Over the last decade programmes have been established throughout the country that have prepared paramedics for specialist practice in primary care. As the need for safe and appropriate out-of-hospital treatment and/or referral for low-acuity cases increases, it is inevitable that the paramedic profession will take responsibility for recommending the curriculum and standards. In this article Stuart Rutland describes the approach taken in the South East Coast Ambulance Service which aims to provide an appropriate and defensible examination for paramedic practitioners.
As the profession advances ever forward it is essential that paramedics are seen to be a professionals in their own right. What is it though, that infers the status of profession upon a role? This question is often debated by the professions themselves as they seek to define their identity and therefore develop curriculums that refect relevance, excellence and ability (Professionalism Project Medical Professionalism, 2002; Van Mook et al, 2009; O'sullivan et al, 2012). Professionalism is undoubtedly inherent within such definitions however it is a rather subjective trait that is often hard to define although recognised when seen and generally refecting attitudes and appropriateness of behaviour. Beyond this the consensus among sociologists (Flexner, 1917; Durkheim, 1984; Hanlon, 1999) is that a profession can be identified through the possession of certain abstract traits such as value, autonomy, altruism, duty and responsibility linked with more concrete traits, namely specialist knowledge. These are said to be the core requisites for the status of the professional and although the debate will undoubtedly continue have been widely accepted as such.
The Health and Social Care Bill (DH, 2011), Darzi (2008) and Bradley (2005) all outline a vision of the National Health Service where the very professionals that deliver care will take on more responsibility and autonomy and therefore become more effective within their roles. The rhetoric here is both compelling and seductive for commissioners, clinicians and the public alike but what is not made clear is how this will be practically achieved.
The profession has responded to this and we have seen the specialist paramedic role has developed nationally over the last few years, the definition of specialist practice within the profession however remains elusive and somewhat confused (Woollard, 2007; Newton, 2011). Individuals and groups of practitioners as a result have, by and large created their own individual scopes of practice and bodies of specialist knowledge; this has been inevitable given the variety of academic programs and awards designed to support such practice and what is clear is that it is left to us to stake our claim as a profession that has the capability and status to embrace such change and determine our own future. It is now time to learn from collective experiences and set national standards for specialist paramedic practice, standards that will carry the profession forward and properly respond to the agenda for efective community based urgent health care provision at point of access.Achieving this is an enormous challenge considering that historically the paramedic curriculum centres on a set of guidelines that respond to acute medical emergencies (JRCALC, 2006). Knowledge and skills are easily tested against such text and this testing constitutes proof of retention of knowledge and basic psychomotor skill application in the context of acute care only.
While this is a well proven and suitable for the delivery of critical care it is not for the delivery of urgent care. Proper testing of core knowledge, skills and attitudes across a broad spectrum of clinical presentation framed by decision making in the context of risk stratification rather than risk avoidance will develop the standard that the profession can rightfully claim as a specialist body of knowledge.
The South East Coast Ambulance Service NHS Foundation Trust (SECAmb) have embraced this challenge, creating the first true peer assessment of competence for specialist paramedic practice. This assessment provides the first academically defensible standard as set by practicing peers. It is a standard that is based wholly around the day to day job we undertake as identified by our patients needs and recognised by specialist paramedic colleagues working in a variety of clinical settings. It is not constructed from a single text but from the combined years of clinical practice and experience of our peers.
The assessment process itself comprises an applied knowledge test (written exam questions) and practical test of clinical and communication skills, behaviours and attitudes (Objective Structured Clinical Examination, or OSCE). A formal mapping process, or blueprinting, determines the content of these assessments and provides for a balance of competencies against a range of clinical domains encountered in everyday practice.
Applied knowledge is tested using a form of multiple choice, single best answer format (SBA) questions. All questions are written and reviewed by peers and referenced against contemporary literature, national guidelines and practice. The paper contains 150 questions and the candidates are given three hours in which to complete it.
The pass mark is set at the standard of the borderline, minimally competent practitioner as determined by the peer group using established methodology and assessment principals (Postgraduate Medical Education Training Board (PMETB), 2007) used by medicine and designed to identify ft for purpose practice.
The second element of assessment is that of clinical skills using Objective Structured Clinical Examinations (OSCE) consisting of 14, ten-minute practical scenarios each examining up to three particular elements of practice (e.g. information gathering, communication, explanation).
As part of the moderation process all SBA questions are reviewed in light of the candidates’ performance to check how each question has performed. Any questions that appear ambiguous are removed before the final mark is allocated
For OSCEs the performance of each element is similarly considered, all are examined by experienced specialist paramedics or external specialists all of whom have either taken the exam or been involved in its creation. Examiners will have received formal examiner training from St George's University of London medical school and overall this process constitutes a robust, fair and academically defensible method of assessment.
Unquestionably this is a high pressure assessment and a departure from how our practice has traditionally been validated. Engaging in this process will allow us all to play our part in the development of the profession by identifying and proving competence within our own body of specialist knowledge.
It is this that will be the platform for the specialist paramedic and will allow us to provide appropriate and exemplary care in the community at point of access.
The exam programme will be a rolled out nationally and there are currently some spaces available this year for candidates from other services.
If you would be interested in taking the exam then please contact Stuart Rutland for further details.