Representing contemporary paramedic practice in Canada: Development of the National Competency Framework for Paramedics

Representing contemporary paramedic practice in Canada: Development of the national competency framework for paramedics Alan M. Batt 1,2,3 , Jennifer L. Bolster 2,3,4 , Meghan Lysko 3,5 , Pierre Poirier 6 , Derek Cassista 6 , Michael Austin 7 , Cheryl Cameron 2,3,8 , Elizabeth A. Donnelly 3,9 , Becky Donelon 3,10 , Noël Dunn 11 , William Johnston 3,12 , Chelsea Lanos 2,3 , Matthew S. Leyenaar 3,13,14 , Tyne M. Lunn 2,3 , Paige Mason 3,12,15 , Mary Osinga 3,16 , Dugg Steary 3,17 , Sean Teed 3,18 , Charlene Vacon 3,19 and Walter Tavares 3,20,21 Abstract Paramedicine is a domain of practice and health profession that specialises in the provision of health and social care across a range of settings including, but not limited to, emergency and primary care. Paramedics work in a variety of clinical settings such as paramedics services, hospitals, and clinics, in the community as well as non-clinical roles, such as education, leadership, policy work, public health and research. A previous competency framework for paramedics in Canada had become increasingly poorly aligned with contemporary practice. We sought to develop a competency framework that represents contemporary paramedic practice in Canada. This project was guided by a conceptual framework informed by systems thinking and used a six-step model for developing competency frameworks. We engaged paramedics from across Canada in working groups to explore various contexts of paramedic practice. We gathered data using multiple methods and coded this data into activity statements. We grouped these statements and developed or expanded corresponding professional activities through five drafts of the framework from 2022 to 2024. A technical committee reviewed and edited the draft framework throughout the process, culminating in a public review period from January 1 Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada 2 Department of Paramedicine, Monash University, Frankston, VIC, Australia 3 McNally Project for Paramedicine Research, Toronto, ON, Canada 4 BC Emergency Health Services, Clinical Governance and Professional Practice, Bancouver, BC, Canada 5 Oxford County Paramedic Services, Woodstock, ON, Canada 6 Paramedic Association of Canada, Ottawa, ON, Canada 7 Department of Emergency Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada 8 Canadian Virtual Hospice, Winnipeg, MB, Canada 9 School of Social Work, University of Windsor, Windsor, ON, Canada 10 Health Sciences Division, Justice Institute of British Columbia, New Westminster, BC, Canada 11 Saskatchewan Health Authority, Regina, SK, Canada 12 Ottawa Paramedic Service, Ottawa, ON, Canada 13 EMS Board of Prince Edward Island and Prince Edward Island Department of Health and Wellness, Charlottetown, PE, Canada 14 University of Prince Edward Island, Charlottetown, Canada 15 School of Interdisciplinary Studies, Royal Roads University, Victoria, BC, Canada 16 Fleming College, Paramedic Program, Peterborough, ON, Canada 17 BC Emergency Health Services, Provincial Coordination & Disaster Resilience, Bancouver, BC, Canada 18 Medavie HealthEd, Dartmouth NS, Canada 19 Regional Paramedic Program for Eastern Ontario, Ottawa, ON, Canada 20 Department of Health and Society, Wilson Centre for Health Professions Education Research, University of Toronto, Toronto, ON, Canada 21 York Region Paramedic Services, East Gwillimbury, ON, Canada Corresponding author: Alan M. Batt, Faculty of Health Sciences, Queen’s University, 99 University Avenue, Kingston, Ontario, Canada, K7L 3N6; Department of Paramedicine, Monash University, Building H, Peninsula Campus, 47-49 Moorooduc Hwy, Frankston VIC 3199, Australia; McNally Project for Paramedicine Research, Toronto, ON, Canada. Email: [email protected] Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage). Primary research Paramedicine 2025, Vol. 22(3) 111–126 © The Author(s) 2024 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/27536386241284092 journals.sagepub.com/home/pam to March 2024, and a subsequent final version of the National Competency Framework for Paramedics (NCFP). The National Competency Framework for Paramedics reflects contemporary paramedic practice in Canada. It describes the professional activities of paramedics organised under five domains - Person-Centred Care; Collaborative Care; Safe Care; Self-Care; and Professional Care. Paramedics perform these activities across multiple contexts of practice by enacting a variety of roles depending on the event. By exploring the variety of practice contexts and the expectations of paramedics across Canada, the NCFP provides a holistic, contemporary description of paramedic practice in Canada, providing a foundation for professional practice in a variety of settings. The five domains provide a comprehensive representation of paramedic practice helping to ensure care is ultimately and sufficiently aligned with the needs of the community and settings in which paramedics can practice. The NCFP can be used to inform education programmes to better prepare paramedics for complex, interprofessional health and social care practice now and as practice continues to evolve. Keywords paramedic, competency, competency framework, professional, competencies Date received: 5 May 2024; revised: 12 August 2024; accepted 12 August 2024 Introduction Paramedicine is a domain of practice and health profession that is enacted using a range of healthcare models including, but not limited to, emergency and primary care. Paramedics provide care in a variety of clinical settings such as paramedic services, hospitals, clinics, and in the community as well as non-clinical roles, such as education, leadership, policy work, public health, and research. 1 The contexts in which paramedics practice and the roles they enact are constantly evolving, which presents challenges when attempting to describe them. Context for the purposes of this study may mean a physical setting (e.g. in a clinic), a geographic location (e.g. Northern Canada), a cultural setting (e.g. within an Indigenous community), or indeed a combination of all three. Paramedic practice in Canada was previously described in the 2011 Paramedic Association of Canada (PAC) National Occupational Competency Profile (NOCP) that outlined the competencies required of a competent paramedic. 2 The document described 37 general competencies across eight competency areas. The 37 general competencies were supported by 233 specific competencies, which were further supported by over 1300 sub-competencies. Since its publication in 2011, paramedics have expanded their clinical scope of practice, broadened their contexts of practice, and assumed roles and responsibilities reflective of shifting societal needs. 3,4 For example, in addition to the ‘traditional’role that involves treatment and emergency transport to the hospital, paramedics also increasingly provide home-based care through community paramedicine programmes, 5,6,7,8,9 and employ virtual care solutions to expand equitable access to healthcare. 10,11 Recent years have prioritised the health and wellbeing of all health care providers internationally, including paramedics, 12,13 the need to embrace advances in health professions education, 14 and team based care or interprofessional practice. 15,16 Given how such advances are underor mis-represented in the NOCP, the existing description of practice and supporting competencies has become poorly aligned. The NOCP formed the foundation of paramedic education programme accreditation in Canada; subsequently resulting in poorly aligned education and assessment models that may not adequately prepare learners for the realities of complex professional practice. Since then, efforts have been made in the Canadian context to offer corrections and better alignment. For example, authors introduced the various roles paramedics might need to adopt to function effectively. 17 They identified that variable contexts of practice, the need to rethink care as a health and social obligation, and the need to organise paramedics and paramedicine within additional team settings were new ways to think about paramedicine. The Canadian Organization of Paramedic Regulators (COPR) also developed a regulator-focused competency framework that describes current responder and paramedic practice in Canada. 18 However, these efforts were limited in their engagement with the influencing role of context and did not attempt to identify how to respond to the dynamic nature of professional practice. Others have made renewed efforts to provide this needed futurelooking perspective. The Paramedic Chiefs of Canada (PCC) identified several new principles to guide the profession at a system level, introducing new ways of thinking about and representing paramedicine, with implications for what this means for paramedics. 15,19 Additionally, authors have identified emerging concepts in the paramedicine literature related to shifting societal expectations of health professions. 3 Finally, recent advances have been made in how best to develop competency frameworks that have shed light on new ways to examine professions that have not yet been applied in this context. 20 Collectively, this suggested the need to examine the profession in more detail and develop a competency framework that attended 112 Paramedicine 22(3) to advances and any existing limitations to further describe and ultimately holistically represent paramedic practice in Canada. Aim We aimed to develop a competency framework that reflected the needs of contemporary paramedic practice in Canada. Philosophical and theoretical positions This project was approached from a pragmatic perspective, whereby we considered human experience as the primary means for building knowledge and understanding paramedic practice, as opposed to relying on absolute truths. 21 We used both qualitative and quantitative methodologies and multiple methods of data collection to investigate different components of the project. We were guided by a systems-thinking approach that was founded in third-wave systems thinking, which we next describe as a foundation of our conceptual framework. Conceptual framework In this project, we leveraged existing frameworks to structure a conceptual framework to guide our overall approach. This included merging a novel systems thinking approach with existing and published Canadian frameworks available at the time. 20 Guided by earlier research that used systems thinking to strengthen the development of competency frameworks, 20 we leveraged earlier work that identified the features of the system of paramedic practice in Canada. 22 Briefly, that study revealed that paramedic practice considers the person receiving care, caregivers, and paramedics. It highlighted several issues for us to consider when developing the NCFP including ensuring culturally competent paramedics; engaging meaningfully with Indigenous communities; involving other health and social care professionals, people receiving care, caregivers, and the public; seeking insights from those with contextual expertise; and attending to the variations in regulation, education, funding, and scope of practice across Canada as just some examples. 22 We combined the findings of this systems thinking approach with three conceptual models to structure our understanding of the system (place) and the paramedic’s (person) role in it. The first of these publications was the PCC ‘Principles to Guide the Future of Paramedicine in Canada’. 15,19 This framework outlines key issues that paramedicine as a system, and paramedics as individuals need to engage with to improve and evolve practice to meet changing societal needs. These include for example, further integrating with the healthcare system, acknowledging the interaction between health and social needs, and putting patients and their communities first. Some of these principles are systems-level concerns, while others can be enacted at both a systems level and an individual level. The second was the PAC ‘Canadian Paramedic Profile and Roles’. 17,23,24 This framework describes the roles that individual paramedics enact in practice, such as clinician, team-member, and health and social advocate. We structured the ‘Person’focus of the NCFP by organising the competencies required to perform professional activities by the roles. Finally, the ‘Emerging Concepts in the Paramedicine Literature’review, which outlines key social and societal issues that paramedics must attend to in their practice, such as planetary health, social responsiveness, virtual care, and anti-racism. 3 As with the principles, some of these concepts are systems-level concerns, while others can be enacted at an individual level. The relationship between these four conceptual elements (systems thinking, principles, profile/roles, and emerging concepts) is outlined in Figure 1. Methods Six-step development model This project used a contemporary six-step model for developing competency frameworks (see Figure 2). 25 The model highlights the need for a theoretically informed approach to describing and exploring practice that is appropriate, 20 and offers guidance for developers on reporting the development process and outputs. 26 Multiple professions have used this model to guide the development of competency frameworks, including occupational health, health research ethics, dietetics, intimate partner violence specialists, and mental health nursing. 27,28,29,30,31 The steps include (1) identifying purpose, intended uses, scope, and stakeholders; (2) theoretically informed ways of identifying the contexts of complex, ‘real-world’professional practice, which includes (3) aligned methods and means by which practice can be explored; (4) the identification and specification of competencies required for professional practice, (5) how to report the process and outputs of identifying such competencies, and (6) built-in strategies to continuously evaluate, update and maintain competency framework development processes and outputs. Next, we describe the people and groups involved in the development process, and then outline each step of the development process in detail. Stakeholders, rightsholders, and system partners Steering group. A steering group was convened and comprised of the NCFP Development Lead (AB), the President of PAC, a CSA Group Project Manager, an independent standards consultant, and two officials from PAC –the Director of Standards, Research and Government Relations (PP), and the Chief Operating Officer (DC). This group commissioned and funded the project, provided strategic direction, Batt et al. 113 issued updates to the community, and provided oversight of the development process. Figure 3 outlines the relationship between the various groups involved in developing the NCFP. CSA group technical committee. A technical committee was recruited of 34 members from across Canada, representing diverse sectors of paramedicine (e.g. clinicians, education institutions, service operators, regulators, professional associations, and unions) and those intersecting with or supporting paramedicine (e.g. researchers, accreditation bodies). The group reviewed materials provided and created by the Development Group (DG), suggested edits and comments, approved drafts, and voted on the final version of the standard. Five subcommittees reviewed each domain of the draft NCFP and reported back to the main Technical Committee. The Technical Committee was chaired by PP. Development group. A development group led the data collection, analysis, and drafting of the competency framework for the NCFP project. The Development Group lead (AB) recruited members to represent a variety of intersecting Figure 1. Conceptual framework guiding the development of the National Competency Framework for Paramedics (NCFP). From left-to-right and from system to person, we first used systems thinking to gain insights into the system of paramedic practice in Canada. (1. Batt et al. 2021 20 ; Batt et al. 2024 22 ) Next, we incorporated the principles to guide the future of paramedicine in Canada (2. Tavares et al., 2021 15 ) Some of these principles are system level issues, and some paramedics individually enact. Then we used the paramedic profile (3. Tavares et al., 2016 17 ) to structure our understanding of the professional roles of the paramedic enacted within a defined system. Finally, we incorporated insights on emerging concepts in the paramedicine literature (4. Bolster et al., 2022 3 ). By developing specific competencies, the paramedic can perform a variety of professional activities. The NCFP focuses on the role of the paramedic within the system. A brief video presentation describing this conceptual framework is available at https://osf.io/kyqj2. Image design by Alan Batt, used under a CC-BY 4.0 Licence. Figure 2. The six-step national competency framework (NCFP) development process. Image design by Alan Batt, used under a CC-BY 4.0 Licence. CSA: Canadian Standards Association Group. 114 Paramedicine 22(3) clinical practice, education, research, governance, regulatory, policy, leadership, and advocacy experiences within and outside of paramedicine. The Development Group was composed of 19 individuals from across Canada with experience across multiple contexts of paramedic practice in urban and rural settings, including emergency care, community, military, remote and isolated, critical care, substance use, special operations, interprofessional primary care, and palliative care. They also had experience in regulation, clinical governance, health systems leadership, research, education, policy and strategy, social work, and private industry. Most of the group identified as Canadian, female, and white, had postgraduate qualifications, and resided in Ontario, followed by British Columbia. Several of the group were bilingual (English and French), while the remainder spoke English as their primary language. PM is a member of the Mohawks of the Bay of Quinte First Nation. This collaborative project was conducted on colonised Indigenous lands now referred to as Canada. These lands are home to the many diverse First Nations, Inuit, and Métis Peoples whose ancestors have stewarded this land since time immemorial. The NCFP was developed with a commitment from the outset of the project to action the Truth and Reconciliation Commission’s Calls to Action, 32 particularly the calls related to health (#18 to 24), and professional development and training for public servants (#57). Working groups. Details of working groups including membership and process are described under Step 2. Individual membership of the various groups is outlined in Supplemental File 1. Trustworthiness and rigour We enacted measures to improve the trustworthiness and rigour of our processes and outputs. We identified the features of the system of paramedic practice in Canada via a robust systems-thinking approach. 20 This preliminary step ensured the NCFP development process considered the features of contemporary paramedic practice. We engaged members of the profession to provide descriptions of what they do and where they do it without imposing restrictions on how this data was provided. The Development Group and Technical Committee recruited individuals across various sectors of paramedicine (e.g. clinical practice, education, research, leadership, regulation). We ensured a clear audit trail, capturing all documents, codes, activity statements, mapping exercises, and edits throughout multiple drafts. All public-facing materials were open-access and archived on the Open Science Framework (OSF). The six-step development model was mapped to and aligned with the CSA Group’s standard development organisation (SDO) processes. 25,33 We engaged people receiving care, care partners, members of the public, members of Indigenous communities, and the broader profession throughout the development process and public review period, through both broad and targeted measures. Finally, we report the development process in accordance with the CONFERD-HP reporting guideline for the development of competency frameworks in health professions. 26 Figure 3. Relationships between stakeholder groups in developing the NCFP. Image design by Alan Batt, used under a CC-BY 4.0 Licence. Batt et al. 115 Software We used Google Office Suite for collaborative writing and document management; secure Google Drive folders for cloud storage; Webex, Zoom, and Microsoft Teams for video conferencing; Google Jamboard for interactive whiteboards; Dedoose for qualitative data analysis; Zotero for reference management; and Signal for group messaging. We used Microsoft PowerPoint, Microsoft Visio and miMind to generate presentations, figures, flowcharts, mind maps, and timeline diagrams. We used voicebooking.com to generate the AI voiceover for the conceptual framework video. Data stewardship All public-facing materials related to the project were archived via OSF in a publicly available project (https://osf. io/escxk). The CSA Group maintains a copy of all standards development materials used by the Technical Committee, and Technical Committee members have continued access to all materials shared on the CSA Communities workspace for this project. All materials and inputs received from Indigenous communities were managed in accordance with OCAP® principles. 34 Knowledge brokering Core to the development of the NCFP was an ongoing knowledge translation and information-sharing strategy. The Development Group published seven updates from 2022 to 2024 as open access articles in ‘Canadian Paramedicine’(a national trade magazine), 35 which were also uploaded to ResearchGate, OSF, and shared via website posts and social media platforms (LinkedIn, Twitter/X, and Facebook) to keep the paramedic community apprised of the development process. Members of the Development Group presented the NCFP development process in oral and poster format over 30 times at invited talks, conferences, and workshops across Canada, Australia, Ireland, the UK, and Japan. The Development Group presented to, and solicited feedback from paramedics, federal and provincial professional associations, leaders of paramedic services, educators, unions, regulators, Indigenous communities, research conference attendees, accreditation groups, other health professions, and paramedic students. This was achieved via direct requests, questions submitted via email, and in-person discussion. The NCFP development lead (AB) met regularly with the consultant leading the COPR regulatory requirements project to share mutual updates. All feedback was memoed and referenced in Steps 3 and 4 when developing professional activities and competencies. A comprehensive public engagement strategy was conducted during the public review period. Full details of the knowledge brokering strategy are outlined in Supplemental File 2. Ethics approval This was a standards development project conducted under the auspices of the CSA Group’s standards development process and thus was not subject to ethics approval. It used both primary and secondary data, and all who contributed were involved in the project as developers and are acknowledged in Supplemental File 1. We maintained awareness of the rights of all people who contributed across the project and aimed to ensure equity of representation at every step of the process. Results –development process Step 1. Identify purpose, scope, use and timeline of the framework The Steering Group, Development Group, and Technical Committee collaboratively drafted the purpose, intended uses, terminology, timeline, and scope of the NCFP. The NCFP was intended to describe the professional activities performed by paramedics, and the core competencies required to enact professional, person-oriented practice in diverse contexts. Our aims were not to consider, nor describe competencies related to the Emergency Medical Responder (EMR), service leadership, education, research, policy, or specialist roles that paramedics may fulfil in Canada. Nor did we intend to provide curriculum guidance or career pathway options. EMR competencies are already outlined in the 2015 PAC Emergency Medical Responder Competency Profile, 36 while leadership competencies are addressed via the 2016 PCC Leadership Competency Framework. 37 The Technical Committee considered education, research, and policy competencies out of scope, and recommended that specialist clinical competencies be identified via separate contextspecific projects in the future. We elected to describe scope of practice separately to the NCFP, acknowledging that we expect all paramedics in Canada to have the same common competencies which may be enacted in different ways depending on clinical scope, context, and jurisdiction. Scope of practice, education guidance, and ethics will be addressed through the creation of a suite of supporting documents for the NCFP. Working draft #1 of the NCFP was created in February 2022 which described the purpose, scope, and use of the framework. The timeline and workflow of the project as enacted is outlined in Figure 4, and detail on each step of the development process is provided in Figure 5. At the end of this step, we had clearly outlined the scope, purpose, and boundaries of the project, which informed the development of the conceptual framework and the identification of the system in Step 2. 38 We identified system partnersand end-users to be involved during the development of the NCFP. Guided by the findings of Lepre et al., 39 we sought to ensure input from practitioners, academics, employers, regulators, service users, policy 116 Paramedicine 22(3) makers, other health and social care professionals, and educators. Specific initiatives to seek input from under-represented voices were included at various stages in the process. We elected to structure the NCFP using the concept of professional activities. We define a professional activity for the purpose of this project as ‘a synthesis of multiple competencies that requires the integration of knowledge, skills, and attitudes’. 40 While similar in concept to EPAs, professional activities are not always ‘entrustable’, and are not task driven. We adopted Epstein & Hundert’sdefinition of competence ‘The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served’. 41 At the end of this step, we had a clear scope, a project plan, interim definitions, a proposed timeline, and a stakeholder engagement plan. Step 2. Identify contexts of paramedic practice in Canada We identified contexts of paramedic practice in Canada by using a comprehensive systems-thinking approach, the details of which we published separately. 22 The contexts of practice were explored in this project through 15 pan-Canadian working groups –see Table 1 for details. The project advertised applications to serve on working groups via email and social media, in both English and French in May 2022, and closed in June 2022. From the 165 applications we received and reviewed, we appointed 154 applicants to 15 working groups. Working Group members and leads were appointed with considerations of inclusion, diversity, equity, and accessibility (IDEA), and geographical representation across Canada. Members appointed to working groups had expertise with the assigned context of practice, which we defined as ‘Practice, research, education, policy, and/or lived or living experience with the context.’Each Working Group had an identified lead person(s) appointed, along with a liaison person from the Development Group. Central to the development of the NCFP was a conscious effort to engage with system partners and end-users with considerations of Indigeneity, cultural proficiency, and IDEA. As such, we established an Indigenous Paramedic and Communities Engagement Working Group, an Interprofessional Perspectives Working Group, a Patient, Caregiver, and Public Engagement Working Group, a Cultural Proficiency Working Group, and a Healthy Professionals Working Group. All working groups represented various intersections of roles, gender, disability, sexual identity, race, ethnicity, age, and other identities. Indigenous paramedic and communities engagement An Indigenous paramedic service representative was appointed to the Technical Committee to provide a critical strategic perspective, while an Indigenous Paramedic and Communities Engagement working group liaised with Indigenous paramedics and communities from across Canada. This group synthesised the TRC Calls to Action, 32 the UN Declaration on the Rights of Indigenous Peoples, 45 Figure 4. Workflow of NCFP development. Image design by Alan Batt, used under a CC-BY 4.0 Licence. Batt et al. 117 the First Peoples, second class treatment report, 46 the Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls, 47 and other foundational documents to inform the overall project. In addition, we committed to, undertook, and supported Indigenous community consultations during Step 5. Patient, caregiver and public engagement This working group led the development, implementation and evaluation of a patient, caregiver, and public engagement strategy for the NCFP. Patients, caregivers, and members of the public were engaged at various points Figure 5. Timeline of NCFP development process . Image design by Alan Batt, used under a CC-BY 4.0 Licence. 118 Paramedicine 22(3) during the development process via co-creation and/or consultation. We sought patient and caregiver feedback on the framework during Step 5. Interprofessional perspectives This working group leveraged social media and personal networks to solicit input from nurses, physicians, social workers and other allied health and social care professionals on their perspectives of paramedic work, competencies, and roles using an online survey. This is important because limiting the conceptualisation of paramedic competence to that determined by paramedics may not provide insight into the complexity of healthcare and may fail to address the needs of all those who will use the framework. Cultural proficiency The Cultural Proficiency working group aimed to engage diverse clinicians and experts, and the literature related to the context of culture in paramedic practice across Canada. The group sought to explore health along a health and social continuum and promote enhanced understanding of the implications of intersectionality and social determinants of health on healthcare experiences, health status and outcomes. Recognising that cultural proficiency is not a static competency, the working group aimed to develop evidence-informed recommendations to inform development of iterative standards to better prepare students for entry to practice in paramedicine and advance the NCFP by including cultural proficiency across all professional domains. Healthy professionals This working group, comprised experts in paramedic wellbeing, professional identity, occupational safety and mental health, developed a framework for wellbeing leveraging subject matter expertise, a review of the relevant peer-reviewed literature, and the extant work developed for the PCC ‘Principles and Enabling Factors Guiding Paramedicine in Canada’ and the COPR ‘Health of Professional’with the goal to create complementary content so that leaders, regulators, and paramedics would have a shared focus on wellbeing from both systems and person perspectives. Table 1. Working groups and methods. Working group Methods and approaches Contexts of practice working groups Prehospital and Out-of-Hospital Emergency Care Review of existing 2011 NOCP competencies, 2 expert input from group. Community, Public Health, and Primary Care Literature review, review of CSA Standards, expert input from group. Emergency Department Literature review, expert input from group. Rural, Remote, and Isolated Literature review, expert input from group. Military Practice Literature review, review of CAF Military Employment Structure Phase 2, expert input from group, focus groups with CAF members across the country Substance Use and Mental Health Literature review, document analysis, expert input from group, engagement with PWLLE during public review period. Critical Care and Interfacility Transfer Literature review, expert input from group. Industrial Paramedicine Literature review, expert input from group. Palliative and End-of-Life Care Literature review, review of existing competency frameworks, expert input from group, engagement with national CoP. Special Operations Literature review, review of existing competency framework, expert input from group. Correctional and Remand Practice Expert input from group. Focused working groups Indigenous Paramedic and Communities Engagement Literature review, expert input from Indigenous paramedics (group members), targeted engagement with Indigenous communities during public review period. Interprofessional Perspectives Survey by group members, review of existing competencies, 42 environmental scan of inter-professional literature. Patient, Caregiver, and Public Engagement Literature review, review of existing competencies, 43 expert input from group, targeted engagement with patient and caregiver groups during public review period. Healthy Professionals Literature review, framework review, expert input from group. 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