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Are paramedic students ready to be professional? An international
comparison study
Brett Williams Associate Professor, PhD a,*, Chris Fielder Research Assistant,
BEH (Paramedic) a, Gary Strong Lecturer, PG Cert Ed b, Joe Acker Senior Lecturer, MPH c,
Sean Thompson Lecturer, PG Cert AdvParamedic b
aDepartment of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
bDepartment of Paramedics, Whitireia New Zealand, Wellington, New Zealand
cSchool of Biomedical Sciences, Charles Sturt University, Port Macquarie, New South Wales, Australia
ARTICLE INFO
Article history:
Received 27 March 2014
Received in revised form 17 July 2014
Accepted 19 July 2014
Keywords:
Student
Paramedic
Professionalism
Professionalisation
Regulation
Registration
ABSTRACT
Introduction: The last decade has seen rapid advancement in Australasian paramedic education, clini-
cal practice, and research. Coupled with the movements towards national registration in Australia and
New Zealand, these advancements contribute to the paramedic discipline gaining recognition as a health
profession.
Aim: The aim of this paper was to explore paramedic students’ views on paramedic professionalism in
Australia and New Zealand.
Methods: Using a convenience sample of paramedic students from Whitireia New Zealand, Charles Sturt
University and Monash University, attitudes towards paramedic professionalism were measured using
the Professionalism at Work Questionnaire. The 77 item questionnaire uses a combination of binary and
unipolar Likert scales (1 =Strongly disagree/5 =Strongly agree; Never =1/Always =5).
Results: There were 479 students who participated in the study from Charles Sturt University n=272
(56.8%), Monash University n=145 (30.3%) and Whitireia New Zealand n=62 (12.9%). A number of items
produced statistically significant differences P<0.05 between universities, year levels and course type.
These included: ‘Allow my liking or dislike for patients to affect the way I approach them’ and ‘Discuss
a bad job with family or friends outside work as a way of coping’.
Conclusions: These results suggest that paramedic students are strong advocates of paramedic profes-
sionalism and support the need for regulation. Data also suggest that the next generation of paramedics
can be the agents of change for the paramedic discipline as it attempts to achieve full professional status.
© 2014 Elsevier Ltd. All rights reserved.
1. Introduction
A profession has a number of distinguishing characteristics that
usually revolve around the application of specialised esoteric skills
and knowledge obtained through formal training and education
(Williams et al., 2009). Professions have a direct or fiduciary rela-
tionship with clients and are required to deliver services with a high
degree of personal integrity (Fitzgerald and Bange, 2007).
Professionalisation on the other hand is the political process of an
occupation attempting to achieve the distinction and recognition
of a profession (Freidson, 1970; Vollmer and Mills, 1966). Where
the Australian and New Zealand paramedic discipline is located in
this process is hotly debated among practitioners and scholars
(Williams et al., 2012) and thus forms the basis to this paper.
In order to ensure the professionalisation of the workforce, the
Australian Health Workforce Productivity Commission research
report released in January 2006 recommended the registration of
all health professionals under a single national registration board
(Australian Government Productivity Commission, 2005). In re-
sponse to this report the Australian Intergovernmental Agreement
for the National Registration and Accreditation Scheme for the Health
Professions was established on 1 July 2010, which is currently regu-
lated by the Australian Health Practitioner Regulation Agency (2013).
All those registered under this scheme are considered profession-
als and are recognised as such by law. Regrettably, the role of the
paramedic discipline is not part of this registration scheme and thus
paramedics are not considered professionals.
Currently there are 14 professions recognised by AHPRA. These
include: aboriginal and Torres Strait Islander health worker, chiro-
practic, Chinese medicine, dental, medical, medical radiation, nursing
and midwifery, occupational therapy, optometry, osteopathy, phar-
macy, physiotherapy, podiatry and psychology professions (Australian
* Corresponding author. Tel.: +61 3 9904 4283; fax: +61 3 9904 4168.
E-mail address: brett.williams@monash.edu (B. Williams).
http://dx.doi.org/10.1016/j.ienj.2014.07.004
1755-599X/© 2014 Elsevier Ltd. All rights reserved.
International Emergency Nursing 23 (2015) 120–126
Contents lists available at ScienceDirect
International Emergency Nursing
journal homepage: www.elsevier.com/locate/aaen
Health Practitioner Regulation Agency, 2013). The primary purpose
behind professional registration is occupational regulation; to protect
the public interest by ensuring that only suitably trained, compe-
tent, qualified and ethical practitioners are registered and permitted
to practice (Australian Health Practitioner Regulation Agency, 2013;
Eburn and Bendall, 2010). The purpose of the registration is not
specifically to protect the interests of health practitioners, though
it is arguable that registration will benefit health practitioners in
a number of indirect ways; including making it easier for para-
medics to access specific medications and equipment that are
required for their practice (Eburn and Bendall, 2010). Benefits of reg-
ulation for the health care system include helping to deal with
pressures/workforce shortages experienced by Australian health
workers, reducing red tape and increasing health workers’ respon-
siveness, flexibility, sustainability and mobility (Australian College
of Ambulance Professionals, 2010;Australian Government
Productivity Commission, 2005; Fitzgerald and Bange, 2007).
In New Zealand, sixteen health professions are regulated under
the Health Practitioners Competence Assurance Act (Medical Council
of New Zealand, 2011). An all-party parliamentary health select com-
mittee recommended in 2008 that paramedics be regulated under
the Act and an application for regulation was submitted in Sep-
tember 2011 (Ambulance New Zealand, 2008). A strategic review
of the Act has been undertaken in 2012–2013, and at the time of
writing, no public response has yet been made to the paramedic
application.
Paramedics have also been registered in other countries such as
the UK (Health Professions Council, 2013; Woollard, 2009), Ireland
(Pre-Hospital Emergency Care Council, 2013) and South Africa
(Health Professions Council of South Africa, 2013) for a number of
years. Additionally there are moves towards national registration
in Canada (Bowles, 2009), therefore it is of little surprise that the
national registration of the Australian and New Zealand para-
medic sector is constantly being mooted in academic, industry and
government circles. The application for regulation in New Zealand
was made on behalf of the profession by the employer represen-
tative body Ambulance New Zealand, after extensive consultations,
including a comprehensive survey of ambulance officers’ views, gov-
ernment reports, and analysis and discussion periods (Clapperton,
2008; Cotton, 2012; Health Committee, 2008). Although Austr-
alia’s appeal for registration is independent, information,
documentation and viewpoints from the New Zealand process could
potentially assist Australian paramedics in their approach to
professionalisation. The issue of recognising professionalism of para-
medics is not just isolated to Australasia with a number of other
countries also highlighting similar struggles (Ambulance New
Zealand, 2003; Bowles, 2009; Woollard, 2009). The Productivity Com-
mission’s Report on Governmental Services 2012 (Australian
Government Productivity Council, 2012) noted that 130 per 1000
people in Australia were assessed, treated or transported as pa-
tients by ambulance services. Yet many of the clinical interventions
performed by paramedics under these conditions would fall under
the scope of requiring professional accreditation if it was per-
formed by a registered medical practitioner. This raises the question
of whether paramedic interventions are monitored to the same stan-
dards as their professional and registered counterparts, indicating
the potential for a severe and dangerous gap in the Australian and
New Zealand health care systems. Registration would be a step
towards ensuring that Australasian paramedics are regulated by the
same administrative standards that govern other health care pro-
fessionals. Fortunately for those disciplines yet to be registered, a
clear national registration blueprint exists. In Australia and New
Zealand a number of criteria have been set out to guide and measure
professional registration requirements. In Australia, this has been
developed by The Australian National Registration and Accredita-
tion Scheme (NRAS), and in New Zealand by New Zealand Ministry
of Health (Ministry of Health, 2010). As can be seen in Table 1 a
number of commonalities exist between both countries.
To be considered a health profession by AHPRA or under the HPCA
it is expected that these criteria are met. The proposed profession
must be considered a health-related field that, if unregulated, could
potentially cause harm to the public. Additionally the current reg-
ulation of that profession must also fail to protect patients from sub-
optimal care and the registration of that profession should be both
practical and beneficial (Council of Australian Governments, 2008).
Taking all of these factors into consideration it would appear that
many of these criteria have direct application and/or potential con-
sequences for the paramedic sector. Obtaining a better understanding
of professionalism in the paramedic sector is vital for the protec-
tion of the public and for the future of emergency healthcare.
The aim of this paper was to explore paramedic students’ views
on paramedic professionalism in Australia and New Zealand. Stu-
dents at the three institutions all examined professionalism at some
point in their respective curricula. For example, syllabi includes: pro-
fessional development, mentoring, legal and ethical issues for
example. These students will form the next generation of para-
medics and thus interpreting their views on professionalisation will
give an indication of the direction the Australian and New Zealand
paramedic discipline is heading.
2. Method
2.1. Design
This was a cross-sectional study using a convenience sample
of undergraduate paramedic students using a paper-based
questionnaire.
Table 1
Australian and New Zealand registration criteria.
Australian National Registration and Accreditation Scheme (NRAS) New Zealand Ministry of Health
It is appropriate for Health Ministers to exercise responsibility for
regulating the occupation in question, or does the occupation more
appropriately fall within the domain of another Ministry?
The profession delivers a health service as defined by the Act
Do the activities of the occupation pose a significant risk of harm to the
health and safety of the public?
The health services concerned pose a risk of harm to the health and safety of the public
Do existing regulatory or other mechanisms fail to address health and
safety issues?
It is otherwise in the public interest that the health services be regulated as a health
profession under the Act.
Is regulation possible to implement for the occupation in question? Existing regulatory or other mechanisms fail to address health and safety issues.
Is regulation practical to implement for the occupation in question? Regulation is possible to implement for the profession in question.
Do the benefits to the public of regulation clearly outweigh the potential
negative impact of such regulation?
Regulation is practical to implement for the profession in question.
The benefits to the public of regulation clearly outweigh the potential negative
impact of such regulation.
121B. Williams et al./International Emergency Nursing 23 (2015) 120–126
2.2. Participants
Students were eligible to be enrolled in this study if they were
enrolled in the respective undergraduate programmes from Charles
Sturt University (CSU), Whitireia New Zealand (WNZ), and Monash
University (MU). Convenience sampling was used to recruit
participants. Students who were enrolled full-time or part-time were
eligible for inclusion in the study.
2.3. Instrumentation
To examine students’ attitudes and perceptions of profession-
alism a slightly modified version of the Professionalism at Work
Questionnaire (PWQ) (Durham University, UK) was used with per-
mission (Burford et al., 2013). The PWQ was originally developed
to measure professionalism across three groups: paramedics, student
paramedics, and paramedic technicians (Burford et al., 2013). While
the original version contained 91 items, some items were not ap-
propriate for our study, for example reflecting actual paramedic
organisations and workforce issues. The PWQ included 77 items,
using a combination of binary ‘yes’/‘no’ questions; unipolar Likert
scale (Strongly disagree =1, Strongly agree =5; or Never =1,
Always =5) and has 11 subscales (Pride in professional identity;
Organisational support; Focus on time; Comparative professional
status; Focus on professional development; Flexible communica-
tion; Appropriate behaviour; Confidence in action; Appearance;
Communication with patients; Adherence to rules). Given the recent
development of the PWQ, psychometric data on the reliability and
or validity of the questionnaire is as yet unknown.
2.4. Procedures
During semester 1 of 2013, students were invited to partici-
pate on a voluntary basis in this study. Students were provided with
an explanatory statement and were informed that participation was
voluntary and anonymous at the conclusion of a lecture. The ques-
tionnaires took students approximately 15–20 minutes to complete
and consent was implied by its completion and submission. Ques-
tionnaires were only distributed once with no follow-up
questionnaires undertaken.
2.5. Data analysis
The Statistical Package for the Social Sciences Version 12.0 (SPSS)
was used for entry, storage, retrieval and analysis of the quantita-
tive and demographic data. Student participant responses to the
professionalism measure were tabulated and descriptive statistics
were calculated. Due to the abnormal distribution of data (Q–Q plots)
and small sample size non-parametric tests; Mann–Whitney U test
and Kruskal–Wallis test were used to compare the differences
between universities, gender, year level and course of study. Results
with a Pvalue of <0.05 were considered statistically significant.
2.6. Ethics
Ethics approval was initially obtained from MU human re-
search ethics committee, then fast-tracked by CSU, and WNZ ethics
committees.
3. Results
3.1. Participant demographics
The 479 participants involved in this study were enrolled in the
respective undergraduate paramedic or paramedic/nursing pro-
grammes from MU, CSU, and WNZ. This represents a response rate
of 63%. The majority of participants were enrolled in CSU n=272
(56.8%), predominately female n=276 (57.6%), under the age of 25
n=358 (74.7%) and participating in a single paramedic degree n=427
(89.1%). This profile is consistent with the broader profile of stu-
dents enrolled in the undergraduate paramedic programmes within
Australia and New Zealand. The full demographic profile is out-
lined in Table 2.
3.2. Item-level scores
Overall, students supported paramedic registration with 94.6%
of valid answers either agreeing or strongly agreeing with item: ‘It
is important that paramedics are a regulated profession with a pro-
tected register’. Almost 100% (98.7%) of participants either agreed
or strongly agreed with item: ‘Members of the public expect para-
medics to be professional’. Nine in 10 participants (97.5%) also agreed
or strongly agreed with item: ‘Paramedics have special qualities
which mark them out from other professions,’ while 97% of par-
ticipants agreed or strongly agreed with item: ‘Becoming a paramedic
requires a high degree of expertise and knowledge’. The overwhelm-
ing majority of students (96%) agreed or strongly agreed with
item: ‘I think paramedics should have to regularly update their skills’
and item: ‘I think of being a paramedic as ‘a career’, not just a job’
(91.4%).
The item that was ranked the lowest overall was item: ‘Post com-
ments about work on the internet (e.g. Facebook, other social media)’
with 91.6% of valid responses answering either rarely or never. Stu-
dents also disagreed on average with items: ‘It is a waste of time
to report a minor collision in an ambulance, if there was no damage
and no one else was involved’ and item: ‘It is a waste of time re-
porting a near miss if no one was aware of it and there were no
adverse consequences’ with only 4.2% and 10.3% of valid answers
indicating that they either agreed or strongly agreed with these state-
ments. Full distribution of results are found in Table 3.
When comparing item-level scores between variables (age,
gender, course type, and university) a total of 26 items were sta-
tistically significant. Of note, four items produced statistically
significant differences P<0.05 across three variables. These in-
cluded: ‘Allow my liking or dislike for patients to affect the way I
approach them’, ‘Swear around colleagues’, ‘Tailor information to
a patient’s or relative’s needs’ and ‘Discuss a bad job with family
or friends outside work as a way of coping’.
Table 2
Participant demographics.
Variable Descriptor Total Percentage (%)
Gender Male 202 42.2
Female 276 57.6
Undisclosed 1 0.2
University CSU 272 56.8
MU 145 30.3
WP 62 12.9
Age <25 years 358 74.7
25–34 years 93 19.4
35–44 years 19 4.0
35–54 years 5 1.0
undisclosed 4 0.8
Year level Year 1 195 40.7
Year 2 174 36.3
Year 3 101 21.1
Year 4 9 1.9
Course type Single degree 427 89.1
Double degree 46 9.6
122 B. Williams et al./International Emergency Nursing 23 (2015) 120–126
Table 3
Item-level scores.
Item Strongly
disagree
Disagree Neither agree
nor disagree
Agree Strongly
agree
N/A Sig
The organisation I work/volunteer for allows me to be professional 0 4 10 174 203 83 †,§
The organisation I work/volunteer for looks after my welfare 1 17 46 214 111 83 †,§
The organisation I work/volunteer for is professional 1 6 26 195 163 83 §
Patients are more important than targets to my organisation 1 14 45 165 173 66 §
I think of being a paramedic as ‘a career’, not just a job 1 2 9 103 360 2
I think paramedics should have to regularly update their skills 1 0 13 162 298 3 §
Paramedics have special qualities which mark them out from other professions 2 2 37 184 252 0 §
The paramedic profession is vital to society 1 0 3 90 381 2 §
Becoming a paramedic requires a high degree of expertise and knowledge 1 1 17 158 298 2 ‡,¥
It is important that paramedics have their own professional organisations (such as the Paramedics
Australasia)
0 8 69 166 231 4 †
It is important that paramedics are a regulated profession with a protected register 0 2 24 162 282 6
Paramedics are as valued by the general public as fire fighters 22 51 63 139 198 4
Paramedics are as valued by the general public as police officers 25 65 83 119 178 5 †
Paramedics are as valued by the general public as nurses 8 55 98 159 152 3 †
Paramedics are as valued by the general public as doctors 25 98 120 134 96 1
I feel I represent the ambulance service or university when I am wearing the uniform in public 1 1 10 176 280 10 †
I try to always act in a manner that brings credit to the profession 1 0 6 170 290 11
Members of the public expect paramedics to be professional 1 3 1 100 365 7
It is not always possible to follow codes of conduct to the letter 19 65 126 210 47 8 §
It is not always possible to follow procedures exactly 15 43 88 262 62 7 §
I have occasionally realised after the event that I did not follow the rules regarding informed consent 24 78 132 110 13 118 §
It is a waste of time to report a minor collision in an ambulance, if there was no damage and no one
else was involved
159 253 39 15 5 6
It is a waste of time reporting a near miss if no one was aware of it and there were no adverse
consequences
111 208 101 43 5 6 †
Sometimes there are good reasons to delay making myself available for the next job after taking a
patient to the hospital
72 120 111 119 23 33 †,§
If I witnessed a paramedic delivering substandard care I would intervene directly 8 51 159 209 45 *
If I witnessed a paramedic delivering substandard care I would report him/her 2 22 153 233 60 *†,§
I have a good work/life balance 3 20 55 250 105 35
Being a paramedic is important to me 1 1 10 113 331 11
Being a paramedic makes me feel good about myself 2 2 22 159 246 36 †
Never Rarely Sometimes Often Always N/A
Feel some patients waste the ambulance service’s time 7 52 243 115 19 36
See some referrals from other healthcare providers (e.g. GPs, urgent care centres) as a waste of time 47 161 151 32 9 68
Think patients may be responsible for their problems (through alcohol, drug misuse, obesity) 13 66 232 121 16 24 †
Treat all patients with respect and sensitivity 5 4 6 49 372 34 †,§
Allow my liking or dislike for patients to affect the way I approach them 252 135 28 6 11 38 †,‡,¥
Make sure patients understand what is happening 2 1 7 108 311 40 †,§
Listen carefully to patients’ concerns 1 0 5 111 311 41 †,§
Enjoy talking to patients 0 0 30 184 214 40 §
Try to take time to reassure patients and their families 1 5 24 131 264 46 †
Disclose personal information about myself to patients 110 160 103 30 15 49 ‡,¥
’Take the mick’/banter with colleagues while they are there 106 73 149 63 18 56
’Take the mick’ out of colleagues when they are not there 192 151 62 6 4 53
Use humour about patients as a way of letting off steam after a job 98 113 120 62 14 58
Swear around colleagues 146 154 96 32 6 33 †,‡,¥
Work well with other healthcare professions, in general 1 11 25 191 172 65 †,§
Talk or don’t pay attention during lectures or training courses 114 213 115 17 1 7 †,§
Arrive late for training/classes 204 222 31 1 2 9 §
Leave station duties for other people 205 153 17 2 1 90
Arrive late for work 242 159 11 4 9 42 §
Check equipment at the start of a shift 2 3 7 68 283 105 †,§
Complete the appropriate paperwork as soon as I am able to, after each job 0 4 16 103 241 102 †,§
Take responsibility for my own work 0 2 7 69 367 25
Approach work in an organised way 0 8 22 142 268 27 †
Think about my next break or end of shift when I am working 29 96 231 52 19 42 §
Think doing a job ‘well enough’ is acceptable 111 195 105 24 8 25 †
Feel able to justify my actions/clinical decisions 3 5 36 195 167 59
Act decisively in critical situations 1 2 36 237 144 45 †,§
Read books and articles on paramedic practice 6 30 157 187 70 18 †
Attend training which is not mandatory 4 25 153 192 58 35 §
Attend training which is not mandatory 8 25 92 123 93 122
Regularly refresh my skills 0 6 63 238 115 46 §
Feel enthusiastic about going to work 1 6 32 193 191 41 †,§
Get bored in training/classes about non-clinical elements of practice 39 136 205 43 17 26 §
Seek help when I need it 0 8 79 208 159 12
Take the initiative to improve or correct my behaviour 0 4 49 224 173 14
Accept constructive criticism in a positive manner 0 1 41 212 204 10
Make sure my uniform is well presented (ironed, shoes polished) 0 7 22 136 287 15
Make sure I look clean, tidy and well-groomed at work 0 1 18 112 324 12 †,§
Adjust how I speak to different patients (e.g. how formal to be, vocabulary to use) 1 1 15 144 277 27
Adjust how I speak to different colleagues 5 6 43 183 201 28 §
Tailor information to a patient’s or relative’s needs 14 7 16 162 220 48 †,‡,§,¥
Post comments about work on the internet (e.g. Facebook, other social media) 316 76 24 8 4 34 †
Discuss a bad job with family or friends outside work as a way of coping 96 91 137 74 11 54 †,‡,¥
(continued on next page)
123B. Williams et al./International Emergency Nursing 23 (2015) 120–126
4. Discussion
Overall, students believed it is important that paramedics are a
regulated profession with a protected register. They also demon-
strated that members of the public expect paramedics to be
professional. The majority of students felt that being a paramedic
was more than simply a job; being a paramedic is a career that re-
quires a high degree of expertise and knowledge. Students also
displayed a wide range of professional attitudes, such as a desire
to report near misses, turning up to work/training on time, com-
pleting paper work, equipment checks and station duties in a timely
and organised manner, taking responsibility for their work, and not
allowing their feelings about patients to affect their clinical ap-
proach. Results from this study provide important landscape data
in the emerging profession for paramedics.
For example, there is evidence to suggest that the Australasian
paramedic discipline desires to become a professional body
(Ambulance New Zealand, 2008; FitzGerald and Bange, 2007; Tye,
2008; Williams et al., 2010; Williams et al., 2012). Williams et al.
(2010) demonstrated that the majority of the paramedic academ-
ic community believes that Australian paramedics would greatly
benefit from becoming a registered profession.
More recently Williams et al. (2012) proved that this desire was
not restricted to the academic community, but was also found within
members of the Australian College of Ambulance Professionals
(ACAP) believing that the health care sector as a whole will benefit
from the professionalisation of paramedics due to the high amount
of interaction that paramedics have with other health profession-
als (Paramedics Australasia, 2012). Additionally a number of writers
have argued that the paramedic discipline in Australia is already
very close to professional recognition (Grantham, 2004; Reynolds,
2004; Wyatt, 1998) while some argue that the profession still lacks
a unique body of knowledge (FitzGerald, 2003; Myers et al., 2008;
Williams et al., 2010).
Interestingly, students in WNZ are of the opinion that paramed-
ics are less valued by the public than both police officers and nurses
compared to their Australian counterparts. More research would be
required to understand the reasons for this; however, this percep-
tion seems at odds with a 2013 poll ranking paramedics as New
Zealand’s most trusted profession with nurses and police at fourth
and ninth places respectively (Readers Digest, 2013).
This study found that males reported less professional and more
confrontational attitudes compared to their female counterparts.
Additionally female students were found to display more enthusi-
astic attitudes towards work compared to males. Older/mature aged
students are less inclined to identify themselves as university stu-
dents. It is possible that mature students tend to have a previously
established sense of identity before attending the university, but
this would require further exploration.
Traditionally, paramedics were perhaps considered to be emer-
gency workers similar to fire fighters and the police given that
governance was provided not by health departments but rather state
emergency service boards. Today paramedics are more closely allied
to the role of a health care professional (Council of Ambulance
Authorities, 2008; O’Meara, 2009; Williams et al., 2009). Given this
change in perception it is not surprising that students in this study
align themselves more closely to the idea that they are health pro-
fessionals the further they progress through their course. Most state
ambulance services in Australia fall under the advocacy of their re-
spective health departments (NSW Department of Health, 2013;
South Australia Department of Health, 2008; Tasmania Department
of Health and Human Services, 2013;Victorian Department of Health,
2013). New Zealand ambulance services are private entities but ser-
vices are commissioned by the Ministry of Health and Accident
Compensation Corporation (National Ambulance Sector Office, 2013;
Standards New Zealand, 2008). In addition, paramedic work in Aus-
tralasia is generally becoming more complex and should no longer
be thought of as an occupation referred to as “ambulance drivers”
governed by state emergency services (Council of Ambulance
Authorities, 2008; Lazarsfeld-Jensen et al., 2013; Reynolds, 2009;
Sheather, 2009).
Paramedics perform a range of physically invasive treatments to
their patients, many of which involve some degree of risk (Burgess
et al., 2003). In addition paramedics can administer powerful drugs,
many of which are restricted under Schedule 4 (prescription only
drugs) or Schedule 8 (controlled drugs) of the Drugs, Poisons and
Controlled Substances Act 1981 in Australia (Drugs, Poisons and
Controlled Substances Act, 1981) and the Medicines Act 1981 in New
Zealand (Parliamentary Counsel Office, 1981). Without careful clin-
ical judgment, many of these treatments could have dangerous and
potentially fatal consequences for the patient. Results from this study
suggest that students feel that special training and professional at-
titudes are required to administer these treatments. This is possibly
due to the fact that often these treatments must be administered
with minimal or no clinical support while under time critical cir-
cumstances where delay in treatment could have adverse effects for
the patient. A further aspect of clinical judgement that carries risk
is the increasing emphasis on paramedics making decisions to leave
patients to be cared for in the community (Swain et al., 2010).
The vast majority of paramedics working in Australia are em-
ployed by the various state ambulance services (Australian College
of Ambulance Professionals Ltd, 2008; Burgess et al., 2003). Any reg-
ulation of these paramedics is enforced by the ambulance service
themselves based on individual clinical practice guidelines and the
Council of Ambulance Authorities (CAA) standards. However, ACAP
estimates that 10–12% of paramedics are privately employed in Aus-
tralia and do not actually fall under the authority of CAA-affiliated
providers (Australian College of Ambulance Professionals Ltd, 2008).
Table 3 (continued)
Not at all Slightly To some
extent
Very
much
Completely
Indicate how much you define yourself as a member of each of these groups – a paramedic 45 65 142 133 78 *†
Indicate how much you define yourself as a member of each of these groups – a healthcare
professional
42 57 146 146 74 *†,§
Indicate how much you define yourself as a member of each of these groups – a member of an
emergency service
47 50 109 149 108 *
Indicate how much you define yourself as a member of each of these groups – a university student 2 8 24 139 293 *§
Indicate how much you define yourself as a member of each of these groups–astudent paramedic
student paramedic
2 8 19 133 305 *
* Indicates that this field was not an option on the questionnaire.
†University.
‡Gender.
§Year level.
¥Course.
124 B. Williams et al./International Emergency Nursing 23 (2015) 120–126
This means that over 10% of paramedics in Australia may not be re-
quired to perform according to the CAA standard, potentially having
no regulation at all. Moreover, the rate of prehospital errors that
result in preventable deaths in road trauma patients has been shown
to be as high as 77% (Boyle, 2009; Cooper and Winship, 2007;
McDermott et al., 2005a, 2005b, 2007). This high rate of errors among
regulated paramedics, let alone the potential high rate of errors
among those who have an absence of a regulation is clearly a danger
to the public and may be one of the reasons students strongly
demonstrated for the need for professional organisation and a
protected register. All paramedics need to have obvious account-
ability to the community, with the opportunity and incentive for
improvement.
In New Zealand, the regulation of clinical standards for virtu-
ally all paramedics is governed by their employer, either St John New
Zealand or Wellington Free Ambulance. Together these organisations
account for the provision of all emergency ambulance services in
New Zealand. Both providers are full members of CAA. The number
of paramedics employed outside of these organisations is not
known but is believed to be much smaller than the Australian
equivalent. No data regarding error rates are currently publicly
available.
An important part in the regulation of a profession lies in how
well defined that profession is. Part of criterion 4 of NRAS re-
quires all registered professions to have a unique body of knowledge
that forms the basis of its standards of practice. Currently this part
of criterion 4 is under dispute for paramedic practice, with many
who argue that this body of knowledge does not exist or that it re-
quires some development (FitzGerald, 2003; Myers et al., 2008;
Williams et al., 2010). There are others that argue that paramed-
ics are quickly gaining a unique body of knowledge (Reynolds, 2004).
Results of this study suggest that students regarded that paramed-
ics have special qualities that mark them out from other professions,
indicating the belief that a unique body of knowledge may already
exist.
Another important part of NRAS is that the profession in ques-
tion requires specialised training. Paramedic education in Australia
and New Zealand has shifted from ambulance service vocational
training of the past to the widespread requirement of tertiary degree
education as a minimum for entry to practice (Ball, 2005). As guide-
lines become more focused on evidence-based practice, the provision
of primary care health services, and a greater focus on the social
sciences, it is becoming increasingly obvious that paramedics require
a broader degree-based education. Degrees have content that pre-
pares students to develop critical thinking skills and keep updating
their knowledge well after they have left the university. Results of
this study suggest that students believe that to become a para-
medic they require a high degree of expertise and knowledge.
Additionally students are in concordance to the core professional
principle that paramedics should have to regularly update their skills
and knowledge.
5. Limitations
The use of convenience sampling in this study helped facilitate
recruitment; however, there is the potential that students who vol-
unteered their time to participate may be more academically inclined
or proactive learners which may introduce bias into the sample.
Since, for ethical reasons, this questionnaire was anonymous no per-
sonal information was taken from students and thus we are not able
to calculate the distribution of those students who did not choose
to participate. Another limitation is the lack of fourth year respon-
dents. They were too few in number to produce reliable results and
thus were excluded from the comparison analysis. Also, given that
the questionnaire was developed for paramedics and students, a
number of items were inappropriate for students, for example, they
were not able to report on organisational professionalism beyond
their clinical placements. Until psychometric appraisal has been
carried out, these specific results should be viewed with some
caution. Finally students may have responded to questions in a ‘so-
cially desirable’ manner. Therefore it is advised that caution is used
when interpreting these results as students’ private views may vary
from those they have reported.
6. Conclusion
These results suggest that students are strong advocates of para-
medic professionalism and support the need for regulation. Overall
students showed the importance of updating their skills after gradu-
ating from the university and showed professional attitudes towards
their work. The majority of students felt that being a paramedic is
a career that requires a high degree of expertise and knowledge and
that the public in general expects paramedics to be professional.
This international comparison study provides important informa-
tion about current students, the next generation of paramedics, who
have an opportunity to be agents of change for the paramedic dis-
cipline as it attempts to achieve full professional status.
Acknowledgements
We would like to thank the students for participating and com-
pleting the questionnaires. We also acknowledge Dr Bryan Burford,
Newcastle University, UK (formerly at Durham University, UK) for
permission to use the Professionalism at Work Questionnaire.
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