In the early 1970s further changes to the size and shape of the ambulance vehicles facilitated advancements in the treatment offered by paramedics before reaching hospital. The ambulance as a mobile intensive care unit was flagged as a model that could help produce better outcomes for patients. The model was trialled for three months. The training required ambulance officers to work a roster alongside a doctor at the hospital in
265 Technical and Further Education Board, Certificate of Applied Science: Ambulance Officer: Course
Prepared for Ambulance Officers’ Training Centre, Ambulance Service of Victoria (Education Department (Vic), 1979).
266 Sally Wilde, From Driver to Paramedic: A History of the Training of Ambulance Officers in Victoria
(Ambulance Officers Training Centre, 1999).
267 Ian Kaye-Eddie, A Short History of the Convention of Ambulance Authorities 1962–1995 (St John
cardiology, emergency, coronary and intensive care before going out on the road. The type of skills that paramedics were performing had previously been performed only by doctors. These included intubation and cannulation. Initially doctors attended patients along with the ambulance officers. Eventually it was acknowledged that the ambulance officers were suitably skilled to carry out the protocols and procedures the doctors had developed without medical oversight.268 Confidence in the ability of the ambulance staff increased and the range of work they attended broadened. It was recognised that they could play an instrumental role in assisting patients to better outcomes if definitive and advanced interventions were applied early, in cases not only of motor accidents and cardiac events but also in drug overdoses, gunshot wounds and industrial accidents.269 This was evidence of the discipline’s continuing professionalisation. Not only were paramedics extending their knowledge, skills and training to undertake their unique work; they were slowly gaining control over their own work in the sense that although they were legally required to adhere to their employer’s clinical practice guidelines, paramedics were not working under the immediate authority of a doctor or a nurse.
By 1975 NSW had begun trialling the model of an extended scope of practice ambulance officer who was referred to, for the first time, as a ‘paramedic’.270 Tasmania, South Australia, Queensland, Northern Territory and the Australian Capital Territory (ACT) all followed with various forms of advanced life support training.
3.5.1A Shift to the Tertiary Sector
The early 1990s saw a standardisation of skills and training that was designed to allow for national recognition and mobility.271 The qualification was undertaken in an apprentice- style, vocation-based approach with people being employed by the various state ambulance authorities and then enrolled in the course; thus, the process was not controlled by the discipline but rather by the employers of ambulance officers. Ambulance personnel undertook the course while working full time. There was a stratification of skill level and title within most state-based ambulance services. In NSW for example, the preliminary
268 Sally Wilde, From Driver to Paramedic: A History of the Training of Ambulance Officers in Victoria
(Ambulance Officers Training Centre, 1999) 90.
269 Ibid.
270 ASNSW <http://www.ambulance.nsw.gov.au/about-us/History.html>.
271 Gerry Fitzgerald and Ray Bange, ‘Defining a Regulatory Framework for Paramedics: A Discussion
training at the base level was undertaken by all paramedics with staff moving from level I to level III over three years of vocational curriculum work supported by practical experience. Staff could remain at level III and be considered a fully qualified ambulance officer. If staff wished to extend their scope of practice they were able to apply in a competitive process to undertake advanced training at level IV and intensive care training at level V. However, the credential awarded had shifted beyond a certificate-level qualification to a diploma with a base-level ambulance officer requiring a Diploma of Paramedical Science (Pre-Hospital Care). More advanced levels of practice with greater skills required higher qualifications, the highest being the Advanced Diploma of Paramedical Science (Pre-Hospital Care) for Level V officers.272
In 1994 the first degree qualification was developed for ambulance officers at Charles Sturt University in NSW; a similar program was offered by Victoria University the following year.273 The degree qualification was offered as a full pre-employment qualification, a model that had not been previously offered. Nursing had moved to the tertiary sector only five years previously to increase the professional status of nurses. Another reason for the move was that apprenticeship-based form of nursing education was too costly for the state to continue to subsidise and so the training shifted to the tertiary sector where it could receive federal funding and be subsidised by the student.274 The same financial pressures did not apply to paramedics because there were fewer of them and therefore training costs were lower; but as with nursing, there was a decision to shift paramedic education to the tertiary sector to progress the professionalisation of the discipline.275 However, unlike the situation with nursing, this decision was not made by members of the discipline; it was made in NSW by Charles Sturt University and the ASNSW.
272 ASNSW <http://www.ambulance.nsw.gov.au/about-us/History.html>.
273 Bill Lord, ‘The Development of a Degree Qualification for Paramedics at Charles Sturt University’
(2003) 1 Australasian Journal of Paramedicine.
274 Steering Committee for the National Review of Nurse Education in the Higher Education Sector,
Parliament of Australia, Nursing Education in Australian Universities: Report of the National Review of
Nurse Education in the Higher Education Sector—1994 and Beyond (1995) Collegian 2.2: 18-22.
275 Bill Lord, ‘The Development of a Degree Qualification for Paramedics at Charles Sturt University’
(2003) 1 Australasian Journal of Paramedicine <
3.6
High-level Skills and Vulnerable Patients—the Development of
Professionalism
Advancements in paramedic practice have continued to increase exponentially in the last decade with paramedics now performing skills that once only doctors could perform,276 including the intubation of a patient, the administration of anaesthetic agents, and the performance of assessment skills to determine not only what is wrong with a patient, but the treatment priorities, the appropriate transport options (e.g., trauma, cardiac or stroke bypass) or the suitability for non-transport. These literally can be life-and-death decisions. Indeed, a recent case heard by the Fair Work Commission recognised that it had received a ‘considerable volume of evidence about the nature of the changes to paramedic work since 2005’ that justified increases in paramedic salaries.
The provision of paramedic treatment occurs largely out of sight of the public or other professionals as it is undertaken in the patient’s home or elsewhere in the pre-hospital environment. The emergent nature of the work of paramedics means that the patient is likely to be particularly vulnerable and unable to protect themselves from an incompetent or unprofessional practitioner. Those practitioners are working in an ever-increasing number of areas beyond just the more tightly regulated state-based ambulance services, including in:
the mining and offshore oil and gas industries, entertainment events, in-house medical services in hotels and casinos, international air medical retrievals, combat medic roles in defence forces and private inter-facility patient transport services. Paramedics are also engaged in non-clinical roles to support the advancement of the profession, including clinical education, research, administration, management, university academia, professional advocacy and clinical governance.277
The expanded and increasingly onerous role of the modern-day paramedic has necessitated a change to the way in which paramedics are educated and regulated. All state-based ambulance services—which employ the majority of paramedics in Australia—operate via
276 Urgent and Emergency Care Team, NHS England, High Quality Care for All, Now and for Future
Generations: Transforming Urgent and Emergency Care Services in England—Urgent and Emergency Care Review: End of Phase 1 Report (2013).
277 PA, Submission No 9 to Senate Legal and Constitutional Affairs References Committee, Parliament of
Australia, Establishment of a National Registration for Australian Paramedics to Improve and Ensure
clinical practice guidelines originally developed from protocols developed by medical practitioners. However, the introduction of tertiary education programs has allowed paramedics to develop critical thinking skills that have enabled them to move beyond the reliance on prescriptive protocol-based decision making, to assessing and determining appropriate treatment for patients under less strict guidelines.278
Today there are more than a dozen Australian universities offering paramedic degree programs developed and largely delivered by paramedics.279 The objective of the shift to tertiary education has been to provide paramedics with an opportunity to develop their ability to engage in higher-order thinking and appropriately apply their professional discretion to patient treatment options; thus making them capable of working with professionalism.280
However, unlike in medical and nursing education, there is currently no external accrediting body in paramedicine. Hugh Grantham argued that this issue is politically fraught because ‘accreditation has been seen to be synonymous with control and standardisation’.281 The Council of Ambulance Authorities (CAA)—an industry group representing employers who are mainly state-based ambulance services—developed and initiated a process of accreditation that was trialled in 2007 at Charles Sturt and Edith Cowan Universities. The process allowed for institutional diversity and the delivery of materials using a variety of educational philosophies and methods. However, this model was unable to produce standardisation of curricula that would allow paramedics to develop
278 For example, in complex clinical decision making about end-of-life care and treatment, the Queensland
Ambulance Service (QAS) has provided paramedics with guidelines that allow them to make an assessment
of the appropriate treatment of the patient. See QAS, Clinical Practice Guidelines Patient Refusal of
Treatment (2016) <https://www.ambulance.qld.gov.au >.
279 Auckland University of Technology NZ—Bachelor of Health Science (Paramedicine); Charles Sturt
University NSW—Bachelor of Clinical Practice (Paramedic); Edith Cowan University WA—Bachelor of Science (Paramedical Science); Federation University Vic—Graduate Diploma of Paramedicine; Flinders University SA—Bachelor of Science (Paramedic); Monash University Vic—Bachelor of Emergency Health (Paramedic); Queensland University of Technology Qld—Bachelor of Paramedic Science; University of Sunshine Coast Qld—Bachelor of Paramedic Science; Victoria University Vic—Bachelor of Health Science (Paramedic); Australian Catholic University ACT—Bachelor of Paramedicine; Curtin University WA—Bachelor of Science (Health Sciences); University of Southern Queensland Qld—Bachelor of Paramedicine.
280 Eliot Freidson, Professionalism: The Third Logic (Polity Press, 2001) 23.
281 Hugh Grantham, ‘Ambulance Education—Past, Present and Future’ (2004) 2 Australasian Journal of
the same base level of knowledge and skills that would allow them to move freely among states and territories to find suitable employment without the need for additional training.282 In short, paramedics have developed a unique body of knowledge but there are several barriers to the translation of this knowledge into training and practice. The minimum qualification to work as a paramedic within almost every state-based ambulance service in Australia is a bachelor degree; however, there are still some services and private providers who will employ paramedics with sub-degree qualifications (a diploma or advanced diploma).