Paramedicine has evolved significantly over the past decade. It is moving towards an all-graduate profession with enhanced focus on evidence-based practice and professionalism. Alongside this is an increasing number of fitness-to-practise concerns raised to the Health and Care Professions Council (HCPC). There are more fitness-to-practise concerns against paramedics and social workers than all other health and social care professionals regulated by the HCPC. Of the total fitness-to-practise cases received by the HCPC in the 2016–2017 period, 13.6% related to paramedics, who comprise 6.85% of the register; and 54.27% related to social workers, who comprise 26% of the register (HCPC, 2017). Medicine and dentistry, which are regulated by separate bodies, remain the professions with the highest number of concerns (Chief Executive Steering Group, 2016). Complaints to the HCPC relating to paramedics originate from:
The HCPC commissioned a study to better understand the reasons for the disproportionate number of concerns relating to paramedics and social workers and discussed appropriate preventative action in response to this trend. A mixed-methods research study was designed and implemented to capture the breadth and depth of data necessary to respond to these two complex questions.
The current article reports findings from the Delphi process which brought insights together from an international expert panel. The focus of the discussion is on paramedics. A second article will follow, exploring the reasons behind paramedic self-referrals to the fitness-to-practise process.
Fitness to practise
Paramedics function at the frontline of emergency care practice. A literature review identified a number of themes that illuminate their practice:
Everyday paramedic practice is characterised by fast pace, unpredictability and risk (New South Wales Government, 2009; Lu et al, 2013; McCann et al, 2013). Managerial pressure contributes to the challenging nature of the practice by ‘harrying’ staff to meet performance targets (McCann et al, 2013). Poor communication and a lack of support from supervisors adds to the pressure of paramedic practice. The potential for error in highly pressurised environments and cultural barriers to raising concerns within the organisation are additional challenges for paramedics (Vike, 2006; Jennings and Stella, 2011; Bigham et al, 2012).
A recent report from the National Audit Office (2017) highlighted findings demonstrating increased demand for ambulance services, funding and resource challenges, and difficulty in meeting response time targets. At the time of writing, an ambulance delay of almost 4 hours was reported as contributing to the death of a woman (BBC News, 2018). The East England Ambulance Service had 4200 calls to the service that day and was said to be under ‘extreme pressure’ (BBC News, 2018).
A combination of pressure on services and public expectations is likely to contribute to dissatisfaction. Evidence suggests that this is more likely when four or more services are contacted in a care episode (Knowles et al, 2012). A qualitative study by Togher et al (2015) found that the public valued being listened to, reassured and informed; and treated with courtesy and the appropriate use of humour.
The evolving nature of paramedic professionalism and professional identity is an important aspect of this relatively new profession. The practice has progressed from practice-based training to university degree-level education over a relatively short time period (Metz, 1982; Campeau, 2008; Devenish, 2014). This, coupled with the advent of statutory regulation in the UK, involved the acquisition of an enhanced knowledge and skills base, and engagement with the requirements of professionalism.
Recent research relating to paramedic professionalism identified a wide range of factors that may enhance, or inhibit, how it is embedded in practice. Factors include (Gallagher et al, 2016):
As the profession continues to evolve, changes in the scope of practice and the impact of new roles such as specialist, consultant and hybrid roles have not yet been established. However, it is likely that these changes are playing an important role in reducing unnecessary hospital admissions (Donaghy, 2016).
In terms of paramedic wellbeing, the impact of a complex and pressurised context of practice takes its toll. Previous research reports a significant number of injuries at work (Weaver et al, 2012) and psychological issues resulting in sleep problems, stomach problems and headaches (Aasa et al, 2005). A Norwegian study (Sterud et al, 2011) found that gender and age can change paramedic experience of musculoskeletal pain, with older women having a higher number of concerns when combined with lack of co-worker support and higher levels of physical demand. Shift work was also found to have a negative impact on paramedic wellbeing (Blau, 2011; Strzemecka et al, 2013). There is evidence from both the UK and Sweden that post-traumatic stress disorder (PTSD) was experienced by approximately 15% of paramedics (Jonsson, 2003).
There is a paucity of literature specifically relating to the prevalence of concerns. This may be connected to some of these themes identified here: public expectations; the challenging and complex nature of paramedic practice; the evolution of paramedic professionalism; and the impact of practice on paramedic wellbeing. These themes are revisited in the discussion.
Methodology
The Delphi process was one of a number of methods designed to respond to the research questions regarding the disproportionate number of fitness-to-practise concerns against paramedics and preventative measures. In addition to a literature review, qualitative interviews, focus groups and case analysis, it was considered valuable to obtain the consensus views of an expert international panel. The Delphi process is a tried, tested and effective method to obtain diverse expert views. The rationale for an international Delphi panel was to capture the perspectives of experts in other countries which may shed light on UK paramedic practice. The expert panel members were people with a range of expertise in paramedic and general professional regulation, and were well-placed to share insights regarding the reasons for complaints, preventative actions and examples of good practice from which the UK regulator could learn. Other research methods, such as interviews and focus groups, capture the perspectives of UK experts.
The Delphi process is considered a proactive and productive way of involving stakeholders in the quest for responses to complex research questions. It is a process of structured group communication which is designed to work towards group consensus in areas of complexity and uncertainty. The Delphi process has been used since the 1950s and was used initially to:
‘forecast likely inventions, new technologies and the social and economic impact of technological change’ (Adler and Ziglio, 1996)
Two main phases of the Delphi technique are described. The first is an exploration phase (Round 1) where the topic area is explored and open responses invited. The second and third are evaluation phases (Rounds 2 and 3), and this is where experts' responses are distilled and assessed for agreement and disagreement (Adler and Ziglio, 1996). This is a form of analysis where response statements are reduced to their essence. Experts are invited to rate their level of agreement or disagreement with the statements.
The advantages of the Delphi process include the fact that the method can be used with relatively little expense, time and inconvenience. Another advantage is the anonymity afforded by the process, whereby individuals are able to express opinions and progress from individual opinion to group consensus.
In the current study, the authors used a three-round collaborative Delphi survey. This was sent to individuals known to be experts in paramedic practice, social work practice or professional regulation.
Ethical considerations
The project was submitted to the University of Surrey Ethics Committee and a favourable ethical opinion was obtained before recruitment and data collection commenced. Potential Delphi panel participants received an email and participant information sheet with details about the project, and were invited to participate.
The Delphi panel
The research team sought advice from the project Advisory Group—a small multidisciplinary group with paramedic practice, research and educational experience—and the project funder regarding appropriate experts to approach. Twenty-five experts were approached. The experts worked in the fields of professional regulation, paramedic and social work practice, education and research. Those invited were from Europe, Canada, Australia, New Zealand and the United States. The Round 1 questionnaire was completed by 14 experts; 12 individuals completed the Round 2 questionnaire; and 9 individuals completed Round 3. Three experts identified as paramedics, from New Zealand, Norway and South Africa, and three of the regulators, worked directly with paramedic cases.
| Round | Area of expertise | Country |
|---|---|---|
| 1. 14 experts |
|
New Zealand, Norway, South Africa, Ireland, Australia, USA, Wales, Canada and Netherlands |
| 2. 12 experts |
|
New Zealand, Norway, Ireland, Australia, USA, Wales, Canada and Netherlands |
| 3. 9 experts |
|
New Zealand, Norway, Ireland, Australia, USA, Wales and Canada |
The Delphi Process
This article focuses on three of the questions put to Delphi panel members:
The Round 1 Delphi questionnaire, which was emailed to the expert panel members, invited them to respond with open-text responses to the questions. The experts' responses to the questions were then distilled into statements. The process of distillation and validation involved three researchers who checked and agreed each of the statements to be included on the Round 2 online questionnaire.
The link to the Round 2 questionnaire was then emailed to expert panel members who had agreed to participate in the Delphi process. Panel members were invited to express their level of agreement on a 5-point Likert scale from ‘strongly agree’ (1) to ‘strongly disagree’ (5), and add further statements if they felt something was missed
Researchers collated a Round 3 questionnaire so expert panel members could consider again their responses, and have the opportunity to express their level of agreement in relation to the entire list of statements. They could also compare their previous responses with the group mean. Additional statements that were added to the Round 2 questionnaire were included, and panel members were invited to score these on the 5-point Likert scale. At the end of Round 3, statements reaching over 70% agreement (combining ‘strongly agree’ and ‘agree’) were considered consensus statements providing valuable data in response to the question areas.
First question
In relation to the reasons for the increasing number of conduct and competence concerns relating both to paramedic and social work practice, the 39 statements which reached consensus relating to the first question aligned with the following themes: public attitudes/expectation; pressure on services; media factors; regulatory factors; and workforce factors.
Public attitudes/expectation
Statements 1–9 that reached consensus highlighted:
Consensus statements 24–28 make explicit specific issues regarding dissonance between public expectations and paramedic service capability. For example, statement 25 discussed the ‘my home is my castle’ attitude whereby a member of the public assumes a dominant stance and conflict may arise.
Pressure on services
As in the literature review, this was a strong theme and constituted consensus statements 10–14, referring to services ‘under pressure’, complex work environments, resources ‘stretched to the limits’, high workloads and having to make ‘tough decisions’. Consensus statements in response to question 1a (29–31) make explicit some challenging aspects of paramedic practice, e.g. ‘situations of extremis’, ‘on the front line of crisis, trauma and emergency services’ and ‘in public view’.
Media factors
Consensus statements 25, 26, and 28 point to the impact of the mainstream and social media in disseminating negative reports about health and social care professional practice.
Regulatory factors
Two consensus statements, 19 and 20, point to the impact of the regulator in raising awareness of accountability and drawing attention to concern processes.
Workforce factors
Consensus statement 15 highlighted ‘insufficient professional development opportunities contributing to increasing fatigue, decreasing employee loyalty’ and a reduction in moral commitment. Statement 60 suggests the need for ‘more inter-professional training and education.’
Second question
Consensus statements relating to the second question on preventative actions emphasised the following areas: selection/training/education of workforce; educating the public; and preventative measures.
Selection/training/education of workforce
A significant number of consensus statements (1–13) highlighted the importance of rigorous admission protocols and criteria, assessment of communication skills and education in ethics and reflective practice. Putting learning from concerns data back into professional education was also recommended.
Educating the public
Consensus statements 14–16 recommend guidance for the public on channels of concerns and about the nature of the professional role with input from professional bodies.
Preventative measures
Overall, the preventative actions recommended suggest ‘a role for different stakeholders’:
One statement that achieved 100% consensus (36) questioned whether there was a problem to be addressed asking ‘do we need to take preventative action?’
Discussion
Findings from the Delphi process resonated, to a large extent, with the literature review and qualitative data findings. The challenging nature of care practices was a strong theme. Paramedics are working in pressurised environments with limited resources and high, sometimes unreasonable, public expectations. For example, when a member of the public calls an ambulance they expect to be taken to hospital. The public is also more informed about concern processes and have, it is suggested in the findings, a less deferential attitude than previously. However, determining ‘reasons’ that result from these pressures and changing attitudes is not clear-cut. Some of the contextual factors are also experienced by other health professions with smaller numbers of fitness-to-practise concerns.
To be confident that the ‘reasons’ that reached consensus impacted directly on a concern would involve analysing individual cases to determine the impact of contextual factors on the behaviour of the individual paramedic. Nevertheless, different levels of explanation as in a previous professionalism and paramedic study (Gallagher et al, 2006) are discernible in the Delphi panel experts' consensus statements. The three levels of macro, meso and micro are commonly referred to in sociology (Blackstone, 2017) to refer to explanations and approaches that focus on the broader societal and global level (macro), groups and organisations (meso), and individuals (micro).
Regarding macro-level ‘reasons’ for fitness-to-practise concerns, it is not difficult to see how political and societal changes can contribute to concerns being raised about paramedics. The media, including social media, generally focuses on negative events and this can have a demoralising impact on professionals—this seems less common in relation to paramedics (e.g. Smith, 2014) than to social workers. It is not certain how media reporting contributes to an increase in concerns.
On the other hand, it is not difficult to appreciate how policies to implement targets can put pressure on managers who may then ‘harry’ paramedics resulting perhaps in error or misconduct (McCann et al, 2013). Similarly, a more demanding and distrustful public may prove challenging to respond to and this may result in some paramedics engaging in misconduct. However, it is arguable that although this may go some way towards an explanation, it does not constitute a ‘reason’ for the high number of concerns in an accountable professional.
Meso-level explanations for fitness-to-practise concerns, most particularly pressure on services, provide plausible explanations for pressure on paramedics. The literature from social psychology suggests how moral erosion can occur when individuals work within unethical organisational or team cultures (Zimbardo, 2008). For example, Paley (2014) argues that care failures as detailed in the UK Mid Staffordshire NHS Trust can be explained by phenomena such as ‘inattentional blindness’ and ‘cognitive dissonance’. Both can lead to the dehumanisation of care recipients. Again, without considering specific instances of paramedic case reports, it is not possible to confirm that paramedics complained about being subject to institutional pressures that could not be resisted. Nevertheless, statements that point to preventative organisational strategies such as ethics education, staff development and rigorous selection processes can only contribute to the development of ethical organisational cultures.
Interestingly, there were little data in the Delphi panel on micro-level reasons. Attention was drawn to ‘insufficient professional development’ that contributes to fatigue, and challenges loyalty and moral commitment. However, the connection between this and fitness-to-practise concerns has not been made. A fruitful area for future research would be an investigation of the relationship between opportunities for staff development and concerns. It is plausible that a pressurised work environment can contribute to error and stress in the workforce. However, an analysis of factors that precipitated misconduct or incompetence leading to concerns is necessary. One of the most interesting preventative measures suggested relates to raising awareness of practice hazards and strategies to encourage practitioners to self-care and minimise the risk of burnout. Recent literature relating to moral resilience is relevant here also (Rushton, 2016). Overall, the data suggest insufficient organisational support with scope for employers, educators, the regulator, professional bodies and the registrants themselves to be proactive with preventative strategies.
Limitations
Rich data were generated from the Delphi process. However, we need to be mindful that there were a small number of participants overall and a significant number of those statements that did not reach consensus had ‘no opinion’ rather than ‘disagree’ responses. This was particularly the case in the profession-specific sections. While the responses are valid and reached or did not reach the consensus level of 70%, not all participants felt they had the confidence or expertise to comment authoritatively in relation to the profession-specific statements. Nevertheless these limitations do not diminish the depth and breadth of contributions from the expert panel members.
Conclusion
An extensive range of statements reached consensus in relation to the three questions discussed here. The themes that emerged from the Delphi statements shared a good deal of common ground with findings from the literature review and the qualitative data. The categorisation of findings as three levels (macro, meso, micro) is a framework that proved illuminating in relation to both ‘reasons’ and ‘preventative’ strategies. Both macro-level (public attitudes) and meso-level (pressure on services) explanations generated a significant number of consensus statements, whereas there were fewer statements relating to micro-level issues. This is echoed by preventative strategy statements that focus on public education, staff development and support. It is noteworthy that a Delphi statement that reached 100% consensus pointed to the positive implications of concerns as it suggests a more informed public and enhanced awareness of avenues for raising concerns.
In a second article in next month's issue of the Journal of Paramedic Practice, the authors will explore fitness-to-practise case data and the possible reasons behind the disproportionately high number of self-referrals by paramedics.