From trade to profession-the professionalisation of the paramedic workforce

Background

The status of professions dates back to the Medieval age, leading to the establishment of ‘the three great professions of “law”, “divinity” and “medicine”‘ (i.e. lawyers, the clergy and doctors) (Abbott and Meerabeau, 1998) in the 18th century.

They distinguished themselves from other ‘occupations’ by defning themselves as possessing three major traits, namely an elite education, an exclusive body of expert knowledge and autonomous self-regulation (also known as Trait theory). They elevated themselves in a hierarchy of superiority, above the ‘occupations’ excluding trades and unskilled/unqualifed occupations in order to give themselves an advantageous monopoly of power in the labour market (Abbott and Meerabeau, 1998).

Professionalism or professionalisation?

However, current debates on the subject, besides trying to defne professionalism (Table 1) also focus on how professions are formed and what it means to be or become a professional through behavioural professionalism (Evetts, 2010).

According to Evetts (2012), professionalism is essentially an occupational value, something that is a good thing, worth preserving and protecting, because a practitioner who exhibits professionalism is essentially doing a good job in providing a social service that is valued and useful. ‘Professionalisation’ is the process of the occupation itself trying to protect its practitioners by closing the market to a particular occupation, so that only those that are trained in that particular category of knowledge can practice that occupation.

As such, is it professionalism or professionalisation which is the primary concern for paramedics? Will the desire to seek professional status truly enhance the care of service users orbeneft individuals within the professional itself?

The Health Professionals Council (HPC) commissioned a report that described professionalism as:

‘a metaskill comprising situational awareness and contextual judgement that allows individuals to draw on the communication, technical and practical skills appropriate for a given professional scenario. The true skill of professionalism may be not so much in knowing what to do, but when to do it.’ (HPC, 2012)

It was the previous government’s agenda to professionalise the NHS workforce and encourage trades and occupations to seek ‘professional status’ through higher education to increase underpinning theoretical knowledge and apply this in practice (Department of Health (DH), 2005). Paramedics, in line with other occupations in the health sector, have attempted to regulate their occupation, by standardising the education and training received and moving that training into the university sector in order to add status to their occupation. This is something that is in the interest of the professional practitioners, as well as regulating the occupation itself and can only be regarded as a useful thing for clients, patients, and all stakeholders, who can at least anticipate that the service they are receiving will be of a particular standard. This drive for professionalisation is seen as an important factor in delivering quality (HPC, 2012).

Clinical leadership and higher education

This increased academic input integrates clinical leadership within the career structure alongside the Skills for Health Career Framework and the need for a career pathway, was highlighted by the College of Paramedics (2008) and the NHS Ambulance Chief Executive Group (ACEG )(2009a) reports on Clinical Leadership within the Ambulance service.

These reports identifed the need for a structured progression from paramedic to clinical leader as being vital to the development not only of ambulance organisations but also to the paramedic profession itself.

In 2005, the DH increased the scope for career progression of paramedics to become clinical leaders with greater opportunities to develop clinical career pathways and practice at more advanced levels. The College of Paramedics (CoP) (2008) identifed the need for complex problem solving skills in an unpredictable environment, where clinical leaders are expected to develop practice and team performance, while undertaking clinical leadership roles in more complex patient cases and becoming role models and advisors to other clinicians.

In 2008 the DH empowered professionals to become clinical leaders within their organisations and challenged clinicians to ‘step up’ and work with other leaders to change systems where it will beneft patients (DH, 2008). The NHS ACEG (2009b) therefore asks trusts to consider how they can provide the adequate level of supportive clinical leadership to establish a culture of clinical professionalism and support

‘Clinical leaders passion for their role, a clear picture of what they want their organisation to achieve ’

NHS ACEG Report (2009b) of the National Steering Group on Clinical Leadership in the Ambulance Service states that clinical leadership is the core business of the NHS, relating it to clinical governance, workforce planning, education and training, organisational development and continual professional development. Clinical leaders should have a passion for their role, a clear picture of what they want their organisation to achieve, and an ability to share that vision and motivate others.

Discussion

Higher education engenders a professional attitude of critical thinking professionals, encouraging paramedic students to understand their own self and an acknowledgement of their own limitations while challenging the traditional perspectives of care to create innovative service redesign. Likewise, its effects in progressing a practitioner from unconscious incompetent to conscious competent should be celebrated. Modifcation of behaviour and a consideration of demeanour, conduct, language and appearance are all congruent with that of a professional. Professionalism can be taught, but this must be in an open, secure and challenging learning environment, in order to be able to infuence behaviour change. Woollard, (2009) however, highlights how:

‘professionalism can best be demonstrated by the example of others working as mentors and preceptors. This ensures a full range of behaviours are witnessed and the opportunity to discuss attitudes and beliefs is available within real-world settings with another experienced professional.

There are two aspects to the professionalisation of the trade of paramedics, which are tangible clinical leadership and the move to higher education. Behavioural change infuenced by higher education and clinical leadership is how paramedics prepare to become a profession. Clinical leaders are at the coal face, accessible during an event and post event, for training and clinical supervision, and are therefore transforming practice and professional behaviour at every level. However, clinical leadership is ineffective with an uneducated workforce and an uneducated workforce is ineffective without clinical leadership. The two go hand in hand.

In essence, education alone–i.e. acquiring a ‘specifc body of knowledge’, will not equate to a professional, merely an educated paramedic, nor would the exhibiting of the three major traits produce a profession either. The question that the paramedic workforce should be asking themselves is, how is this professional status maintained?

While increasing the academic base will not guarantee improved professionalism, it does ensure that paramedic practice more accurately refects the needs of the user and of the practitioner in managing what is now a completely different unscheduled care environment to that of just a few years ago.

This, of course, is where the debate becomes interesting. Paramedics can and do behave professionally without being professionals, so what is the motivation of seeking professional status? Though one could debate, quite rightly, that one need not be a professional to behave professionally, the essence of a professional body surely must lie within its members and the behaviour of those individuals who profess to protect the title.

This harks back to the earlier identifcation of the need for professional self regulation and a more powerful aspect of professionalism that many paramedics have yet to consider. Whitmore and Furber (2006) draw attention to the role of the College of Paramedics as the recognised professional body for paramedics within the UK. The CoP identifes that:

‘A professional body exists to protect the interests of specifc professionals and develop and further a particular profession’ (College of Paramedics, 2008)

For paramedics to truly take on board professionalism in its entirety, engagement with their professional body needs to take place to better effect the self-determination of the profession and greater engagement with its future direction.

Likewise, evolving professionalism of paramedics needs to be confrmed by adherence to professional codes of conduct, refective practice and commitment to continuing professional development (O’Meara, 2009).

One must take an honest look at the motivation behind the move to professional status, in order to determine whether paramedics are indeed ready to take on board not just the status that professional recognition brings, but also the professional responsibilities along with it. There is improved remuneration and greater respect and knowledge but this does not lead to a change in personal conduct. A study involving Paramedics in 2005(Brown et al, 2005) found that they identifed professionalism as integrity, teamwork, personal appearance and cleanliness. However, without the correct attitude and behaviour, in conjunction with all paramedics engaging with the future direction and greater self determination of their own profession, it would be a ‘hollow victory,’ which could devalue the status of the paramedic profession and perpetuate reduced credibility among contemporary professions. Paramedics must therefore prioritise professionalism, i.e. behaviours and attitudes, as the driving force along their journey to becoming a profession.

The need for NHS organisations, including ambulance services, to embrace clinical leadership (DH, 2005; DH, 2008; DH, 2010) has changed the current political drivers, transferring the focus from simple quantitative improvements to more qualitative measures. A potential inability for services to improve upon such quality measurements, combined with an increasing call volume all identify the need forambulance services to relook at the methodology as to how they deliver care for this increasingly onerous responsibility. In conjunction with this one can also identify a signifcant number of complaintsfrom service users about attitude, care provision and timeliness of interventions which highlights a potential shortcoming in the profession's ability to meet public and professional expectations(HPC, 2011). The indication for more effective clinical leadership within the paramedic profession has arguably never been stronger.

That said, a recent study by the HPC (2011) highlights the relationship of professionalism to identity and not necessarily behaviour. Therefore, is it more likely the individual’s perception of him or herself that deems them as a professional than any behavioural characteristic? Is the greatest challenge to the profession to encourage and develop the individual’s perception of themselves as healthcare professionals and not simply the traditional ‘ambulanceperson.’

Challenging this inaccurate perception also requires the observer to have awareness of the NHS ambulance services commissioning process, which if not suitably distilled could arguably impact upon the development of the paramedic profession and lead to a continuous cycle of stifed development in services attempts to meet targets and avoid fnancial penalties.

Essentially, it could be argued that the development of professionalism within the group of paramedics is more likely a bottom-up evolution, than a top-down revolution. So in summary, ask not what my profession can do for me, but what can I do for my profession!