Continuing Professional Development: Reflecting on our own professional values and behaviours as paramedics

LEARNING OUTCOMES

After completing this module, the paramedic will be able to:

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Paramedics often work in demanding and challenging environments. A large proportion of paramedic development revolves around the cognition of anatomy and physiology, pharmacology, patient assessment and clinical care. However, there is little evidence correlating paramedics' development as learners, to changes in their traditional working assumptions and behaviour. The seminal work of Lave and Wenger (1991) illustrates how people become accustomed to traditional working patterns in the practice setting—which the authors refer to as ‘communities of practice’. Referrals to the Health and Care Professions Council (HCPC) (2016) concerning Fitness to Practise (FTP) continue to rise year-on-year. Although a number of these referrals are directly related to poor standards of clinical care, many are a result of behavioural concerns and differing professional values to those held by patients (Burford et al 2014; van der Gaag et al, 2017). Corman (2017) found that crews in Calgary, Canada would assume a cynical view of their patients, taking liberties to decide who was culpable, and who was deserving of an ambulance. He found that paramedics became oriented in making assumptions about their patients, dependent on the call location and previous experience. A 7-year ethnography by Metz (1981) likened this behaviour to the realities of the job. He found that tension prevailed following the perceived mundane nature of the calls (Metz, 1981; Corman, 2017). McCann et al (2012) accords paramedics as: ‘Still Blue-Collar after all these years?’ and believes they are restricted in their autonomy by target-driven control over their working lives. McCann et al suggests that paramedics are ‘tethered’ from the time they sign on until they leave duty; they are always contactable for a call or enquiry from the ambulance control centre (McCann et al, 2017).

Enculturation

The concept and nature of enculturation—being drawn into the working practices of the wider group (Schein, 1984)—is complex and multifaceted. Understanding how learners learn in the practice environment, as opposed to a formal classroom, is challenging. It is difficult to quantify the volume of preparation awarded to learners in the classroom setting, and difficult to measure the impact this has on preparing learners for the subtleties, nuances, intricacies and working practices so often hidden within the sub-culture of the ambulance environment. Wankhade (2012) found tension between management and crew staff. Jackson (1997) believes the behaviour of staff could be construed as an artefact of the organisation's culture. Lave and Wenger (1991), as briefly touched upon, liken the students' learning to their community of practice.

There is no simple solution to addressing these perceived shared behaviours and values. The Advisory, Conciliation and Arbitration Service (ACAS) (2018) suggests that conscious thoughts are controlled, well-reasoned and often reflective. Unconscious thoughts however can be based upon stereotypes and prejudices that we may not realise we have.

Case study

You arrive at station on a wet cold January morning for your 12-hour shift. On this particular day, you are working with a paramedic (for the purpose of this case study, we shall call him ‘Jim’). Jim has over 20 years of experience in the ambulance service. You are aware that Jim has a reputation of being despondent about his role as a paramedic; at times, he is derogatory towards patients whom he considers to be ‘time wasters’. You are also aware that Jim has previously received an informal warning about his attitude towards patients and colleagues. Many people on station try to avoid working with him.

While you are checking the ambulance, Jim is in the watch-room making himself a cup of tea. At 7:23 am, a call is received from ambulance control to attend a 50-year-old male suffering abdominal pains. The location of the call is to a known housing estate, situated in an area of poor socioeconomic development, in the east of the city. Jim appears from the watch-room with his tea and advises you not to rush, as this call will be a load of old ‘tosh’. En route to the call, Jim drives at a normal (non-emergency) pace.

On arrival at scene, you are met outside by the carer of the 50-year-old male patient. The carer informs you that the patient is an alcoholic, who since last night presented with abdominal pains and diarrhoea. The carer has no further information of the patient's past medical history.

You listen to the carer before you enter the patient's home. The house has the appearance of being unkempt. There is limited lighting available in the house and a foul smell of urine and faeces is evident. There are empty bottles of alcohol scattered around the living room where the patient is lying on an old sofa bed watching television. Jim had already entered the house while you were speaking with the carer outside. You find Jim preaching to the patient: ‘Help yourself and stop drinking excessively,’ he said. ‘There is nothing the hospital will do whilst you are drinking so don't keep calling us—sort yourself out’.

As the attending paramedic, you speak with the patient to try and diffuse the situation. Jim appears somewhat annoyed that you have stepped in. While you calmly reassure the patient, Jim continues to interrupt you with derogatory and unhelpful comments. You are aware that the carer is watching and listening from the doorway.

You undertake a full history and abdominal examination of the patient. It is clear that Jim doesn't agree with your examination and challenges you on the significance of the procedure for this particular patient. There is tension between you and Jim.

Metz (1981) would attribute this behaviour to the pressures caused by the realities of the job, suggesting that difficulties arise when working together in such challenging environments. Corman believes such tensions exist, often owing to the perceived mundane nature of the calls, as crews become despondent and aggrieved at dealing with ailments, such as alcoholism.

You ask Jim if he would bring some additional monitoring equipment from the ambulance. Jim blankly refuses and suggests you get it yourself if you want it. He continues to say he has ‘been out to this patient many times before and he is a waste of time’.

You use a degree of authority to ask Jim to help with this situation. You ask him again more firmly if he would bring the monitoring equipment you require. Your authoritative tone appears to work and Jim ‘storms’ out to the ambulance. At this point, you are able to gain some control over the situation without Jim's interference. The carer, however, now demands your colleague's name along with the ambulance call sign. She states she has: ‘never seen such abysmal behaviour from an ambulance crew before’.

You wonder if, unwittingly, you have become drawn into this sense of unprofessional behaviour. You reflect on your own unconscious bias, seeking to understand if this may have impacted in any way upon the incident. Jim reappears with the monitoring equipment. He ‘slams’ the equipment on the floor and waits outside. The patient now becomes quite upset, suggesting you are both unwilling to help him ‘because he is an alcoholic’.

The situation is becoming increasingly challenging and you feel unprepared to deal with its complexities. You decide that the patient requires hospitalisation. Jim reluctantly fetches the carry chair and you manage to move the patient to the ambulance. Once you have positioned the patient on the trolley bed, Jim goes to the driving seat and leaves you to undertake all of the necessary observations. As you look through the ambulance window, you notice that the carer is taking note of your ambulance fleet number and vehicle registration number.

Back on station, you try speaking to Jim about his behaviour. You ask whether he felt his behaviour on scene was acceptable. Jim appears dismissive of the whole situation, stating that ‘the patient was a pain in the backside’. You are aware that both you and Jim may be subject to an internal investigation pending a complaint from the carer; you feel very much that you are the innocent party.

As a result of Jim's uncooperative nature and unwillingness to discuss the situation, you decide to approach the local management team to express your concerns and explain your version of events. Burford et al's (2014) study on professionalism explored three health disciplines. These consisted of podiatrists, occupational therapists and paramedics. They found that professionalism was seen as a situational judgment—a set of influenced behaviours, rather than a fixed or defined characteristic. The HCPC's (2014) Standards of Proficiency provide some guidance for the paramedic. Here, standard 2: ‘Be able to practice within the legal and ethical boundaries of their [paramedic] practice’ highlights the responsibilities of the paramedic when confronted with challenging situations—similar to the case study described herein. Under section 2.1: ‘Understand the need to act in the best interest of service users at all times’ and section 2.2: ‘Understand what is required of them [paramedics] by the Health and Care Professions Council’ help to signpost the paramedic to the appropriate course of action in these circumstances. The HCPC's Standards of Proficiency, along with the Standards of Conduct Performance and Ethics (HCPC, 2016) provide further guidance pertaining to one's conduct and behaviour, such as the following:

This also provides a solution to the case study. It is clear that ‘Jim’ fell short of that which is expected of him as a health professional.

Summary

The case study in this article presents a realistic scenario that you or any paramedic could find themselves facing. It allows practitioners to reflect upon the difficulties and challenges experienced where colleagues display a lack of insight and professional accountability in their day-to-day practice This is not necessarily something experienced every day. However, this kind of behaviour still exists despite paramedic registration and university education. The reflective components of the case study also provide an opportunity to explore any unconscious bias and review one's professional values and behaviours. This article concludes with an adaptation from Dworkin (2002):