Paramedics in the US are less likely to hold a college degree than registered nurses. According to the National Registry of Emergency Medical Technicians' (NREMT) National Longitudinal EMTs Attributes and Demographics Study (LEADS ll), 43% of paramedics reported that their highest level of education was ‘some college’, 21% reported an associate's degree, and 23% reported a bachelor's degree (NREMT, 2014). In contrast, in 2008, 13.9% of registered nurses held a non-degree diploma (down from 55% in 1980), 36.1% held an associate's degree, and 36.8% held a bachelor's degree (American Association of Colleges of Nursing (AACN), 2011) (See Table 1). While both paramedics and registered nurses undergo professional education programmes totalling over 1 000 hours in order to attain basic mastery of each profession's body of knowledge—and this basic mastery is assessed both by the college and externally, through passing a state licensing exam in order to practice—the dominant model of nursing education has clearly shifted away from a certificate model and toward a degree-based model over the past few decades (AACN, 2011).
| Diploma/certificate | Associate's degree | Bachelor's degree | |
|---|---|---|---|
| Paramedics | 43% | 21% | 23% |
| Registered nurses | 14% | 36% | 37% |
Having an academic degree may be desirable, enhance career advancement and make you a better-rounded person. However, completion of additional general education courses such as mathematics, English, arts and humanities, social and behavioural science (above and beyond the existing body of knowledge requirements), and physical and biological science (above and beyond the existing body of knowledge requirements) required to earn a degree is not directly related to basic mastery of either the paramedic or nursing body of knowledge required for entry level licensure within the paramedic and nursing profession, and both models retain a certificate pathway (AACN, 2011; California State University, 2015).
This study compares paramedic and registered nurse professional education using the proxy of college credits required for professional education components of paramedic and nursing education. Inclusion criteria in the study consisted of both certificate and degree-level education at community colleges in the Northeast United States which had both paramedic and nursing programmes offered for credit. The aim of the study was to determine if the professional bodies of knowledge of paramedics and nurses are roughly equivalent for each discipline at the point of primary licensure.
Background
Paramedics have provided advanced pre-hospital emergency medical care in the US since the early 1970s (National Highway Safety Traffic Administration (NHTSA), 2007; Edgerly, 2013). According to the National EMS Scope of Practice Model, the paramedic's scope of practice includes:
‘Invasive and pharmacological interventions…based on an advanced assessment and…(diagnosis),’ and although ‘…paramedics work alongside other EMS and health care professionals as an integral part of the emergency care team…the paramedic is the minimum licensure level for practising patient care that requires the full range of advanced out-of-hospital care’ (emphasis added) (NHTSA, 2007).
Paramedic education
Paramedic education in the US is governed at the state level, but 48 out of 50 states (all but Kansas and Michigan) utilise the US Department of Transportation National Standard Paramedic Curriculum (NHTSA, 2011). Paramedic education involves approximately 1 000–1 300 hours of clinical and didactic instruction over 15 months of study. This is preceded by emergency medical technician training that involves 150–190 hours of training, for a total of 1 150 to 1 490 hours of professional education. States are free to determine the structure of delivery: exclusively as a college degree-based programme (one state: Arkansas), as a mix of college degree-based programmes and certificate-based programmes (39 states), or exclusively as a certificate-based programme (10 states) (NHTSA, 2008; 2011; Commission of Accreditation of Allied Health Education Programs (CAAHEP), 2015).
In 2005, there were over 600 paramedic education programmes operating in the US with a large majority of them being certificate programmes, many based within, but separate from, the 350 associate's degree paramedic programmes found in 40 states, and a handful of bachelor's degree programmes (NHTSA, 2008; 2011; CAAHEP, 2015).
According to the EMS expert panel findings within the National EMS Assessment, ‘EMS professional education is most commonly a certificate and not a degree’ (NHTSA, 2011). Although ‘movement should be toward a degree,’ only Arkansas requires that paramedic education be taught exclusively as an associate's degree programme, and only Texas and Oregon require fully-licensed paramedics to hold at least an associate's degree (NHTSA, 2011) (25 Tex. Admin. Code §157.40 (2006)) (Or. Admin. R. 333-265-0000).
Body of knowledge
The registered nursing body of knowledge is a generalist education. After initial licensure, registered nurses may, but are not required to, specialise through advanced degrees. Many hospitals now require all registered nurses to hold bachelor's degrees, and there is an educational track through the PhD level. Alternatively, many nurses may undergo specialised certification. For example, nurses working in the emergency department are often required to establish competency through the Emergency Nurses Association's Certified Emergency Nurse (CEN) certification programme, while critical care nurses working in critical care areas are often required to establish competency through the Association of Critical Care Nurse's Critical Care Registered Nurse (CCRN) certification programme.
The paramedic body of knowledge is specialised education on critical care principles. After initial licensure, degrees are encouraged but rarely required for clinical practice and specialty certification is less common.
To contrast the two professions, the entry-level paramedic body of knowledge covers approximately 90% of the knowledge, skills and competencies contained in the close parallel of nursing's CEN and CCRN specialist certifications (Reilly and Markenson, 2010).
Unfortunately, the narrow, specialised paramedic body of knowledge lacks a recognised education pathway to a more sophisticated career. There are fewer than 25 paramedic-specific bachelor degree programmes, less than a dozen paramedic-specific (non-clinical) master's degree programmes, and no paramedic-specific PhD programmes in the US. This structural difference in educational opportunities limits the ability of paramedics to maintain a professional identity, develop and pursue research, become more clinically sophisticated, or create a realistic pathway into healthcare management, quality assurance or education. As a result, paramedics are limited in their career pathways to remaining in the narrow pre-hospital care arena, where it is generally unrealistic to work for an entire career. A recent Canadian survey revealed that the retirement rate for paramedics is less than 5%, the lowest of all professions (Hofley, 2014).
Nursing education
Nurses are the largest, single healthcare profession in the US, with more than 3.1 million registered nurses providing care in almost every healthcare setting, including functioning as the largest single component of hospital staff (AACN, 2011). Nursing is defined by the American Nurses Association (ANA) as:
‘The protection, promotion, and optimisation of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations’ (ANA, 2015).
Similar to paramedic education, nursing education is managed at the state level with national standards. Nursing education has three pathways into entry-level practice: a 3-year non-degree diploma, a 2-year associate's degree, or a 4-year bachelor's degree. All cover the same basic content that is required to sit for a state-registered nurse licensing exam; however, there has been a dramatic shift away from diploma nursing programmes in the past 35 years (the highest qualification held by 55% of registered nurses in 1980, down to 14% today) and a corresponding increase in associate's degrees (18% in 1980, 3% today) and bachelor's degrees (22% in 1980, 37% today) (AACN, 2011).
For associate's degree registered nurses, 46 states and territories had not set a minimum number of classroom hours, while those that set clock hours ranged from 450–540 hours of instruction and those that set credit hours ranged from 27–64 credits (National Council of State Boards of Nursing (NCSBN), 2014). Additionally, 43 states and territories had no minimum number of clinical hours, while those who set clock hours ranged from 160–900 hours of clinical rotations and those who set credit hours ranged from 18–26 credits (NCSBN, 2014).
Methods
For paramedics, 45 states either require or permit use of the NREMT paramedic certification exam as their state paramedic certification requirement. As of 1 January 2013, the NREMT now requires all paramedic exam candidates to have successfully completed education programmes that are either accredited or are seeking accreditation by the CAAHEP, which is the accreditation body for the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CAAHEP, 2005; NREMT, 2012).
We reviewed the CAAHEP website to compile a list of all paramedic education programmes in the Northeast states of Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Pennsylvania (CAAHEP, 2015). We then surveyed the website of each programme on this list to identify those institutions that offered college credit (although not necessarily a degree) for their paramedic education programme and also had an associate's degree nursing programme. We then followed with a web search to identify any Northeast non-CAAHEP paramedic education programmes that offered college credit (although not necessarily a degree) for their paramedic education programme and also had an associate's degree nursing programme.
A total of 23 comparison pairs were identified where the college had both paramedic and nursing programmes where the number of credits were listed: 21 were associate's degree-to-associate's degree comparisons, two were paramedic certificate-to-registered nursing associate's degree comparisons. No comparable programmes were found in Vermont or Rhode Island.
Curricula were reviewed, and all mandatory courses listed under nursing or paramedic department label were included (e.g. NUR 101, EMS 101). While biology, anatomy and physiology were almost always co-requisites for both professions, they were often not taught by the nursing or paramedic departments, so were not included. If emergency medical technician (EMT) was pre-requisite to the paramedic programme, and the college offered the EMT class for credit, that number was included. If it was a pre-requisite but the college did not offer for credit, it was not included.
Results
Paramedic education programmes ranged from 28–61 college credits, with a mean (average) of 40.65, a median (half above, half below) of 40, and modes (most frequent number) of 30 and 48 college credits, while registered nursing education programmes ranged from 28–50 college credits, with a mean (average) of 37.22, a median (half above, half below) of 37, and a mode (most frequent number) of 37 college credits (Table 2). Overall, more than 3/4ths of registered nursing education programmes were granted between 34–41 credits while the number of credits granted to paramedic programmes were significantly more spread out (Figure 1). Comparing programme length within colleges, paramedic education programmes were granted more credits in 13 cases by an average of 9.08 credits (range: 1–23 credits), while registered nursing education programmes were granted more credits in 10 cases by an average of 3.9 credits (range: 1–8 credits).
| Mean (average) | Median (half above, half below) | Mode (most frequent) | |
|---|---|---|---|
| Paramedic | 40.65 | 40 | 30, 48 |
| Nursing | 37.22 | 37 | 37 |
Discussion
This paper establishes that entry-level paramedic and nursing education, regardless of degree requirements, have bodies of knowledge that although different, are similar in overall scope when compared using the proxy of college credits. While the nursing body of knowledge is focused broadly on health, the paramedic body of knowledge has a deeper but more narrow focus on critical care. But even if the bodies of knowledge are similar in scope, degree completion remains the common metric for assessing ‘professionals’.
According to research conducted by Gibson and Bentley (2011), the public has no real sense of how much education paramedics have, but expected that emergency medical technicians had some college and that paramedics should have an associate's degree. The current certificate model of paramedic education, regardless of the total amount of professional education, confuses the public. In 1996, an article about paramedics working in emergency departments in the Orlando Sun Sentinel stated that ‘[paramedics] have less training and education than nurses’ (La Mendola, 1996). A 2013 article in the Orange County Register stated that, ‘Paramedics fall between EMTs and nurses in terms of medical training’ (Kyle, 2013).
The current certificate model of paramedic education, regardless of the comparable scope of the bodies of knowledge and the questionable direct impact of non-clinical education requirements in basic, entry-level mastery also confuses healthcare professionals and has been reinforced by state regulation. As a result, many state boards of nursing and nursing associations have interpreted their nurse practice act to require that registered nurses supervise paramedics where paramedics are authorised to work in a hospital emergency department (Massachusetts Nursing Association, 2003; Minnesota Nurses Association, 2005; Kentucky Board of Nursing, 2012). However, 14 states permit registered nurses to work as registered nurses on the ambulance without any pre-hospital certification at all (National Association of State EMS Officials, 2008). This is despite the National EMS Scope of Practice stating that, ‘The paramedic is the minimum licensure level for patients requiring the full range of advanced out-of-hospital care’ (NHTSA, 2007). In fact, the Air and Surface Transport Nurses Association objects to registered nurses working in the pre-hospital environment being subject to any non-nursing oversight at all, holding that ‘Transport nursing is a specialty within the scope of nursing practice’ (Air and Surface Transport Nurses Association, 2010).
‘Raising awareness that paramedics and nurses have bodies of knowledge that are roughly equivalent in scope, regardless of other non-clinical education requirements, is a critical precursor to paramedics establishing exclusive domain over pre-hospital care’
This conflict may stem from the early 1970s, when the initial paramedic body of knowledge focused almost exclusively on cardiac care, and was developed, based to some extent, on the critical care nursing body of knowledge (Page, 1979). Those registered nurses transferred their knowledge from the cardiac care unit to the field, and frequently served as the first paramedic programme instructors (Page, 1979). In the ensuing 40 years, paramedic practice has grown significantly more complicated: technology and treatment options have become much more advanced and EMS personnel are dealing with much greater patient acuity (Canadian Patient Safety Institute, 2009). The paramedic body of knowledge has grown in parallel.
So, while allowing the generalist registered nurse to expand their professional scope to include pre-hospital care may have been appropriate 20 years ago, the expansion of the paramedic body of knowledge means that generalist registered nurses would presumably have significant problems mastering it without a formal education programme. However, even with at least two generations of experience, paramedics have not asserted any sort of exclusive domain over pre-hospital care:
‘Very little has changed in terms of nurses' involvement with EMS systems. From initial training through certification, from continuing education to quality assurance (QA) or continuous quality improvement (CQI) programmes, to field-hospital interface, and even into the realm of peer review and disciplinary actions, nurses continue to have significant, and in many cases, virtually exclusive, dominion over field personnel in many EMS systems. This is a questionable design at best’.
Paramedics have to change this general impression of both the public and other healthcare professionals. Raising awareness that paramedics and nurses have bodies of knowledge that are roughly equivalent in scope, regardless of other non-clinical education requirements, is a critical precursor to paramedics establishing exclusive domain over pre-hospital care. As the community paramedicine concept struggles to attain a foothold and expand into the traditional domains of nursing, the idea that paramedics can build outward from a deep knowledge of critical care, while nurses build up from a broad knowledge of health, will also be important to establish.
Limitations
This paper looked at data only from a limited geographic area covering nine states, and only at community colleges where both a nursing and paramedic programme were taught and offered for college credit. While paramedic education content is, for the most part, standardised across the US, and most paramedics in the US take the NREMT exam as a prerequisite of state certification, the length of an education programme may be shorter or longer depending on the institution, and regional differences may exist.
Conclusions
Paramedics educated in community college paramedic programmes in the Northeast United States have a professional education that equals or exceeds the length of the average nurse graduating from the same institution, as measured by college credits, regardless of whether the paramedic education programme grants a degree. This data indicates that paramedics and nurses have bodies of knowledge of roughly equivalent scope (one broad, one deep) and should consider themselves peers. While requiring that paramedic professional education be based exclusively within the associate's degree model would be a significant advantage in establishing equivalency, and we do understand the value of general education requirements to the profession, even within the dominant current certification model, paramedics should aggressively advocate that they share equal professional status to registered nurses.