Análisis de resultados

The HCPC publish several documents that inform its registrants about the standards required of them, such as the standards of proficiency and the standards of conduct performance and ethics (HCPC, 2014; HCPC, 2018c). These are broad in nature and in the context of the large scope of practice already discussed it is easy to see how this presents some very real challenges for paramedic registrants.

10 College of Paramedics

The CoP Curriculum Guidance document (CoP, 2019) concurs with HCPC standards of proficiency in specifying the need for a paramedic to be able to manage patients ranging from the preterm infant to the older adult. The guidance specifies that care may involve assessment, treatment and management of a patient ranging from a minor to a complex nature. It is worth remembering that within this context, many minor illnesses/injuries can actually be very complex to deal with and attract the greatest amount of litigation within healthcare (AACE, 2011).

The latest iteration of the curriculum guidance document highlights the need for a ‘spiral curriculum’, where subjects can be revisited at deeper knowledge levels and understanding as paramedics progress through their careers. This demonstrates a need for advancing cognitive ability and knowledge, and highlights a clear career pathway that promotes lifelong learning/development in order to ‘keep up’ with the demands of the role (CoP, 2019). The ideology behind this is sound; however, maintaining standard paramedic skills whilst progressing through a career or managing an expanding skill-set is a large challenge for paramedics.

The CoP Post Registration paramedic Career Framework document describes the development of the contemporary paramedic role and the wide variety of clinical positions that can be held by paramedics (CoP, 2018b). Figure 1.1 shows this in pictorial form. The same document defines four separate pillars of development which can also be seen in the outer ring of figure 1.1 (clinical practice, leadership and management, research and development, and education), these acknowledge that paramedics will develop and specialise in various domains/combinations of domains following graduation, partially due to the variety of practice areas already

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mentioned and the challenges in maintaining advanced knowledge and skill in all areas of practice.

Figure 1.1, College of Paramedics, Career Framework 2018 (CoP, 2018b)

The Health Education England document, Multi-professional Framework for Advanced Clinical Practice in England built on the idea of the postgraduate

paramedic role. It explained the role of Advanced Care Practitioners, coming from various professional backgrounds (including paramedicine), educated to level 7 and able to provide high quality care by focussing on the patients situation needs rather than their own role (England, 2017). Following this the HEE paramedic specialist in Primary and Urgent Care Core Capabilities Framework was written, with significant input from paramedics and is endorsement by the CoP. It demonstrates further, that

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the role of the paramedic has expanded and therefore specific guidance is required to work in certain areas, such as primary and urgent care. It uses the CoP four pillars of development already discussed to do this. The same document qualifies that in addition to any new knowledge/skills required to work on various specialist roles, a paramedic must continue to meet the professional standards set by the HCPC (HEE, 2019).

Further contextual background relating to the Health and Care Professions Council and the College of Paramedics can be found in appendix 1.

Training/Education

The paramedics working within UK ambulance services have currently come through various education routes, such as traditional HEI full time, various ‘bridging’ part time and ambulance service ‘in-house’ programmes overseen by the IHCD.

Paramedicine has long been considered a vocational career (Bradley, 2005; Cooper, 2005); however, contemporary discussion has supported the evolution of ambulance service education becoming solely HEI based (AACE, 2011; Bradley, 2005; Cooper, 2005; CoP, 2019; Lovegrove & Davis, 2013), something now definitely set to happen following the Paramedic Evidence- Based Education Project. This document asserted that the change would reflect the challenging work undertaken by those practising in the contemporary paramedic role (Lovegrove & Davis, 2013). Following a consultation period in 2018, the HCPC decided to support this, a deadline of September 2021 was set, whereby approval for any non-BSc (Hons) degree programme will be withdrawn by the HCPC (HCPC, 2018b). The HCPCs Standards of Education

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and Training (SETs), ensure that programmes resulting in paramedic registration for successful candidates meet regulatory body requirements (HCPC, 2018a), preparing students for registration and practice. Therefore, graduates of HCPC approved university paramedicine programmes should, as previously mentioned, on graduation, be able to demonstrate that they meet the standards of proficiency at threshold level (HCPC, 2014).

Government Policy

The rapidly advancing professionalisation of paramedics, triggered largely by

government policy, has seen them expanding their practice in multiple areas already discussed. This is demonstrated best in the Taking Healthcare to the Patient

publications, 1 & 2 (AACE, 2011; Bradley, 2005).

Within the urgent and emergency care context, growing emphasis has been placed on treatment in the community, rather than arbitrary transportation to hospital, this was widely discussed in a review of urgent and emergency care provision

(NHSEngland, 2015). In parallel with this, the public expectation of paramedics has increased along with the growing paramedic skill-set (Bradley, 2005; Edwards, 2014). These factors mean that there is now a far greater drive for paramedics to treat patients at home or refer them to other services, rather than simply transport them to hospital (Bradley, 2005; CoP, 2018a; CoP, 2019; Petter & Armitage, 2012), requiring greater knowledge and skill from the clinician.

The opposite end of the assessment and treatment spectrum for paramedics has seen a drive to improve the care provided for the seriously injured patient, as can be seen with publications from the National Audit Office (NAO) and the National

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NCEPOD, 2007). This obviously does require transport to hospital as well as the execution of various clinical procedures. Serious illness and management of patients is also constantly under development/review with guidelines such as the recent National Institute for Clinical Excellence (NICE) guideline for the recognition, diagnosis and management of sepsis (NICE, 2016) and the multiple reviews of the 2008 guideline for the management of Stroke and transient ischaemic attack (NICE, 2008).

These developments have resulted in the introduction of new equipment, skills and patient management pathways for paramedics to use. Many of these new

skills/pathways focus on managing patients with specific life

threatening emergencies, a patient group accounting for a what is suggested as less than 10% of ambulance service workload and thought to be less than 0.2% of NHS emergency department workload (Bradley, 2005; NAO, 2010; NCEPOD, 2007). The result of this situation is that there are now multiple paramedic skills/incident types that may be used/encountered very infrequently.

Paramedic practice is further complicated by a consistent trend of rising ambulance service use by the public (Edwards, 2014), meaning there is little time to engage in practise/simulation within the normal working day. This concern was identified by paramedics in relation to opportunities for continued professional development (Cooper, 2005). The same study highlighted that prior to the advent of HEI

education, paramedics would undergo a five yearly recertification, including hospital placements; research suggested that despite the lengthy timescale, this maintained their confidence by revisiting rarely practised skills (Cooper, 2005).

The issues around increased skills sets, increasing demand for ambulance services and rising public expectation highlight potential challenges within paramedic practice

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relating to confidence and competence due to pressure and expectation; they also potentially impact on the following in relation to service delivery:

 Patient safety

 Public confidence in the paramedic profession

 Organisational liability for ambulance services

 Training/education needs of ambulance services

The above situation has created an environment whereby the paramedic role has been in a varying but constant state of flux since its inception.

In summary, there has been an expansion of paramedic roles including changes in skill sets and practice environments, alterations in the educational setting and

content and increasing work demands. This has led to a wide range of required skills some of which are complex but infrequently used, with a reduction in working hours practise time. This in turn could impact on paramedics’ confidence as well as actual and perceived competence. Competence could in part reflect the complexity of a skill. What is a skill and how it varies in complexity will be explored in the next section.