Higher education is becoming increasingly more international, with both governments and universities seeking to expand beyond traditional markets as globalisation increases. The internationalisation of education is a broad term that describes the ‘process of integrating an international, intercultural or global dimension into the purpose, function or delivery of post-secondary education’ (Knight, 2003). Transnational Education (TNE) is a more defined area of internationalisation, where students are able to study a higher education course away from the host country (British Council, 2013).
Paramedics in the UK are in a relatively unique position from an international perspective where they are trained, educated and practice within a distinct and uniform set of professional standards as set out by the Health and Care Professions Council (HCPC) (2008). This is set against a background of higher education institutions in the UK enjoying a good reputation on an international setting, where much of the delivery of paramedic pre-registration education takes place. There exists the potential for countries to look towards the UK as a provider to develop paramedic services to enrich their existing pre-hospital systems. Unfortunately, there is no specific guidance or literature to inform this process. The following article is a case study account with personal reflections of an example of the transnational provision of higher education to develop paramedic services in an overseas region. In November 2013, a small cohort of students successfully graduated from an HCPC validated paramedic programme in Gibraltar.
Background
Gibraltar is a British Overseas Territory with an independent government that is almost entirely autonomous in overseeing it's 30 000 population, despite having a status listed by the United Nations as a Non-Self-Governing Territory (United Nations, 2013). Located at the southern tip of the Iberian Peninsula, it forms part of the western border of the Mediterranean Sea. Gibraltar enjoys a warm climate and a rich range of resources for a small geographical area. From a paramedic perspective, this presents a distinctive environment that includes a number of key areas for consideration:
The Faculty of Health, Social Care and Education (FHSCE) is a partnership between St George's, University of London and Kingston University and have worked in the past with the Gibraltar Health Authority (GHA) to educate nurses in Gibraltar. Following some developmental training with the South East Coast Ambulance Service NHS Foundation Trust (SECAmb) that saw the ambulance service in Gibraltar bring all of their accident and emergency ambulance personnel to an equivalent of UK emergency technician level (EMT), the GHA approached St George's, University of London and Kingston University with the intention of initiating a small cohort of ambulance personnel on a Foundation Degree in Paramedic Science programme.
Professional and organisational considerations
The delivery of education, whether it is national or international is often a multi-agency endeavour, that requires effective institutional communication and methods of working (Henard et al, 2012). It could be argued that this becomes even more important as the physical and cultural distances between agencies increase.
Once selected the cohort was first enrolled on a level four certificate of higher education in pre-hospital care with no HCPC validation. This study lasted for one year and served two purposes. Firstly, it allowed the commissioning body (GHA) and the students to test the water in terms of potential scope for future study. Secondly, it allowed the delivering body (FHSCE) to test and adjust educational practice with the intention of continuing study beyond level four.
On successful completion it was decided that the HCPC would be approached to validate the delivery of a Foundation Degree in Paramedic Science using a transnational approach to education. The validation was successful and was based upon the programme following the existing UK-based curriculum as closely as possible. The following sections give an overview of how this was planned and delivered.
Pedagogical approach
Teaching and learning activities were largely separated into three distinct areas. Firstly, a number of visits by FHSCE lecturers were undertaken to deliver teaching sessions. These were focused towards simulation and practice to maximise the face-to-face opportunities for learning paramedic-specific skills. Most of the equipment needed to facilitate these sessions was readily available, although some equipment was carried from the UK, such as intra-osseous drills.
The second area was live or synchronous online activity where both staff and students met online from Gibraltar and the UK to undertake learning activities. Online live classrooms were used for this purpose. Although there was a traditional lecture approach to many of these sessions, as the course developed these become more and more focused towards experiential incidents and paramedic-centred discussions. This also offered the opportunity to blend UK and Gibraltar cohorts together where shared sessions were held.
The final area was independent or asynchronous online activity where predesigned online activities such as text material, formative MCQ exams, discussion board tasks and virtual patients were provided for the students to complete in their own time. With hindsight, the combination of face-to-face visits and synchronous, shared online live classrooms were the most valuable activities. This reflected in internal evaluations completed during the course. The sharing of knowledge between students based in the UK and in Gibraltar helped to create a platform for paramedic discussion that transcended local issues and examined more universal issues for education. It may have also gone some way in preventing the perception of isolation felt by many students that undergo distance education (Croft et al, 2010).
Placement
Each student was required to produce evidence that they had attended 750 hours of supernumerary placement during their level five study to satisfy the College of Paramedic's and HCPC validation criteria. This highlighted the question of how do you place a student with a paramedic to undergo supervised clinical work when there are no paramedics in Gibraltar? Hospital-based placements were going to feature heavily as an alternative to this. In comparison to the UK, the Gibraltar students enjoyed relatively easy access to theatre placements to carry out an extensive number of advanced airway techniques amongst other skills. This is largely due to the effective and close working relationships found within the GHA, combined with the lack of competition from other students or staff for anaesthetic opportunities found in the UK. Phlebotomy, maternity, mental health and emergency department placements were also undertaken.
To ensure that the cohort had adequate access to paramedic supervision, two strategies were undertaken. Firstly, the students each individually travelled to spend one month with SECAmb to undertake a placement with a paramedic. Beyond the obvious benefit of working with a paramedic mentor, it also allowed the student to observe and participate in developed pre-hospital systems of management and referral that are yet to exist in Gibraltar. However, such a placement arrangement places a significant burden on the student being away from family for an extended period and an operational drain of resources from a relatively small ambulance service.
The second approach to paramedic mentorship involved paramedic lecturers undertaking clinical shifts with the students in Gibraltar. The advantages of this system are the comparatively low disruption to operational duties compared to UK visits and the opportunity for the paramedic mentor to observe the students working in their own environment. With hindsight, this opportunity greatly influenced the delivery of education and future strategic planning for paramedics in practice as it offered an experience to appreciate the unique setting first hand. A disadvantage of this system is that the mentor—and therefore the students—had to operate within a limited scope of practice as legislation was yet to be put into place to allow for extended practice beyond EMT level. However, core paramedic practice involving communication, patient assessment, decision making and team work can still be explored even within a limited scope of practice.
Legislation and guidelines
Gibraltar possesses an independent parliament which requires distinct legislation before any change of practice can be delivered. Gibraltarians enjoy relatively close links to their elected ministers, which can make the process of changing law more accessible. In order to facilitate the implementation of paramedics into Gibraltar, there were identified a number of areas that had to be covered by legislation. These were:
Although EMT staff were administering a range of drugs similar to that of the UK, it was appreciated that there was no existing research or governance resources relating directly to paramedics in Gibraltar; therefore, it would be difficult to generate their own set of clinical and pharmacological guidelines. The UK Ambulance Services Clinical Practice Guidelines 2013 (Association of Ambulance Chief Executives, Joint Royal Colleges Ambulance Liaison Committee, 2013) together with the 1999 Professions Supplementary to Medicine (Paramedic Board) Order of Council were used as a template to guide the drafting of legislation. At the time of writing, the new legislation was about to be passed into parliament for consideration. The implementation of this legislation will be one of the final steps in order to allow the paramedic graduates to fully practice in Gibraltar.
Personal reflection
By delivering an educational programme to the GHA, I have been able to experience many opportunities beyond what you would describe as a typical educational role in the UK. This has involved working with many aspects of the health care system in Gibraltar, from a ministerial level to the front line of ambulance care. It has cemented the view that in order for an innovation such as this to be successful, that strong support is needed from all levels as the introduction of a paramedic system relies on multiple financial, staff, process and system changes to occur.
Although the distance itself was a factor, I believe that having previous experience of delivering online education by the FHSCE was crucial and it would have been difficult to instigate such a programme without systems already in place. Although it is undeniable that the experience of the cohort was very different to courses run in the UK, the reduced contact time and increased physical distance was offset against smaller, more manageable student numbers. This allowed for that rare opportunity for a lecturer to facilitate learning not only in a classroom setting, but also to see that learning manifest in a real clinical setting first hand as the course progressed for all students.
The success of the programme relied on many factors, but in my opinion the most important was the students themselves. The additional commitment from the students was essential and it is important to recognise that not only did this cohort have to travel away from their families for an extended period of time, but also that they have had to operate beyond the normal role of ‘student’. They were the ones that were in many cases the driving force behind many of the clinical changes brought about or initiated through education. This has included the implementation of 12 lead ECG technology and cardiac pathways in Gibraltar, the introduction of new drugs, mentorship systems for new non-paramedic staff and the recognition of the need and delivery of maritime rescue training.
The future for Gibraltar
Now that the initial education and registration of paramedics has been completed in Gibraltar, those paramedics await the final approval of legislation to allow them to practice. Part of the introduction of a paramedic service should be to monitor and support this new role to ensure both staff and patient safety. Recommendations have been made to initiate both a preceptorship system to facilitate an effective transition into this new role and to create a clinical governance process focused specifically on the role of paramedics. It does raise the issue of who should lead on the governance of paramedic practice in a system that has had no paramedics working within it. Is it safe for a newly qualified group of professionals to monitor their own practice? Although many aspects of practice are generic across healthcare, there does exist unique elements of unscheduled, emergency pre-hospital care where it is difficult to find personnel who have the knowledge and experience to effectively monitor and react to practice. A solution may involve both a multi-disciplinary approach from all partners within the Gibraltar, but also oversight from experienced paramedic personnel to rectify the issue of who should monitor safe and effective paramedic practice. Ultimately the aim of this process should be not only to monitor new paramedics, but also to develop staff based in Gibraltar to be in a position to effect this system themselves in the future to encourage autonomy.
The prospect of delivering subsequent cohorts in Gibraltar also changes now that a cohort has successfully graduated. Future paramedic placements could now be delivered in Gibraltar instead of requiring students to travel overseas to attend placement. This also comes with the need to further develop mentorship skills for those paramedics who have graduated to ensure effective placements are available.
Beyond the delivery of education, thought must also be given to how to best use the new paramedics. Unlike the UK where single responders are primarily used to meet response times, Gibraltar enjoys a small and relatively well served population, making response times a secondary concern. To maximise the introduction of paramedics, it was suggested that the paramedics’ focus should be on providing extended assessment, decision making and treatment options to all patients attended by the ambulance service. To do this, recommendations have been made to allow the paramedics to operate as single responders, giving them a greater range of flexibility to maximise the population coverage possible.
The future for the internationalisation of paramedic education
The delivery of education and the implementation of paramedics into a non-paramedic ambulance system is possible using transnational delivery methods based in the UK to overseas locations. The field of international paramedic education may follow that of higher education in general and look to use the UK as a source of delivery for those countries wishing to introduce paramedics into their health care systems. However, to do this effectively more research is needed to establish which methods could be used effectively. In my opinion, there will be no one set template on how education should be delivered but instead a group of principles that must be considered and applied to each individual location who wishes to develop paramedic services. This article describes such a development and from this a number of areas have become apparent which require closer examination. This includes research into the educational processes involved, the professional and clinical implications of initiating such systems, and research into the impact on students and stakeholders. With an increased evidence base, institutions within the UK may be able to find themselves in a position to deliver best educational and professional practice overseas and therefore lead on the development of paramedics on an international stage.