Community Paramedic Education
Responding to the challenges of an evolving profession
July 2012 Today’s health policy emphasizes the ongoing shift toward community based primary and secondary care services, yet for the most part the paramedic profession has not yet fully embraced this opportunity (Ruston & Tavabie, 2011).
This health policy has brought with it the expectation that those requiring care — including urgent care — be treated closer to home (Ruston & Tavabie, 2011). According to Ruston & Tavabie (2011, p.168), urgent care has been defined as “the range of responses that health and social care services provide to people who require – or who perceive the need for – urgent advice, diagnosis or treatment.”
Evidence has shown the public does in fact find the current health system confusing and complex when it comes to accessing urgent health-care services; and to this end paramedics continue to act as an important gateway into the health-care system notwithstanding the introduction of alternative urgent care services such as medi-centres and walk-in clinics (Ruston & Tavabie, 2011).
The issue at hand is not only the relative slow response of the profession to address and adjust to these new opportunities but also the increasing number of individuals who are dialing 9-1-1 have an underlying chronic condition for which they could potentially be treated for within the primary care setting (1) (Ruston & Tavabie, 2011). This continues to be the founding reason for community paramedicine and Ruston & Tavabie (2011, p. 168) support this by stating “as a mobile health resource the ambulance service (and paramedics) has the potential to ensure that patients get the right quality of care, at the right time and in the right place.”
But how do we, as a profession take the next step to ensure that the opportunities and challenges within the current health-care system are seized? Great strides have been achieved across the pond in the United Kingdom with respect to these opportunities and challenges. The UK paramedic setting has experienced a gradual change in paramedic education that has moved away from the traditional and basic acquisition of clinical skills in favour of developing an autonomous practitioner (Ruston & Tavabie, 2011). This has resulted in the creation of a number of education and training programs aimed at developing what the UK considers to be “advanced” emergency care practitioners (ECPs) capable of assessing, treating and discharging/referring patients at the scene (Ruston & Tavabie, 2011). The so-called autonomous practitioner program is offered by St George’s/Kingston University and the South East Coast Ambulance Service (SECAmb) and aims to address the clinical limitations of the emergency care practitioner program. The autonomous practitioner curriculum was developed and written in collaboration the Kent, Surrey and Sussex Deanery (2) with paramedic practitioner students being educated under an apprenticeship learning model with accredited workplace-based teaching and assessment (Ruston & Tavabie, 2011). The program pilot offered placements in a variety of health-care settings including a general practice training placement consisting of a two-month placement followed by a final “sign off” placement.
Paramedics take part in a training exercise. From Canadian Paramedicine archives.
The apprenticeship model is based on Vygotsky’s theories of learning (1). The first idea is the zone of proximal development. This refers to the activities and tasks a learner is unable to complete without the assistance of an expert. The second idea is expert scaffolding; this represents a situation in which a learner experiences a particular cognitive activity in collaboration with an expert practitioner. Initially this is accomplished as a spectator with most of the cognitive work being done by the expert. Then, gradually the learner assumes a more in-depth role under the supervision of the expert until the learner is capable of assuming full responsibility for the activities and tasks (Ruston & Tavabie, 2011).
This process culminates in the learner and expert engaging in a cooperative dialogue that enhances the learning experience. This apprenticeship model within general practice has been defines by Ruston & Tavabie (2011, p.169) as “education and service blended together for professional growth through legitimate peripheral participation in a community of practice.” This process not only allows for modeling of skills but also of values; the transfer of learning is said to take place visually and subconsciously through the observation of good practice leading to the reinforcement of basic principles and the integration of topics with the achievement of higher levels of complexity (Ruston & Tavabie, 2011).
The rationale for the general practice placement was to support paramedic students to:
- Become autonomous practitioners with the appropriate skills, knowledge and understanding to be able to work effectively within primary care;
- Be exposed to a wide range of patients and conditions;
- Gain an understanding of the work and ethics of the primary health-care team;
- Develop their diagnostic, assessment, consulting and communication skills; and
- Exposure to collaborative working in general practice. (Ruston & Tavabie, 2011)
On the East Coast of Tasmania, emergency care does not simply end on the hospital doorstep; rather it involves co-operation between paramedics and hospital staff in the ongoing care of patients (Mulholland et al., 2009). Due the system design in this region of Tasmania (paramedic services been primarily a volunteer system delivery) physicians and other health-care practitioners who were previously involved in after hours call outs as well as various other time-consuming tasks have now been freed by the expanded scope and role paramedics play in these communities (Mulholland et al., 2009).
Paramedics have been welcomed as part of the health-care team in this part of the world and have been presented with the opportunity of developing effective working relationships with hospital staff and physicians, other volunteers and members of the community. An important part of these various relationships is the health education (health promotion) delivered by paramedics (Mulholland et al., 2009).
The paramedic profession is slowly coming of age and realizing that regardless of the setting, urban or rural emergency response is only a small part of paramedic practice (Mulholland, et. al., 2009). The elements important in paramedic practice to achieve a multidisciplinary and community-based response to patient care are community involvement, organizational support, professional support and appropriate training as demonstrated by the UK example (Mulholland et al., 2009).
Emergency response is not all lights and sirens, as Mulholland et al. (2009) revealed. A paramedic’s role is without exception first response to emergency cases. A deeper examination revealed that emergency response was not only about “lights and sirens,” but rather that paramedics’ role encompassed several intertwined layers.
The picture that emerges from this multidisciplinary focus is an extended role for paramedic practice that reaches far beyond specific skills or task substitutions (Mulholland et al., 2009). It is obviously very easy to think of paramedics providing “light and sirens” response to medical and traumatic emergencies, however much of the elements in paramedic practice are ingrained in a foundation of informality. A transition from informality to a more formal design and framework would enable paramedic practice to ultimately emerge as a health-care discipline in its own right and be considered as an integral part of the multidisciplinary health-care team at last (Mulholland et al., 2009).