Within the UK paramedic scene, the College of Paramedics (2019) has been a strong supporter and reformer in terms of the evolution of education when there are changes to the delivery model of paramedicine. Initially, paramedic education in the UK involved in-house, apprenticeship-style training. As part of reforms to the NHS, paramedic education shifted towards academisation through university-based undergraduate programmes (Givati et al, 2017).
In Australia and New Zealand, paramedicine has undergone a transitional shift from an internship model of vocational education to a model of pre-employment tertiary education qualifications. This model has experienced some disapproval from industry since its inception, with a number of studies identifying the lack of vital skills such as mathematics (Eastwood et al, 2012), care for the elderly (Ross et al, 2016), and clinical exposure (Michau et al, 2009) which prevents students from being ‘road ready’. It has also been identified in the literature that the inflexibility of current tertiary curricula is precluding students from adapting to the changing practices of paramedicine (O'Meara et al, 2017). Paramedic education in developing road-ready health professionals is ominously comprised of competency and skill-related tasks solely focused on ambulance service protocols and are the cornerstone of curricula (Donaghy, 2010). With the ever-changing roles and scope of paramedics, it is important that the foundations of paramedic practice are supported with a signature pedagogy or a distinguishing form of learning and teaching, which defines one profession against another (Shulman, 2005).
Curriculum consistency is developed when there is a consistent theoretical framework that guides subject selection and assessment design (Lee et al, 2013). Conceptual and theoretical frameworks are important in paramedic education as they set the path to distinguishing where paramedicine is positioned along the healthcare continuum. Paramedic education remains relatively recent in tertiary education, resulting in a tendency to over-rely on skills-based and competency-based curricula (First et al, 2012). A similar transition was undertaken in nursing; educators progressed from industry to academia, whereby curricula evolved from skills-based tasks, to an approach of critical thinking that provided a thorough understanding of why a particular skill was being performed (Wilson et al, 2015). The notion that accreditation competency standards or curriculum design should be adapted or developed based on a conceptual or theoretical framework is also supported by Shulman (2005), who identified that each profession has a distinct signature pedagogy. It has been recognised that pedagogical shifts, as a result of the change in practices, are important as long as the theory supports these changes (Mann, 2011).
The present study was undertaken in response to the changing context of paramedicine. Since December 2018, paramedics in Australia have become registered with the Paramedicine Board of Australia managed by the Australian Health Practitioner Regulation Agency (AHPRA) (2018). Changes in regulation, professionalism, standardised care and scope of practice may well influence the standards of education expected of paramedics in the future. The uncertainty of expected educational standards suggests an urgent need to assess paramedicine curricula. Assessment of the curricula requires a review into consistent curriculum design based on the future needs of the profession. Just as important is that curricula should be underpinned by a framework relevant to these requirements.
The position of paramedic education within higher education progressed rapidly from 1995 after a consortium of educators and ambulance service senior management discussed the future scope of paramedic education (Grantham, 2004). The group led the development of paramedic education in the university sector through an initial recognition of prior learning (RPL) process that was aimed at existing paramedics to increase their professional status in the health sector. This then progressed to establishing degree programmes nationwide (Willis et al, 2009). As early as 2006, the National Health Workforce Taskforce (NHWT) discussed consistency across a number of health disciplines as a way of supporting national curricula to address foreseeable issues associated with clinical education (Willis et al, 2009). A set of accrediting body competencies and capabilities reflecting paramedic professional practice, for accreditation of higher education institutions, was imposed to develop students into road-ready paramedics (Council of Ambulance Authorities Inc (CAA), 2013). These standards were supported by the ambulance professional body through its own set of paramedic competencies and capabilities which were in line with CAA requirements (Paramedics Australasia Inc, 2011). As these competencies and capabilities reflect paramedic professional practice rather than informing curriculum development and design for higher education institutions, individual curricula have evolved around these standards. Currently, Australian paramedic qualifications are assessed under the professional capabilities for registered paramedics set out by the Paramedicine Board of Australia.
While the CAA (2013) recognised that the competency standards prepare students for current clinical practice in the ambulance service, they also acknowledged that these standards require regular review. The World Health Organization (WHO) also identifies the need for regular review of medical curricula. Their Patient safety curriculum guide for medical schools document, identifies that curricula require evidence-based approaches and ongoing review through comment on curriculum, case studies and authentic examples (Walton et al, 2010).
It has been over 10 years since a report on the state of paramedic education in higher education in Australia and New Zealand identified issues facing paramedicine training within higher education (Willis et al, 2009). It scoped national and international trends for future paramedic education in meeting industry needs and highlighted that the future of paramedicine should be founded on a signature pedagogy (Willis et al, 2009). Although this was reported nearly 12 years ago, and despite changes in the scope of practice of paramedics, as well as recommendations from the CAA that regular reviews of curricula should occur, curriculum models based on the CAA competencies, and now the Paramedicine Board of Australia's capabilities, are still used today. It is possible that current curricular formats are ineffective in educating the present and future workforce, and universities need to make changes to facilitate these needs through curriculum renewal supported by a framework relevant to the profession.
There are many facets to consider when renewing curricula as part of the role of paramedics within the healthcare curriculum, including the scientific basis for which paramedics can diagnose and manage patients effectively. Identifying frameworks that are relevant to current and future practice, supported by fundamental paramedic clinical judgement developed through a pedagogical framework, is a model for educators to consider. Curriculum consistency developed from current research could assist higher education institutions to prioritise courses which could support the development and retention of knowledge and prepare the student to be an independent practitioner (Lee et al, 2013). The purpose of consistent curriculum design is the development of a competent and proficient out-of-hospital clinician. Furthermore, the goal for the clinician is to then provide the best possible care using underpinning declarative knowledge to inform clinical judgement and apply the most efficient and effective delivery of care. This will not only reduce death, disability and suffering among the community, but also contribute to improvements in medical outcomes, community health through promotion strategies, public safety and disaster management response.
A review of current conceptual and/or theoretical frameworks for paramedic education is required. The intended outcome would be adoption of a framework into current education practices, which is adaptable to the changing practice of paramedicine, supported by the professional capabilities of registered paramedics. This study identifies within the literature relevant frameworks and suggests how education providers can use them as a basis for curriculum development.
Methodology
As paramedicine education is still progressing as an established tertiary institution qualification, it is yet to gain credibility as a scientific discipline. Pertinent to this impasse is whether there exists a theoretical model that grounds teaching and learning in paramedicine as a discipline, and supports curriculum development in paramedic education for the university sector. As such, the current review aims to answer the following questions:
The authors initially undertook a focused discourse analysis of the grey literature; university handbooks, accreditation documents and curriculum renewal documents were reviewed to identify existing frameworks to support curriculum development, and their validity to inform the current and future practice of paramedics.
The PRISMA protocol for systematic reviews was used (Moher et al, 2009). A search of EMBASE, EBSCO, Medline, CINAHL, ScienceDirect and PubMed was undertaken using the following key words: ‘paramedic education’, ‘paramedic higher education’, ‘paramedic curriculum’ and ‘paramedic theoretical frameworks’.
In this study, the authors considered peer-reviewed journal articles published between 1994 and 2019. The year 1994 was when two universities first introduced paramedic education in the higher education sector in Australia; therefore, it can reasonably be assumed that research and literature around paramedic higher education in Australia and New Zealand commenced after this time. The inclusion criteria were publications in English by paramedic academics; due to their association with higher education institutions and experience as practitioners, they would be best positioned to discuss pedagogical approaches to paramedic education. The inclusion criteria also directly described paramedic education or curriculum development, learning, teaching and/or assessment.
Findings
A review of the university handbooks, accreditation documents, and curriculum renewal documents identified that only three of the 18 institutions in Australia and New Zealand that offered a paramedic qualification identified some form of framework, although it is argued that none supported current and future paramedicine practice. In only one instance, the themes for the structure of the course were clearly set out: clinical competency, patient-focused care, evidence-based practice, reflective practitioners and professionalism (Monash University, 2019).
Further discussions with academics from other universities revealed that one Australian University, through a search of the literature, identified no apparent philosophy or identity for a paramedic. The Course Review Team (CRT), members of the paramedic academic faculty, held a multi-campus workshop to identify a paramedic philosophy and identity; the statement developed was:
‘A paramedic is an emotionally-intelligent health professional who is motivated to improve communities by providing primary, urgent and emergency healthcare in dynamic environments.’
Another university identified a need for theoretical model for skills acquisition. They therefore focused on the Dreyfus model of competency, which was readily recognised in the accreditation documents (CAA, 2010).
As no frameworks were noted relating specifically to the current and future practice of paramedicine, which forms curriculum development and design, a systematic review was undertaken.
The initial search using the terminology ‘paramedic education’ yielded 4803 abstracts. A secondary search was then carried out with the key words, ‘paramedic’ and ‘higher education’. Next, a screening approach was undertaken to examine the large number of articles from both searches to exclude duplications. Based on article title only, all titles were entered into a spreadsheet and custom-sorted to identify duplicate articles, reducing the number of articles to 4689. Thirdly, an extra search was undertaken that included the words ‘paramedic curriculum’; the same process was applied to these articles as with the first; this reduced the number of relevant articles down to 1546.
The types of studies that were identified in stage 3 included both quantitative and qualitative methodologies, literature, prospective and systematic reviews, as well as theses. The abstracts of these articles were entered into an Excel spreadsheet and the ‘find’ command was used to locate the words ‘paramedic curriculum’. Finally, 151 articles underwent full review over a 6-month reviewing period. A modified version of the traditional qualitative thematic analysis (Clarke and Braun, 2017) was undertaken focused on conceptual frameworks. The preliminary examination identified no systematic reviews of conceptual and/or theoretical frameworks that ground teaching and learning in paramedicine. A number of articles did highlight critical theory as a prospective theory for paramedicine, but no articles related specifically to paramedic curricula.
Review criteria then included the provision of undergraduate education of paramedic students, with a focus on frameworks for curriculum development (Figure 1). At the full-text stage, only four articles were identified as offering a conceptual or theoretical framework associated with paramedic education written by paramedic academics.
The results of the review are represented in Figure 2 and illustrate that although frameworks are discussed in relation to their importance in forming curricula, none supported the current and future development of paramedicine. Although, a thorough analysis of the literature across Australia and New Zealand failed to locate any systematic reviews, it did identify references made to the use of a theoretical framework in curriculum development. One article was a narrative review discussing the extended scope of practice for paramedics in an ever-evolving healthcare system (Tavares and Boet, 2016). The article highlights the need for multiple conceptual frameworks that support best practices for educators when assessing paramedic competence (Tavares and Boet, 2016). Tavares et al (2016) also authored a paper describing the need to have a framework that supports actual or intended practice, highlighting that current frameworks may be outdated.
Shaban et al (2004) emphasised a requirement of a paramedic framework to ensure that graduating students have a detailed understanding of what paramedicine is and what it entails (Shaban et al, 2004). A further study by Shaban (2005a) suggested that paramedic training in mental illness could address this deficiency in a new and innovative way, with no evidence of this framework being used in current paramedic curricula.
Discussion
Paramedicine is an evidence-based healthcare profession that employs academic knowledge, coupled with the application of skills that are often practised in a variety of high- and low-acuity situations, across the health-illness continuum. Therefore, paramedicine needs to go from a training-based model to professional education of the future workforce (Donaghy, 2008; Willis et al, 2009; First et al, 2012).
Nursing care focuses on a more evidence-based approach to curriculum development, aligned with their current practices; therefore, their conceptual framework provides a more professional distinction of critical reflection and evidence-based practice (Chinn and Falk-Rafael, 2018). Nursing has long used this approach in developing tertiary educational curricula (Gold et al, 2000). To develop a curriculum based on a paramedic theory, similar to nursing, a tertiary level education—as opposed to a competency-based model of teaching the curriculum—is required to achieve an effective conceptual framework (Shulman, 2005).
For paramedic qualifications to be accredited, curricula are to be mapped against the CAA competency standards, and are required to meet the Paramedicine Board of Australia's (PBA) professional capabilities for registered paramedics. The competency standards and professional capabilities define the core level competence required for paramedic students to be considered ‘road ready’ (Table 1) (CAA, 2016; PBA, 2018). Although important for the accreditation of paramedic qualifications in tertiary institutions and now for the provision of entry-level registration of paramedics, these accreditation requirements have not provided a theoretical or conceptual framework for the profession and provide minimal direction to educational providers for curriculum development.
| Council of Ambulance Authority Professional Competency Standards | Paramedicine Board of Australia Professional Capabilities for Registered Paramedics |
|---|---|
| 1. Acts in accordance with accepted standards of conduct and performance | Domain 1: Professional and ethical conduct |
| 2. Makes informed and reasonable decisions | Domain 2: Professional communication and collaboration |
| 3. Demonstrates professional autonomy and accountability | Domain 3: Evidence-based practice and professional learning |
| 4. Develops and maintains professional relationships | Domain 4: Safety, risk management and quality assurance |
| 5. Demonstrates the knowledge and understanding required for practice as a paramedic | Domain 5: Paramedicine practice |
| 6. Operates within a safe practice environment | |
| 7. Identifies and assesses health and social care needs in the context of the environment | |
| 8. Formulates and delivers clinical practice to meet health and social care needs within the context of the environment | |
| 9. Critically evaluates the impact of, or response to, the paramedic's actions |
Conceptual and/or theoretical frameworks have been well documented in providing a link between curricula, learning and teaching strategies, and student outcomes related to the profession (Wilson et al, 2015). Conceptual frameworks have established nursing curricula within undergraduate studies to ensure that students have had a comprehensive understanding of what the profession is and what nursing care involves (Wilson et al, 2015). It has even been suggested that due to the diverse role of nurses in such areas as critical care, emergency care, paediatrics, and obstetrics and gynaecology, numerous conceptual frameworks may be applied to nurse education (Wilson et al, 2015). Wilson et al (2015) also suggest that nursing curricula need to be adaptive to the changes in workplace practices. Similarly, research into the changing role of paramedics has identified that curricula are to be adaptive to the changing scope of practice (O'Meara et al, 2017). Wilson et al (2015) and O'Meara et al (2017) align with the current and ever-evolving scope of practice of paramedics, with paramedics' role now becoming specialised.
Three framing concepts were identified from the grey literature. One handbook entry highlighted a curriculum that was themed; a curriculum renewal review document identified a philosophical approach to curriculum design; and probably the most notable educational framework identified in an accreditation document was the Dreyfus Model of Skills Acquisition.
The Dreyfus model—a model of skills competency—is commonly used to measure the progress of skills acquisition, and to define the levels of this attainment at prescribed levels of training (Dreyfus, 2004). There are five levels identified throughout the model: novice, advanced beginner, competence, proficiency and expertise (Dreyfus, 2004).
Within the pre-clinical phase of their degree, students are noted to be inexperienced in situations of their daily duties for the job they will perform. Novice practitioners are taught skills and procedures that are context-free and independent of real-life performance (Dreyfus, 2004). The students have no ‘life experience’ in the application of skills and procedures. The students' movement and transition phase into an advanced beginner stage can demonstrate slightly improved performance, with experience in recurring meaningful situational components, either through simulation or actual experience (Dreyfus, 2004). Competence develops when the student begins to reflect on his or her performance and begins to apply effective management plans (Dreyfus, 2004). The competent student paramedic performs appropriately and can cope with and manage the many possibilities of clinical applications to patients but is more rigid in judgement than the proficient student paramedic.
The proficient practitioner perceives situations as wholes rather than in terms of chopped-up parts or aspects, and performance is guided by real-life and simulated experiences (Dreyfus, 2004). Proficient student paramedics identify a situation through a holistic lens, plan contingencies and adapt to rapid change. They obtain a tacit knowledge through experience in typical events and modify plans in response to a change in events. The ‘expert’ level represents ongoing lifelong and life-wide learning; student paramedics can therefore only attain the level of ‘proficient’ within their course, while preparing them as expert practitioners (qualified paramedics) that need to continuously appraise their practice and keep up to date with new evidence, enhancing their clinical judgement abilities. Although the Dreyfus model is useful in the learning needs and different levels of skill acquisition of student paramedics, it does not support the complex and ever-changing environment of paramedicine.
Within the literature on judgment and decision-making explicit to paramedicine, Shaban (2005b) suggest there is a lack of current theoretical and methodological frameworks. Variables associated with judgment and decision-making, which Williams (2005) identified as paramount in paramedic education, do not fully identify a conceptual framework that facilitates grounding of the paramedic view (Williams, 2005).
An article by Shaban (2005a) detailed an approach to mental health, mental illness, or mental health assessments and the need for a theoretical framework. Shaban (2005a) developed a paramedic framework aimed at the undergraduate level that provided students with the base knowledge of what paramedicine is and what it entails as it pertains to the assessment, judgement and implementation of the management of patients with mental health issues (Shaban, 2005a).
A discussion paper by First et al (2012) focused on the trait theory in identifying the aspects that form professional behaviours in paramedics. The authors highlighted that the mechanisms required to become professional are achieved through an effective higher education curriculum with a focus on clinical leadership. The theory of academia, combined with an effective career structure and well educated clinical leaders, is changing paramedic practice in the field. The authors argued that professional behaviour is formed by effective clinical leadership, which is developed through paramedic education taught in higher education curricula (First et al, 2012).
Although not identified within the paramedic literature as a framework currently used in curriculum development, another model that was identified in the present literature review was critical theory. Critical theory supports the purpose of the current study as it tests contemporary thinking among higher education institutions and ambulance services around job capabilities of current students to evolve into independent and competent paramedics. It also supports the idea that due to the ever-evolving scope of practice of paramedicine, curricula need to be adaptable (Matthews, 2014). Critical theory is a paradigm that represents a shift towards critical enquiry, social justice and democracy (Chinn and Falk-Rafael, 2018). It is founded on interpretivist epistemology and the ontological theory of historical realism that proposes what is seen as real is shaped by various values, while the realities are considered truth or seen as real now (Wang and Torrisi-Steele, 2015). The paradigm of critical theory grounds learning and teaching in paramedicine. The status quo of paramedic education teaches beyond just theory, but the practice that is formed by theory is taught through action rather than only lectures and textbooks and is beginning to be formed by research (Dieronitou, 2014). The epistemology in critical theory is based on interactions of academics in providing the scientific knowledge as a base for paramedic practice and passing on their own clinical experience to students. Paramedicine should be seen as more than theory applied to practice and performing clinical skills to a level of proficiency; through paramedic academics being clinicians, there is also a transmission of knowledge and experience to students (Wang and Torrisi-Steele, 2015).
Critical and scientific theories differ in the kind of evidence which would determine whether or not they are acceptable. Critical theory is a model that paramedic curricula could adopt as it can direct current thought processes among higher education institutions and ambulance services towards a more flexible and adaptable standardised curriculum that enhances job capabilities of current students to help them evolve into independent and competent paramedics.
If paramedic education focuses on the ever-emerging scopes of current paramedic practice and best practice is incorporated into curriculum development, this would allow paramedicine to be distinctly defined on the healthcare continuum. For this to be achieved, Willis et al (2009) suggested a conceptual framework underpinned by a signature pedagogy, which would distinguish paramedic education from other health education models. To develop a paramedicine signature pedagogy, similar to nursing, tertiary-level education as opposed to a competency-based model of teaching the curriculum, is required to achieve an effective conceptual framework (Shulman, 2005).
Conclusion
The present study was undertaken to identify conceptual and/or theoretical frameworks that can be used to design a best-practice paramedicine curriculum. It was the purpose of this paper to highlight relevant frameworks that are important in the establishment of teaching, learning and assessment relevant to paramedicine curricula. The authors identified a number of conceptual or theoretical frameworks to develop curricula relevant to current and future paramedic practices. Despite the CAA competency standards, and now the PBA's professional capabilities, curricula remain diverse.
The critical theory model can form core curricula based on the changing scope of paramedic practice, moving away from a skills-focused, competency-based curriculum. It could be used in curriculum development to provide paramedicine with its own identity or signature pedagogy, promote student learning of the profession, and be efficient and comprehensive enough to cover current and future workforce practices.
The present review has recognised a scarcity of research into higher education paramedicine—specifically an absence of evidence-based curricula underpinned by conceptual or theoretical frameworks. Despite conceptual and theoretical frameworks being identified in the literature as pertinent to curriculum development, the current study did not focus on any frameworks that supported the curriculum guidance categories set out internationally. Coupled with the variation in paramedic education being taught across Australia and New Zealand, with no consistency of subjects to be taught and frameworks forming these subjects, further research is required. In medical education, expert opinion and consensus methods are commonly used in forming opinion. Therefore, further research into paramedicine curricula through an expert consensus evaluation is recommended.