the professionalization of paramedics and their discourse of professionalism. Framed within to the ‘new’ sociology of professions, the case of British paramedics demonstrates the complex nature of the relationship between the university and professional practice. It appears that universities, the providers of paramedic education, are caught between two opposing discourses of professionalism: on the one hand, that of providing a platform for students’ socialization and engagement with professionalism ‘from within’ practice which is based on students’ common goals and mutual experiences, and, on the other hand, serving as a conduit for managerial/organizational strategies of professionalism which appear to undermine the role of university socialization.
Background
Paramedicine is a rapidly evolving health profession with increasing responsibilities and contributions to healthcare. This rapid growth has left the profession with unclear professional and clinical boundaries. Existing defining frameworks may no longer align with the practice of paramedicine or expectations of the public. The purpose of this study was to explore the roles paramedics in Canada are to embody and that align with or support the rapid and ongoing evolution of the profession. Methods
We used a concurrent mixed methods study design involving a focused discourse analysis (i.e., analysis of language used to describe paramedics and paramedicine) of peer reviewed and grey literature (Phase 1) and in-depth one-on-one semi-structured interviews with key informants in Canadian paramedicine (Phase 2). Data from both methods were analyzed simultaneously throughout and after being merged using inductive thematic analysis. ResultsSaturation was reached after 99 national and international grey and peer reviewed publications and 20 in depth interviews with stakeholders representing six provinces, seven different service/agency types, 11 operational roles and seven provider roles. After merging both data sets three framing concepts, six roles and four crosscutting themes emerged that may be significant to both present-day practice and aspirational. Framing concepts, which provide context, include variable contexts or practice, embedded relationships and a health and social continuum. Roles include clinician, health and social advocate, team member, educator, professional and reflective practitioner. Crosscutting themes including patient safety, adaptability, compassion and communication appear to exist in all roles. Conclusions
The paramedic profession is experiencing a shift that appears to deviate or at least place a tension on traditional views or models of practice. Underlying and evolving notions of practice are resulting in intended or actual clinical and professional boundaries that may require the profession to re-think how it is defined and/or shaped. Until these framing concepts, roles and crosscutting themes are fully understood, tested and operationalized, tensions between guiding frameworks and actual or intended practice may persist.
Background
Community paramedicine programs have emerged throughout North America and beyond in response to demographic changes and health system reform. Our aim was to identify and analyse how community paramedics create and maintain new role boundaries and identities in terms of flexibility and permeability and through this develop and frame a coherent community paramedicine model of care that distinguish the model from other innovations in paramedic service delivery.
Methods
Using an observational ethnographic case study approach, we collected data through interviews, focus groups and field observations. We then applied a combination of thematic analysis techniques and boundary theory to develop a community paramedicine model of care.
Results
A model of care that distinguishes community paramedicine from other paramedic service innovations emerged that follows the mnemonic RESPIGHT: Response to emergencies; Engaging with communities; Situated practice; Primary health care; Integration with health, aged care and social services; Governance and leadership; Higher education; Treatment and transport options.
Conclusions
Community engagement and situated practice distinguish community paramedicine models of care from other paramedicine and out-of-hospital health care models. Successful community paramedicine programs are integrated with health, aged care and social services and benefit from strong governance and paramedic leadership.
p> SUMMARY
In Australia, the last decade has witnessed considerable changes to both the scope of paramedic practice and the education of these practitioners. Notably within education, there has been a national trend to move from on-the-job training, towards a pre-employment, undergraduate university qualification. Despite increases in depth, breath and consistency to the curriculum and delivery by subject experts with training in education, criticism remains targeted at the preparation of the graduate for readiness to undertake the paramedic role. Australian undergraduate courses are currently experiencing unprecedented enrolment numbers, with complex student learning expectations and requirements. Producing work ready graduates within traditional curriculum frameworks is a challenge. Capstone courses target the final preparation of the graduating student, with a strong emphasis on articulating them successfully with their chosen industrial settings. While widely accepted in other disciplines, such as engineering, capstone is a new concept to paramedicine. This paper discusses how a capstone topic was created and implemented at Flinders University within the Bachelor of Paramedic Science degree. It describes the differentiated student learning methodology employed and the strategies used to respond to specific student and industry concerns regarding university teaching.</p
This volume provides fresh insights and management understanding of the changing role of the ambulance services against the backdrop of massive cuts in health budgets around the world and the changing context of pre-hospital care within the wider healthcare networks. The challenges of funding, training and cultural transformation are now felt globally. The need to learn and adapt from suitable models of ambulance service delivery have never been greater. The book offers critical insights into the theory and practice of strategic and operational management of ambulance services and the leadership needs for the service. One of the highlight of this volume is to bring together scholarship using experts- academics, practitioners and professionals in the field, to each of the chosen topics. The chapters are based in the practical experiences of the authors and are written in a way that is accessible and suitable for a range of audiences. We are confident that this book will cater to a wider audience to inform policy and practice, both in the UK and internationally.
As demand for Emergency Department (ED) services continues to exceed increases explained by population growth, strategies to reduce ED presentations are being explored. The concept of ambulance paramedics providing an alternative model of care to the current default 'see and transport to ED' has intuitive appeal and has been implemented in several locations around the world. The premise is that for certain non-critically ill patients, the Extended Care Paramedic (ECP) can either 'see and treat' or 'see and refer' to another primary or community care practitioner, rather than transport to hospital. However, there has been little rigorous investigation of which types of patients can be safely identified and managed in the community, or the impact of ECPs on ED attendance.
St John Ambulance Western Australia paramedics will indicate on the electronic patient care record (e-PCR) of patients attended in the Perth metropolitan area if they consider them to be suitable to be managed in the community. 'Follow-up' will examine these patients using ED data to determine the patient's disposition from the ED. A clinical panel will then develop a protocol to identify those patients who can be safely managed in the community. Paramedics will then assess patients against the derived ECP protocols and identify those deemed suitable to 'see and treat' or 'see and refer'. The ED disposition (and other clinical outcomes) of these 'ECP protocol identified' patients will enable us to assess whether it would have been appropriate to manage these patients in the community. We will also 'track' re-presentations to EDs within seven days of the initial presentation. This is a 'virtual experiment' with no direct involvement of patients or changes in clinical practice. A systems modelling approach will be used to assess the likely impact on ED crowding.
To date the efficacy, cost-effectiveness and safety of alternative community-based models of emergency care have not been rigorously investigated. This study will inform the development of ECP protocols through the identification of types of patient presentation that can be considered both safe and appropriate for paramedics to manage in the community.
Three versions of the leadership dynamics derived from Hersey and Blanchard's Situational Leadership Theory were identified: (1) the original, 1972, statement of the theory; (2) the revised, 2007, theory; and (3) an alternative statement of the theory's essential principle of differential follower response to “autonomy afforded by the leader” in conjunction with “follower developmental level” (as indexed by employee job experience). Survey data collected from 357 banking employees and 80 supervisors, sampled from 10 Norwegian financial institutions, were analyzed for predicted interactions. Results indicated that the 2007 revised theory was a poorer predictor of subordinate performance and attitudes than the original version. The third, alternative, version (which predicted an autonomy × job experience interaction) offered promise for further exploration of the theory's essential principle that employee outcomes are associated with prescribed leader behaviors in combination with follower developmental level, although this version also did not add substantially to accounting for criterion variance.
IntroductionLike other public safety professions, paramedicine has historically been a male-dominated occupation. Although women are increasingly choosing paramedicine as a career, participation in leadership roles remains limited. Drawing on data from a comprehensive mental health survey, we describe the proportion of women in leadership in a single, large, urban paramedic service in Ontario, Canada.Methods
We distributed an in-person, paper-based survey during the fall 2019 - winter 2020 continuing medical education sessions. Participating paramedics completed a demographic questionnaire alongside a battery of mental health screening tools. We assessed the demography of the workforce and explored differences in employment classification, educational achievement, clinician level (e.g., primary vs. advanced care), and participation in formal leadership roles along self-reported gender lines.ResultsOut of 607 paramedics attending, we received 600 completed surveys, with 11 excluded for missing data, leaving 589 for analysis and a 97% response rate. Women comprised 40% of the active-duty paramedic workforce, with an average of 8 years of experience. Compared to men, women were more than twice as likely to have university degrees (odds ratio [OR] 2.02, 95% compatibility interval [CI] 1.45-2.83), but almost half as likely to practice at the advanced care paramedic level (OR 0.61, 95% CI 0.42-0.88), and potentially less likely to be employed full-time (OR 0.77, 95% CI 0.54-1.09). Women were nearly 70% less likely to hold leadership roles in the service compared to men (OR 0.36, 95% CI 0.14-0.90), occupying 20% of leadership positions.Conclusion
Although paramedicine is witnessing an encouraging shift in the demography of its workforce, our results point to a potential under-representation of women in leadership roles. Future research should focus on identifying and ameliorating barriers to career advancement among women and other historically underrepresented people.
Purpose
There is a growing academic interest in the examination and exploration of work intensification in a wide range of healthcare settings. The purpose of this paper is to explore the differing staff perceptions in emergency ambulance services in the UK. It provides evidence on the challenges for the paramedic professionalisation agenda and managing operational demands and work intensity in emotionally challenging circumstances, with significant implications for patient safety.
Design/methodology/approach
Drawing on the evidence from an empirical study in a large National Health Service ambulance trust in England, this paper examines the challenges and differing staff perceptions of the changing scope and practice of ambulance personnel in the UK. Amidst the progress on the professionalisation of the paramedic agenda, individual trusts are facing challenges in form of staff attitudes towards meeting performance targets, coupled with rising demand, fear of loss of contracts and private competition.
Findings
Research findings highlight differing perceptions from various sub-cultural groups and lack of clarity over the core values which are reinforced by cultural and management differences. Need for greater management to explore the relationship between high sickness levels and implications for patient safety including the need for policy and research attention follows from this study. The implications of work intensity on gender equality within the ambulance settings are also discussed.
Research limitations/implications
Ambulance services around the world are witnessing a strain on their operational budgets with increasing demand for their services. Study evidence support inconclusive evidence for patent safety despite the growing specialist paramedic roles. Organisational implications of high staff sickness rates have been largely overlooked in the management literature. This study makes an original contribution while building upon the earlier conceptions of work intensification.
Practical implications
The study findings have significant implications for the ambulance services for better understanding of the staff perceptions on work intensity and implications for patient safety, high sickness absence rates amidst increasing ambulance demand. Study findings will help prepare the organisational policies and design appropriate response.
Social implications
Societal understanding about the organisational implications of the work intensity in an important emergency response service will encourage further debate and discussion.
Originality/value
This study makes an original contribution by providing insights into the intra-organisational dynamics in an unusual organisational setting of the emergency ambulance services. Study findings have implications for further research inquiry into staff illness, patient safety and gender issues in ambulance services. Evidence cited in the paper has further relevance to ambulance services globally.
Models addressing urgent clinical needs for older adults with multiple advanced chronic conditions are lacking. This observational study describes a Community Paramedicine (CP) model for treatment of acute medical conditions within an Advanced Illness Management (AIM) program, and compares its effect on emergency department (ED) use and subsequent hospitalization with that of traditional emergency medical services (EMS). Community paramedics were trained to evaluate and, with telemedicine-enhanced physician guidance, treat acute illnesses in individuals' homes. They were also able to transport to the ED if needed. The CP model was implemented between January 1, 2014, and April 30, 2015 in a suburban-urban AIM program. Participants included 1,602 individuals enrolled in the AIM program with high rates of dementia, decubitus ulcers, diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease. Participants had a median age of 83 and an average of five activity of daily living dependencies (range 0-6). During the study period, there were 664 CP responses and 1,091 traditional EMS transports to the ED among 773 individuals. Only 22% of CP responses required transport; 78% were evaluated and treated in the home. Individuals that community paramedics transported to the ED had higher rates of hospitalization (82.2%) than those using traditional EMS (68.9%) (P < .001). Post-CP surveys showed that all respondents felt the program was of high quality. Results support the potential benefits of CP and invite further evaluation of this innovative care model.
Background:
Health care organizations are considered complex systems that represent both formal leadership as well as more informal and shared leadership models. Implementing these models is essential for optimizing care and patient outcomes. The paramedic profession specifically, although considered informally, leads out of hospital patient care.
Purpose:
To date, few empirical studies investigate shared leadership in health care settings. In paramedicine specifically, studies of leadership are scarce, despite paramedics' essential role in leading on the front lines of care. Using an exemplar of paramedics, we examine what it means to informally lead on the front lines of patient care with the emphasis on paramedics responding out of hospital.
Methodology:
We employed a qualitative, semistructured interview methodology with 29 paramedics from a group of companies in central/eastern Canada to explore the conditions and practices surrounding shared leadership.
Findings:
Paramedics argue that, despite their job title, they classify themselves as informal leaders who share the leadership role. More specifically, the paramedics discuss the precursors, practices, and structural conditions surrounding shared leadership within the realm of emergency medical services. They note that they often face out-of-hospital care without a formal manager, requiring them to collectively lead. The leader will shift in times of urgency, and this is contingent on their skills and competence. Furthermore, managers routinely called upon paramedics to lead in their absence.
Practice implications:
It is shown here that, although informally enacted, paramedics view leadership as a necessary competency for clinical practice. We argue that leadership development of paramedics must begin during their formal education and training as part of the core curriculum. As well, direct managers can promote an environment of shared leadership and encourage paramedics to practice leadership with quality of patient service in mind.
Previous research has identified that paramedics experience high levels of stress and sickness rates which have escalated in recent years due to changes to workforce restructuring. While a number of studies have investigated resilience among healthcare professionals, there is little research exploring how paramedics address work challenges and how they become resilient. Using psycho-social methodology, seven paramedics participated in Free Association Narrative interviewing; all were based at one regional centre. In line with the study design, data analysis adopted a psycho-social approach that generated four themes and 10 sub-themes which, characterised participants' experiences. Coping and resilience was impacted upon via formal methods of support including management, debriefing and referral to outside agencies. Alongside this, more informal methods aided resilience. Informal methods included peer support, support from family and friends and the use of humour. Uniquely, this study uncovered how detachment is used to manage emotions. The study has implications for the services need to support the emotional needs of paramedics.
Transformational Leadership, Second Edition is intended for both the scholars and serious students of leadership. It is a comprehensive review of theorizing and empirical research that can serve as a reference and starting point for additional research on the theory. It can be used as a supplementary textbook in an intense course on leadership--or as a primary text in a course or seminar focusing on transformational leadership. New in the Second Edition: New, updated examples of leadership have been included to help illustrate the concepts, as well as show the broad range of transformational leadership in a variety of settings. New chapters have been added focusing specifically on the measurement of transformational leadership and transformational leadership and effectiveness. The discussion of both predicators and effects of transformational leadership is greatly expanded. Much more emphasis is given to authentic vs. inauthentic transformational leadership. Suggestions are made for guiding the future of research and applications of transformational leadership. © 2006 by Lawrence Erlbaum Associates, Inc. All rights reserved.
Paramedic education has been undergoing major development in Australia in the past 20 years, with many different educational programmes being developed across all Australian jurisdictions. This paper aims to review the current paramedic education programmes in Australia to identify the similarities and differences between the programmes, and the strengths and challenges in these programmes. A literature search was performed using six scientific databases to identify any systematic reviews, literature reviews or relevant articles on the topic. Additional searches included journal articles and text references from 1995 to 2011. The search was conducted during December 2010 and November 2011. Included in this review are a total of 28 articles, which are focused around five major issues in paramedic education: (i) principle on paramedic programmes and the involvement of industry partners; (ii) clinical placements; (iii) contemporary methods of education; (iv) needs for specific programmes within paramedic education; and (v) articles related to the accreditation process for paramedic programmes. Paramedic programmes across Australian universities vary with many different practices, especially relating to clinical placements in the field. The further advances of the paramedic education programmes should aim to respond to population change and industry development, which would enhance the paramedic profession across Australia.