As a practising paramedic on the health professionals council (HPC) register and a masters student of clinical research at the University of Southampton, the author is interested in current influencing factors on the integration of clinical research into paramedic practice. This article looks at national research and development policies, the paramedic role, training developments, the influence of the College of Paramedics and the HPC, research funding bodies, support of organisational structures, ambulance culture, collaborative research between ambulance services and academic institutions, as well as how these factors impact on the integration of research into practice in the pre-hospital setting. Finally, this article will then suggest strategies for overcoming some of the barriers to the integration of clinical and research practice by the paramedic.
National policy
Several current UK national health policies are focused on the promotion of clinical research in healthcare. In the white paper entitled Equity and Excellence: Liberating the NHS (Department of Health (DH), 2010a) the promotion and conduct of research is described as a core National Health Service (NHS) role. The Health and Social Care Act passed by Parliament on 27 March 2012 places duties on the Secretary of State, the board and clinical commissioning groups to have regard for the need to promote research within the health service (DH, 2012a). The research governance Framework for Health and Social Care (DH, 2005a) states that ‘all service and academic staff, no matter how senior or junior, have a role to play in the conduct of research.’
The DH has recently published a strategy entitled Developing the Role of the Clinical Academic Researcher in the Nursing, Midwifery and Allied Health Professions (DH, 2012b) which aims to support the growth of the clinical research workforce. These policies show commitment to improving the growth of UK health research.
In the pre-hospital emergency setting, Taking Healthcare to the Patient (DH, 2005b) has been identified as a key policy driver for ambulance services’ research (Siriwardena et al, 2009), and although the report focuses on developing clinicians’ practical skills and career progression, there is no focus on promoting the active involvement of ambulance clinicians in research in their own clinical setting.
Challenges in pre-hospital research
The integration of clinical research and clinical practice requires the generation of meaningful research questions from the existing knowledge base of the field of healthcare in question. This presents a challenge for researchers designing studies for the pre-hospital setting as there are significant gaps in the pre-hospital evidence base (DH, 2010b). It is an area of research which is less well-developed than that of other fields of healthcare (Tippett et al, 2003; National Research Council, 2007; Smith and Eastwood, 2009) for which there are several contributing factors. On both national and international levels, there is a lack of trained investigators who have elected to focus their work on pre-hospital emergency research (National Research Council, 2007; National Association of EMS Physicians, 2012). The practical, ethical and methodological challenges encountered by pre-hospital researchers are well-documented (Thompson, 2003; Schmidt et al, 2009; Lyon et al, 2010), yet these are not always insurmountable (Osterwalder, 2004; Saver et al, 2006).
There is also a greater reliance by those in the paramedic profession upon other disciplines to provide new learning (Smith and Eastwood, 2009). Situated under the umbrella of emergency medicine research, in-hospital research is often applied to the pre-hospital environment (National Research Council, 2007) despite not always being transferable to this clinical field.
Linked to the concept of applying knowledge from the broader discipline of emergency medicine research to the pre-hospital setting is the fact that many pre-hospital research studies are not designed by clinicians embedded in the pre-hospital setting. This is a characteristic identified by the author through critical evaluation of pre-hospital evidence during the masters in clinical research programme. Many pre-hospital studies are designed and conducted by academics with links to ambulance services, but also with clinicians who are not practising as ambulance paramedics in the pre-hospital setting. While the combination of a high level of clinical expertise and the right set of skills and training in research methodologies is fundamental for rigorous research, some pre-hospital studies are lacking the perspective of the clinician who is delivering patient care. It is from this perspective that clinically meaningful research questions can be generated through first-hand experience of the specific challenges presented in the pre-hospital emergency setting.
History and professional developments
It is important to identify rationales and explanations as to why so few paramedics are actively involved in conducting research in their field, including an evaluation of the barriers and facilitators to their involvement. One explanation is the newness of the paramedic role. It is only since 1974 when the responsibility of the UK
‘compared to more Traditional roles in healthcare, for many clinicians in the paramedic profession, research is a relatively new concept’
Two signifcant professional developments which have had a positive influence on UK paramedic involvement in research have been the advent of professional registration in 2000 and the setting up of the Health Professions Council (HPC) in 2001 (Whitmore and Furber, 2006). With the requirement for all paramedics to be registered with the HPC as their professional body, came a move to autonomous practice and a shift in responsibility from the ambulance service to the clinician to keep clinical knowledge and skills informed and contemporary. The HPC standards of proficiency include a significant focus on research with emphasis on the duty of the paramedic to recognise the value of research and use research to inform practice (HPC, 2007).
The influence of the College responsible for writing the UK paramedic curriculum is also important to the integration of clinical research and paramedic practice. As paramedics have only recently acquired professional status, the identification of the College of Paramedics (CoP) as their professional college (Whitmore and Furber, 2006) has also been recent. As a member of the College’s recently reformed Research and Development Advisory Committee (RDAC) the author has insider knowledge of the college’s commitment to research. RDAC’s Terms of Reference (College of Paramedics, 2012) show an appropriate emphasis on the promotion and encouragement of paramedic involvement in research. As a new college, it currently represents a relatively small, but increasing proportion of the profession.
Training developments
Active paramedic involvement in research is also being influenced by developments in paramedic training. Over the past decade, the three-month in-house Institute of Health Care Development (IHCD) course which focuses on instruction in technique has largely been replaced by two– to four–year university-based degree courses. While the IHCD syllabus does not contain any research element, the degree-level courses usually include an emphasis on the importance of evidence-based practice and sometimes a research methods module (University of Portsmouth, 2012). It is difficult to determine how much emphasis there is from universities on promoting research as a possible career pathway for paramedics. It is likely that those qualifying with degrees in paramedic
‘the practical nature of The ambulance role means that traditionally the job has attracted ‘doers’, rather than ‘thinkers’’
Smith and Eastwood (2009) describe clinical research as ‘an essential element that has not been readily embraced by paramedics or service providers to date’. For paramedics embedded in the clinical setting to become actively involved in research, they must have both an interest in research and also the ability to conduct a research study. Reasons why it is difficult to attract paramedic academics into taking up roles in the university sector include the high work load, the pressure to develop teaching programmes, the need for paramedics to establish their own academic research careers and the difference in salary (Willis, 2009).
UK research training opportunities
In terms of research training opportunities in the UK, paramedics are eligible to apply for the National Institute of Health Research (NIHR) clinical academic training (CAT) programme for nurses, midwives and allied health professionals introduced in 2008 (NIHR Trainees Coordinating Centre, 2012). This is one of several UK programmes offering funding to healthcare professionals to support emerging and advancing research careers (UK Clinical Research Collaboration, 2007). However, places are competitive and paramedics must compete with nurses, midwives and other allied health professionals (AHPs). Furthermore, not all university paramedic courses meet the honours degree standard usually preferred by research funding bodies (HPC, 2012).
‘Mess-room culture’
The influence of ambulance service culture is such that staff members often view research as an academic exercise with little applicability to patient care (National Association of EMS Physicians, 2012). The practical nature of the ambulance role means that traditionally the job has attracted ‘doers’, rather than ‘thinkers’.
From the author’s own experience of working in three UK ambulance trusts, the author has recognised a culture which seems to refect this ‘doing’ rather than ‘thinking’ mentality. Its prominence has led to the use of the label ‘ambulance mess-room culture’ by those working in this environment. In terms of paramedic activity when spending time at the ambulance station, practical considerations are inextricably linked with ambulance culture. ‘Returning to station’ is often seen as an opportunity to recover from difficult, stressful or physically demanding situations, rather than search the evidence for continuing professional development (CPD) purposes. The acceptability of active involvement in research to paramedics is influenced to some extent by the culture—that is the shared values, attitudes and practices—of the staff in the ambulance trust they work for. While the influences of the HPC, the CoP, training opportunities and university teaching may be having a positive effect on the acceptability of research to paramedics, it may take a change in mind-set for some to accept the value of actively engaging in research activity.
Research networks and organisational structures
In addition to clinician awareness and understanding, integration of research and pre-hospital clinical practice requires the support of research networks and organisational structures. Two national research groups have been set up to guide ambulance service involvement in research development; the National Ambulance Research Steering Group and the National Ambulance Clinical Audit Steering Group have been designed to support interaction between knowledge management, quality improvement and research (Siriwardena et al, 2009). The development of strong links between these two groups and the UK Clinical Research Network (UKCRN) and Comprehensive Local Research Networks (CLRNs) has led to funding for developing the infrastructure in ambulance services for supporting research studies (Siriwardena et al, 2009).
With regard to support for research by ambulance organisations, training priorities are usually focused on updating practical skills, rather than teaching research methodologies. My own personal experience of trust support for research has been very positive. Although the author investigated research training opportunities independently, the author received full trust support in applying for a place on the National Institute for Health Research (NIHR) Clinical Advice Training (CAT) programme and have continued to be supported by clinical mentor and ambulance management in studying for the masters in clinical research.
Accessibility of funding
Accessibility of funding to support pre-hospital research studies is an important factor influencing the integration of clinical and research practice in the pre-hospital setting. While ambulance trusts are eligible for NIHR and other research council funding, the UKCRN and NIHR will not overlook deficiencies in pre-hospital research funding applications (Siriwardena et al, 2009). Ambulance trusts have to compete for funding with other healthcare organisations which may have more established research portfolios.
Collaborative research
Current pre-hospital research in the UK is often conducted through collaboration between ambulance trusts and academic institutions. Siriwardena et al (2009) identify recent collaborative studies on Emergency Care Practitioners (ECPs) (Mason et al, 2007), paramedic management of falls (Snooks et al, 2010) and Clinical Performance Indicators (CPIs) (Siriwardena et al, 2010). Collaborative research facilitates a sharing of knowledge and expertise between academics and clinicians (Brown, 1994) and adds valuable knowledge to the pre-hospital evidence base. However, from the author’s own knowledge of pre-hospital studies, the clinicians who play an active participatory role in their design and conduct are usually doctors of medicine, rather than paramedics practicing in the pre-hospital emergency setting. Without input from the clinicians who are embedded in the clinical field, the research questions being generated may be lacking in meaning and relevance to the pre-hospital setting.
The author was involved in the Ambulance
‘…training prioritiesAre usually focused on updating practical skills, rather than teachingresearch mehtodologies’
The project’s unique collaboration of academics with clinicians who work on front line ambulances has enabled knowledge based on practical application to be produced and implemented in the pre-hospital clinical setting. The implementation of this new knowledge by front line ambulance clinicians has been linked with improvements to the quality of pre-hospital care for stroke and heart attack patients in the UK (Shaw et al, 2012).
The dilemma
Thus, two closely linked obstacles to the integration of clinical and research practice in the pre-hospital setting represent one dilemma. The dilemma is that pre-hospital research is being conducted mainly by clinicians and researchers who are not embedded in the pre-hospital clinical setting yet the majority of clinicians who are embedded in the pre-hospital setting do not possess the capability of carrying out formal research studies.
Translation of pre-hospital research into clinical practice
It is difficult to assess the extent to which pre-hospital research is being translated into clinical practice, as a literature search found very little on this subject. A team of paramedics and physicians from Canada have designed an online database to facilitate the incorporation of research findings into pre-hospital practice (Jensen et al, 2009).
Pre-hospital research is categorised and graded according to level of evidence and added to the database. The study claims the database is easily accessible by pre-hospital providers and indeed the author was able to access the information quickly and easily (Emergency Health Services, 2012). The project aims to reduce the gap between the results of research and the implementation of knowledge into practice.
An evaluation of the extent to which research findings are being translated into pre-hospital clinical practice in the UK requires an assessment of the evidence base supporting national ambulance clinical practice guidelines (Joint Royal Colleges Ambulance Liaison Committee (JRCALC), 2012). The JRCALC guidelines facilitate the translation of research into practice where evidence is available. One example is the cautious guideline for fluid administration which refects the ‘little evidence to support the routine use of IV fluids in adult acute blood loss’ (JRCALC, 2012). However, as there are many gaps in the pre-hospital evidence base, some of the guidelines are based on the expert opinion of the JRCALC committee members rather than the findings of formal research (JRCALC, 2012).
Strategies for improvement
It is important to consider possible strategies to resolve some of the issues relating to the integration of research and practice in the pre-hospital setting. Changing national policy is one method of implementing strategies to improve the current situation. Although national health policies show an appropriate commitment to research, national policies specifically relating to ambulance services are lacking in research focus. A young profession with an under-developed knowledge base, training undergoing drastic reforms and a severe shortage of clinicians who are actively involved in research suggests national policies have not yet had a significant positive impact on the integration of research and practice in this particular clinical field. It is too early to evaluate the impact or effectiveness of the recent DH strategy for developing the growth of the clinical workforce (DH, 2012b). However, its specifc aim of providing more clinicians who are embedded in their clinical setting with the opportunity to develop a clinical academic research career suggests more opportunities will be available for paramedics to become actively involved in research.
National policies may be more effective if they were to have a greater emphasis on organisational promotion of research opportunities, including a specific focus on clinician involvement in research. This would involve giving more responsibility to NHS trusts and universities to increase the accessibility of training in research methodologies for pre-hospital clinicians. It would also entail a commitment by universities to raise paramedic awareness about the NIHR CAT programme and other research training schemes.
Communication is required between universities and research networks in the UK to bridge the educational gap between the level of qualifications currently attainable through university paramedic courses and the preferred entry requirements for places on funded research training courses. University courses which do not offer honours degree qualifications should take measures to adjust their degree programmes to achieve this standard. In this way, paramedic students would have the same opportunities as nurses and other AHPs who wish to follow a clinical academic research career.
Similarly, an increased focus is required by ambulance trusts on promoting research career pathways, involving front line clinicians in active research and providing more opportunities for research training. Opportunities could be created through the development of paramedic roles incorporating both clinical practice and research engagement in line with national policies designed to promote growth of the clinical workforce. While several UK ambulance trusts already have active research portfolios, a commitment to active research is required by those lacking in this area.
Ambulance trust encouragement of clinical staff to become members of the CoP could also have a positive impact. Communication between ambulance trusts and the college to establish a reduced fee for NHS trust members would increase College representation of the profession. This would make support from RDAC accessible to more practising clinicians and provide more opportunities for involvement in research training and a future career in research. With more clinicians involved in research, the College could build on its own research portfolio.
One of the aims of RDAC is to develop a database of funding sources for paramedic research which will feature on the College website.This will contribute to the increased accessibility of research support for paramedics.
A positive impact could be made through a national policy focus on communication between ambulance trusts and organisations such as the National Ambulance Research Steering Group to design competitive applications for research funding. Applications should involve input from clinicians working on front line emergency ambulances to generate meaningful research questions with practical applications to the pre-hospital setting. Those already working in ambulance trust research departments and the academics linked with these should encourage the participation of motivated, forward-thinking front line ambulance clinicians in the development of significant research questions.
Conclusions
In conclusion, pre-hospital studies designed and conducted through collaboration of medical doctors or other clinicians with academic researchers have made valuable contributions to the pre-hospital evidence base. However, national policies have highlighted that the perspective of the clinician embedded in the clinical setting is required for the generation of clinically meaningful questions derived from knowledge gained from first-hand experience of specific challenges. Founded on best evidence and containing elements of formal research, quality improvement projects such as the ASCQI project are facilitators to front line clinician collaboration with academic researchers. Such projects provide valuable data regarding clinician perspectives and are a positive step towards more formal research conducted through the collaboration of academics with paramedics embedded in the clinical field.
There is an international shortage of research-trained paramedics. As the majority of paramedics currently practising in the UK were trained through the IHCD programme, for some of these clinicians a gap may exist between the practical role they were trained to carry out and the new profession which entails a responsibility to involve research in their own clinical practice. The increasing number of university-trained paramedics employed within the NHS is likely to have a positive impact on paramedic research awareness and ambulance culture and numbers of clinicians pursuing careers in clinical research are likely to grow. A positive impact on the issues relating to the integration of pre-hospital clinical and research practice could be made through committed support from research infrastructures, funding bodies, ambulance trusts, academic institutions, the College of Paramedics and through improving national health policies.