Care provision is changing and, with it, innovations in healthcare delivery are developing exponentially. One such innovation is the enhanced scope of practice within the community paramedic role. These roles are proving invaluable at reducing conveyance rates and enhancing the patient experience, however are complicated by undefined and varying scopes, causing inequity of care across the UK (Suserud and Haljamae, 1997; Cooper et al, 2004; Machen et al, 2007; Spencer, 2016).
With this in mind, along with treatment innovations across primary, acute and emergency sectors, the development of a new integrated practitioner with a defined skill set was conceived—and the nurse paramedic was born.
Nurse paramedics are not a novel concept internationally—yet evidence of their effectiveness remains largely unpublished. They already exist in Australia and parts of Scandinavia, including Finland and, in some form, in Norway. The combined use of nursing and paramedicine skills is internationally an enhanced professional pathway within many countries (Rasi, 2014; Plummer et al, 2017). In the UK, this has not previously been a suitable option owing to significant differences in higher education-level training (diploma and bachelor's degree) and in the level of skills and practice requirements for each profession.
However, the recent shift to degree-level paramedic higher education and changes to the new pre-registration nursing standards, with a significant jump in skill set, have led to the comparative overlap between these curriculums becoming ever closer (Health and Care Professions Council (HCPC), 2014; Nursing and Midwifery Council (NMC), 2018). As a result, a window of opportunity opened up to create a fully integrated practitioner with crossover knowledge and skills in both adult nursing and paramedic practice.
Nurse, paramedic or both?
On examining the standards for paramedic practice, the paramedic curriculum guidance and the pre-registration standards for nurses (HCPC, 2014; NMC, 2018; College of Paramedics, 2019), the similarities were clear. The underlying knowledge base in anatomy and physiology; assessment and diagnostics; primary and urgent care conditions; public health; research; and professionalism were comparatively the same, except for some descriptive terminology. The overall mapping and comparison of the knowledge, skills and practice were 95% similar across the two sets of standards. This was surprising, not only to us but also to the professional regulatory bodies who therefore carried out further examination.
It became apparent to the programme team (consisting of two nurses and two paramedics, and an external educational expert from both fields of practice) that the difference was in the approach to the underpinning knowledge and its application to practice. Paramedics are fundamentally trained to be on the move; they work flexibly and dynamically across a variety of locations and conditions, ensuring that patients can be treated on scene or safely transported to a treatment facility for ongoing care. Nurses were trained largely within the confines of a particular location, with fewer initial assessment skills but with an expanded clinical decision-making ability about their patient's treatment plans and ongoing care.
The decision to create and drive forward a new combined role was based on this singular premise:
What if we had a practitioner with a wide range of assessment skills, who could treat at scene, use clinical decision-making skills to initiate care plans and forward planning for patients who did not need conveyance to hospital, and also safely convey if required to do so, all with the same skill set and scope of practice, regardless of employer?
In choosing to create a combined and fully integrated role, the curriculum design and development immediately became much easier. The programme became a fluid journey—a transition for the student through a variety of locations, decision-making episodes and stages of the life course, all the while considering the application of each element of the curriculum to the prehospital, hospital and emergency settings.
This represented a ‘first’ in the true attempt to fully integrate the roles and skills in one combined practitioner, who was being taught not to think like a nurse or a paramedic, but like a ‘nurse paramedic’. This is where the major deviation occurred from our European and Australian colleagues' development of their nurse paramedics and their associated curriculums.
Challenges and successes
The integration of the role and its successful articulation into the practice arena was challenging, not least due to the variety of existing roles across nursing and paramedic practice, and the perceived ‘replacement of professions’ by some professionals from both areas of practice. The role was never developed or designed to replace—merely to enhance and add to—the variety of professional roles, but with a distinct regulatory-approved standard and defined set of skills that these professionals can be benchmarked against.
Our most positive driver came largely from our stakeholders who immediately saw this as a positive step to relieve some of the current challenges associated with accident and emergency (A&E) admissions and attendance, enhancing care in the community. The surprise came from the professional regulatory bodies, who were overwhelmingly positively in support of the development, both the HCPC and the NMC being fully appreciative of innovations in healthcare. While there are some ongoing negotiations regarding preceptorship and revalidation, there is time for further discussion before these students complete the 4 years of their programme and successfully achieve an integrated masters nurse paramedic award.