Informing a Canadian paramedic profile: framing concepts, roles and crosscutting themes

RESEARCH ARTICLE Open Access Informing a Canadian paramedic profile: framing concepts, roles and crosscutting themes Walter Tavares 1,2,3,4,5* , Ron Bowles 6,7 and Becky Donelon 8 Abstract Background: Paramedicine is a rapidly evolving health profession with increasing responsibilities and contributions to healthcare. This rapid growth has left the profession with unclear professional and clinical boundaries. Existing defining frameworks may no longer align with the practice of paramedicine or expectations of the public. The purpose of this study was to explore the roles paramedics in Canada are to embody and that align with or support the rapid and ongoing evolution of the profession. Methods: We used a concurrent mixed methods study design involving a focused discourse analysis (i.e., analysis of language used to describe paramedics and paramedicine) of peer reviewed and grey literature (Phase 1) and in-depth one-on-one semi-structured interviews with key informants in Canadian paramedicine (Phase 2). Data from both methods were analyzed simultaneously throughout and after being merged using inductive thematic analysis. Results: Saturation was reached after 99 national and international grey and peer reviewed publications and 20 in depth interviews with stakeholders representing six provinces, seven different service/agency types, 11 operational roles and seven provider roles. After merging both data sets three framing concepts, six roles and four crosscutting themes emerged that may be significant to both present-day practice and aspirational. Framing concepts, which provide context, include variable contexts or practice, embedded relationships and a health and social continuum. Roles include clinician, health and social advocate, team member, educator, professional and reflective practitioner. Crosscutting themes including patient safety, adaptability, compassion and communication appear to exist in all roles. Conclusions: The paramedic profession is experiencing a shift that appears to deviate or at least place a tension on traditional views or models of practice. Underlying and evolving notions of practice are resulting in intended or actual clinical and professional boundaries that may require the profession to re-think how it is defined and/or shaped. Until these framing concepts, roles and crosscutting themes are fully understood, tested and operationalized, tensions between guiding frameworks and actual or intended practice may persist. Keywords: Paramedic, Community paramedic, Health services, Roles framework, Competency profile, Allied health personnel, Primary care, Education, Emergency medical services Abbreviations: ACP, Advanced care paramedic; BD, (Author) Becky Donelon; NOCP, National occupational competency profile; P, Participant; PAC, Paramedic Association of Canada; PCP, Primary care paramedic; RB, (Author) Ron Bowles; WT, (Author) Walter Tavares * Correspondence: [email protected];[email protected]; [email protected] 1 Centennial College, School of Community and Health Studies, 941 Progress Ave. Station A, P.O. Box 631M1K 5E9 Toronto, ON, Canada 2 York Region Paramedic Services, 80 Bales Dr. E. R.R.#1, L0G 1V0 East Sharon, ON, Canada Full list of author information is available at the end of the article © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tavares et al. BMC Health Services Research (2016) 16:477 DOI 10.1186/s12913-016-1739-1 Background Paramedicine has experienced significant growth in recent years. This health profession is moving beyond a purely emergency or acute care based system, to offering in addition, more complex and integrated health care [1–3]. This shift has largely been driven by growing health care system pressures, and evolving views on how health care is conceptualized and delivered, including for example, de-institutionalizing care and reducing in-hospital time for patients [4, 5]. Increasingly, paramedicine has become recognized as a health profession whose growing clinical acumen and unique point of contact with the public/patients can be leveraged to better serve their health care needs and meet policy goals; not only for those who contact paramedic services in a time of acute or emergent crisis (as is traditionally the case), but also for broader patient groups and needs [1, 6–8]. As a result, evolution of the profession has been rapid, with many trying to catch up by rethinking and reevaluating the boundaries of paramedicine. As paramedicine becomes part of system advances, well-established practice boundaries become unclear [8]. For instance, in contrast to more “traditional”responsibilities (e.g., responding solely to emergencies), paramedics have played a large part in the delivery of healthcare in under-serviced areas, or been integrated into long-term care settings as well as primary and/or family health teams [9–12]. Alternative disposition for patients (e.g., bypass protocols, referrals, treat and release programs) are increasingly common [13–16]. Even in more traditional models, innovative, specialized and expanding care programs are emerging [14, 17, 18]. These “non-traditional” practice settings have been effective in helping to manage acute and chronic conditions, reduce unplanned transfers to emergency departments, promote more health care touch points for patients and avoid or minimize admission and readmission rates [19]. These advances reflect conceptual and operational shifts in the profession, with significant implications on the abilities required of those who practice within it. For Canada, the Paramedic Association of Canada’s (PAC) National Occupational Competency Profile (NOCP) defines Canadian paramedic practice nationally by describing the competencies or tasks paramedics are expected to possess when practicing at a specified level (i.e., primary, advanced and critical care) [20]. While the NOCPs have been seminal in helping to describe paramedicine in Canada, the emphasis on decontextualized skills, the profession’s rapid growth and the emergence of increasingly diverse clinical programs, has led to a framework that may now be poorly aligned with the actual experiences of most paramedics and/or the public. Further, the NOCP is limited to specification of what paramedics can do, rather than what roles (i.e., professional capabilities) paramedics are to embody and by extension their place or contributions in the community or health care system [21]. Understanding fundamental roles assumed by paramedics provides the profession, educators, as well as patients, the public and associated health or public safety professions/disciplines, with clarity and direction in how it may be most effectively realized, integrated and/or utilized. Therefore, the objective of this study was to identify current and emerging roles all paramedics are to embody in Canada, regardless of designation or specialty, as defined by the profession. The aim was to be both reflective of current practice but also visionary in offering a conceptual framework that could promote discussion, debate and further study within the profession to ensure that what emerges ultimately has utility. Methods Study overview This study involved a concurrent mixed methods design involving a focused discourse analysis (i.e., analysis of language used to describe paramedics and paramedicine) of peer reviewed and grey literature (Phase 1) [22] and in-depth one-on-one semi-structured interviews with key informants in Canadian paramedicine (Phase 2). Data from both methods were analyzed simultaneously throughout and after being merged using inductive thematic analysis [23–25]. Ethics approval for this study was obtained through the Justice Institute of British Columbia Research Ethics Board (JIBCER-201404) and informed consent to participate in this study was obtained by all participants. For this research we adopted a constructionist approach [23, 25]. This research paradigm treats individual unique accounts and perspectives from authors/author groups and interviewees as valuable, rich and influenced by their specific but still meaningful context [26]. In applying this paradigm we accept that there are no hidden or “true”sets of roles to be discovered. Rather, any middle range theory or understanding that emerges regarding roles emerges as part of accepting that multiple views exist, which requires some degree of interpretation. As such our views and experiences are inextricably linked to the process. Knowledge and any roles that emerge are therefore co-constructed by the researcher-participant and researcher-literature interaction [27]. All authors are active researchers with extensive backgrounds in paramedicine as clinicians, educators, scientists, and/or regulators in Canadian paramedicine. Phase 1 data source: literature Our intention was to explore the literature as sources of language used to describe paramedics and paramedicine. We specifically searched for language used by authors Tavares et al. BMC Health Services Research (2016) 16:477 Page 2 of 16 (while considering context) that might inform our understanding of roles directly, or through interpretation and themed analysis. In other words, we engaged in the literature as sources of language rather than as sources of evidence. Doing so involves an informed and iterative data driven exploration, rather than a highly specific or standardized search and/or evaluation of evidence. This discourse analysis then, is a qualitative analytic method that looks for “broad themes and functions of language” including “recurrent patterns or genres of language that share similar structures and content”[28] and/or a collective viewpoint. This use of literature as data focuses on the terms, phrases, descriptions and concepts within the documents rather than on the content and the arguments of the documents per se. Two researchers (RB and BD) began by intentionally focusing on known seminal literature, both grey (defined as government reports, professional documents, and academic papers not controlled by commercial publishers) and peer reviewed, that has informed paramedicine in Canada broadly, including policy, operations, clinical practice, and education. Including both peer reviewed and grey literature emphasized our interest in language and recognized the presence, value and influential role of both in communicating, guiding and shaping the profession. Additional searches were conducted that used specific databases and search terms (see Table 1). We searched specifically for literature that (a) had at least in part, paramedics, paramedic practice or paramedicine as the focus of the work or unit or analysis; (b) discussed current or future paramedic practice; (c) described or made recommendations related to paramedics or paramedic practice; (d) discussed or informed the articulation of roles, functions, capabilities and/or attributes related to paramedics or paramedic practice. Initial data collection included a search of full-text English language literature published between1999 and 2014. While we focused initially on Canadian literature, we recognized the influence and increasing globalization of paramedicine, and included international works that had an influence on or application to Canadian contexts. We allowed the emerging data to generate framing and sensitizing concepts as they occurred, but remained open to any emerging ideas. We made efforts to be comprehensive and limit bias by seeking new and divergent ideas throughout. Both the literature and emerging concepts were used to iteratively seek additional data to strengthen, support, expand or challenge ideas. Data extraction and analysis We searched for and extracted terms, phrases, extended quotes and concepts used by authors. The extraction process was informed by a series of related concepts. These included descriptions of paramedic practice, emerging trends, expectations of practitioners, identified gaps and recommendations, capabilities and attributes required of practitioners. Coding was performed by two researchers (BD and RB), each of which read an overlapping subset of the full set of documents. The researchers employed an iterative process of data collection and open coding analysis, allowing for emergent themes to inform subsequent data collection and analysis [29]. A constant comparative method [23–25] was employed to further expand and refine codes. Memos, journaling and marginal notes were used to inform the coding structure but were also reviewed and integrated into the emerging data set. We continued this process until we reached saturation (i.e., no new codes or ideas emerged)) but stopped short of finalizing analyses until data from the literature could be merged and analyzed with interview data (discussed in more detail below). Phase 2 data source: interviews with stakeholders/Key informants Overview This phase of the study, which occurred concurrently with phase 1, involved in-depth one-on-one semistructured interviews with key informants. Given the diversity of paramedic programs and models nationally, Table 1 This table provides the search terms use as part of the discourse analysis Category Terms Key Terms for Paramedicine •EMS* •Emergency medical services* •Paramedic* •Ambulance •Prehospital •Pre-hospital Secondary Terms •Attributes •Capabilities •Competence* •Roles •Performance •Standards •Guidelines •Practice •Scope of practice •Themes •Trends •Change Activity # Articles Initial Search (primary inclusion criteria) 817 Initial Full Article Review 25 Expanded Search (secondary inclusion criteria) 3,174 Title/Abstract Review 132 Final Articles for In-depth Analysis and Coding 94 * = a boolean search modifier that has the search engine return and highlight any word that begins with the root/stem of the word truncated by the asterisk Tavares et al. BMC Health Services Research (2016) 16:477 Page 3 of 16 our sampling strategy was designed to ensure breadth in geography, specialties (tradition and non traditional) and stakeholders, while also using saturation of ideas as an end point. Interview questions broadly considered clinician level features and position in the health care/public safety fields that could be used to infer meaningful roles. Participants We recruited and enrolled participants using purposive and snowball sampling strategies. We developed a nomination strategy to: (a) identify those recognized by the community to be most suited to speak on its behalf (e.g., valuable or unique insight, history of meaningful contributions, positions of influence); (b) ensure broad representation both in geography (e.g., provinces, mix of urban, rural, remote communities) and profession breadth (e.g., all levels of paramedicine, diversity in specialty units, service delivery models, stakeholder types). We took advantage of a standing steering committee that was assembled by the PAC and the Alberta College of Paramedics to discuss revisions to the existing NOCPs. This committee included members from a number of stakeholder groups across Canada (e.g., regulators, educators, policy makers, employers, accreditors) and therefore was appropriately positioned as a starting point for our nomination and sampling strategies. We invited this group to offer nominations, but also to distribute the nomination request to other relevant respective provincial groups or individuals as they saw fit. We then rank ordered nominations against the criteria above to begin an initial set of invitations. Following each interview we asked participants whom we should additionally interview. We cross-referenced these ongoing nominations with our existing pool (and sampling goals), revising and adding participants as necessary. Interview guide Interviews were one-on-one and semi-structured. The interview guide was developed (using consensus on initial questions), piloted and revised to ensure clarity and limit biases prior to beginning data collection. We made efforts to use open-ended non-judgmental questions and probes to inquire more deeply where appropriate. Our questions targeted (a) paramedics and the profession in the context of the health care and public safety sectors, (b) the position itself (across whatever context was relevant to the participant) and (c) the individuals who serve in the profession (regardless of specialization or position). We allowed the interview guide to remain open to revision throughout and in remaining flexible we allowed ourselves to discuss issues that had been raised in earlier interviews or on topics the participants wanted to explore. See Table 2 for the final interview guide. Data collection and management Interviews were conducted primarily by WT with some conducted by RB and BD. Consent was obtained in writing and verbally in advance of the interview. All interviews were conducted over the telephone and audio recorded, and allowed to end naturally (i.e., no time limit). All recordings were then transcribed verbatim and reviewed for accuracy before analyses. QSR NVivo (http://www.qsrinternational.com/) was used to store, organize and analyze data. Data analysis and interpretation All transcripts were coded by WT with a subset additionally coded by RB and BD. Open coding was conducted throughout to allow for the identification of areas requiring additional data and/or new lines of inquiry. This initial coding was intended to remain open to any possibilities that could be discerned in the data and to avoid any conceptual leaps as we moved through the analytical work. We used a constant comparative method to refine codes, and engaged in axial coding where we began to synthesize the data into more meaningful codes and groups until eventually themes or groupings (as well as sub groups or supporting codes) began to emerge. Similar to the literature review, we stopped short of completing the analysis, allowing for final analyses to be conducted once data had been merged with the codes/data from phase 1. Merging of the data and analysis The initial analyses and coding in Phases 1 and 2 were merged into a single data set for further analysis. This was a deliberate attempt to allow both data sets, which had already been considered extensively (but not conclusively), and which we treated as equal, to be considered in relation to each other. This served as another and more extensive form of axial coding toward finalizing themes/roles. The research team met repeatedly to carry out the analysis, sharing and merging of codes and data, looking for convergence, divergence and emergence of groupings or themes. This process was inductive, iterative and involved moving back and forth within and between the existing data sets (emerged codes and groupings, as well as original data) until both data sets were fully represented. The intent at this point was not to identify roles, per se, but rather to group together codes and data into conceptual or thematic categories. We avoided overly defining any themes that may have emerged, leaving raw or refined codes (and their associated raw data) that had been grouped to serve as our initial supporting data. We captured these analyses visually first using maps, then converted these into narrative text (derived or inferred Tavares et al. BMC Health Services Research (2016) 16:477 Page 4 of 16 from the data) summarizing these ideas as core concepts within each category. Results Part 1 - initial results from the literature Using saturation as our end-point, we ultimately drew language from a total of 99 peer reviewed/academic (n=77) and grey publications (n= 22). See Table 3 for a final list of publications. Five hundred and eight unique statements were extracted and coded. Preliminary axial coding and inductive thematic analyses (i.e., prior to merging of data with interview data) led to 49 initial emerging groupings before being merged with interview data. Part 2 results –interviews with stakeholder/Key informants A total of 71 individuals were nominated from across Canada. After taking into consideration our sampling objectives and saturation, 20 stakeholders/key informants were interviewed in total, resulting in approximately 32 h of transcribed data. See Table 4 for a summary of participant demographics. In total 321 codes were generated. As part of the axial coding process, open codes were then grouped based on conceptual similarity, resulting in a preliminary set of 16 groupings. Open codes and groupings were then merged with the results from the literature review. Merged results –framing concepts, roles and crosscutting themes Our objective was to identify current and emerging roles paramedics are to embody in Canadian paramedicine. However, our analysis also revealed what we described as framing concepts (i.e., data that were not exactly roles but appeared to provide relevant context) roles and cross cutting themes (i.e., data that were similar to roles but appeared in all identified roles and thus were not distinct). Framing concepts Three framing concepts emerged: (a) variable context of practice, (b) embedded relationships and (c) a health and social continuum. Variable context of practice Paramedicine was discussed in ways that suggest shifts in the profession. These shifts occurred in terms of practice location (e.g., paramedics working in emergency department or clinics) [30] but also models of care [1, 11, 31]. For instance, paramedicine was no longer viewed as exclusively emergency response based, offering more in terms of contributions to health and health care: “I believe that the paramedic profession is at a point of maturation that it is well beyond the singular focus of the resuscitation days…we actually have a greater role to play, with more significant dividends in the areas of prevention, education and primary care.”[P-13] Emergency care was certainly an emphasis, but now for different reasons: “our primary focus is an emergency, likely probably will remain an emergency, but the more work we do on the primary healthcare side, the less I suspect there will be on the emergency side.”[P-09] This is leading to variable work and models of care that increasingly represent deviations from or expansions on traditional emergency care and opportunities: “Paramedicine will increasingly develop a skill set that would permit a larger Table 2 Interview guide for in depth one-on-one interviews with stakeholders and key informants Health Care System 1. In what way do paramedics contribute to the health care system? 2. In what way should paramedics contribute to the health care system? 3. What role are they holding now? (e.g., in ER, Flu shots) 4. Where do you see similarities when considering paramedics and other health care professionals? 5. Where do you see differences when considering paramedics and other health care professionals? 6. What do you see as deficiencies in practicing paramedics in the health care system? Position/Roles 7. At the entry to practice level, what would you like to see in paramedics? Or put differently, what should paramedics be able to do in order to fulfill some of the role(s) or functions we have been discussing? 8. What are “your”(e.g., stakeholder group, practitioner, public) expectations of a paramedic? a. As they interact with you/your organization? b. As independent professionals? c. As collaborative member of a paramedic team or multi-disciplinary team? About the Individual 9. Think of the best paramedic or paramedics you know. What is it about these individuals that make them great? 10. Paramedics work is varied contexts and with a broad range of patients. What do you think is the difference between those that consistently function well and those that don’t? 11. What are common deficiencies or errors paramedics are guilty off that perhaps should be addressed? 12. What professional attributes do you see as essential for paramedics to maintain, develop or refine expertise over the duration of their careers? 13. What attributes or capabilities are integral in paramedic practice? (prompts: can you think of both clinical (i.e., those that are associated directly with patient interactions) and non-clinical (i.e., those that do are not directly associated with patient interactions) attributes?) 14. Do you have anything else you would like to share with us regarding attributes of paramedics in Canada from your point of view, regardless of level, specialization or position, now and to the year 2020? Tavares et al. BMC Health Services Research (2016) 16:477 Page 5 of 16 Table 3 Literature review results Peer Reviewed: 77 Acker, Johnston, & LazarsfeldJensen 2014 Industrial paramedics, out on site but not out of mind. Rural and Remote Health Australia Armitage 2010 Role of paramedic mentors in an evolving profession. Journal of Paramedic Practice UK Backe, Kaul, Klubmann, Liebers, Thim, Mabbeck, & Steinberg 2009 Assessment of salivary cortisol as stress marker in ambulance service personnel: Comparison between shifts working on mobile intensive care unit and patient transport ambulance. International Archives of Occupational and Environmental Health Germany Ball 2004 Setting the scene for the paramedic in primary care: A review of the literature. Emergency Medicine Journal UK; English language literature Brown, Dickison, Misselback, & Levine 2002 Longitudinal emergency medical technician attribute and demographic study (LEADS): An interim report. Prehospital Emergency Care USA Brown, Margolis, Levine 2005 Peer evaluation of the professional behaviors of emergency medical technicians. Prehospital Disaster Medicine USA Burges Watson, Sanoff, Mackintosh, Saver, Ford, Price,…Murtagh 2012 Evidence from the scene: Paramedic perspectives on involvement in out-of-hospital research. Annals of Emergency Medicine UK, USA Campbell & Rasmussen 2012 Riding third: Social work in an ambulance. Health & Social Work Canada Campeau 2008 Professionalism: Why paramedics require theories of practice. Journal of Emergency Primary Health Care None Stated Campeau 2011 The paramedic kairotope theory: Findings. Journal of Paramedic Practice Canada Clarke, Bradley, et al. 2014 Can paramedics use FRAX (the WHO Fracture Risk Assessment Tool) to help GPs improve future fracture risk in patients who fall? Protocol for a randomised controlled feasibility study. British Medical Journal Open UK Commission on the Future of Health Care in Canada, & Romanow 2002 Building on values: The future of health care in Canada: Final report. Commission on the Future of Health Care in Canada Canada Cooper 2005 Contemporary UK paramedical training and education. How do we train? How should we educate? Emergency Medicine Journal UK Cooper & Grant 2009 New and emerging roles in out of hospital emergency care: A review of the international literature. International Emergency Nursing International literature Cooper, Barrett, Black, Evans, Real, Williams & Wright 2004 The emerging role of the emergency care practitioner. Emergency Medicine Journal UK Cummins, Garavan, Dixon, Landymore, Mulligan & O’Donnell 2013 The advanced paramedic clinical activity study (APCAS): An insight into the work of advanced paramedics in the midwest of Ireland. Irish Journal of Medical Science Ireland Dawson, King & Grantham 2013 Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient. Emergency Medicine Australia UK Donaghy 2008 Higher education for paramedics –Why? Journal of Paramedic Practice UK Donaghy 2008 Equipping the student for workplace changes in paramedic education. Journal of Paramedic Practice UK Edwards 2011 Paramedic preceptor: Work readiness in graduate paramedics. Clinical Teacher Australia Evans, McGovern, Birch & Newbury-Birch 2014 Which extended paramedic skills are making an impact in emergency care and can be related to the UK paramedics system? A systematic review of the literature. Emergency Medicine Journal English Language LIterature Everden, Eardley, Lorgelly & Howe 2003 Emergency care: Change of pace. The Health Service Journal UK Heardman 2014 Treating people with cardiac chest pain: Role of paramedics. Emergency Nurse: The Journal of the RCN Accident and Emergency Nursing Association UK Hodge 2014 Developing leadership in the UK’s ambulance service: A review of the consultant paramedic role. Journal of Paramedic Practice UK Tavares et al. BMC Health Services Research (2016) 16:477 Page 6 of 16 Table 3 Literature review results (Continued) Hou, Rego & Service 2013 Review article: Paramedic education opportunities and challenges in Australia. Emergency Medicine Australia Australia Hubble, Brown, Wilfong, Hertelendy, Benner & Richards 2010 A meta-analysis of prehospital airway control techniques part I: Orotracheal and nasotracheal intubation success rates. Prehospital Emergency Care English Language Literature Jackson 2012 Senior paramedic role at North West ambulance service. Journal of Paramedic Practice ?UK Jensen, Croskerry & Travers 2011 Consensus on paramedic clinical decisions during highacuity emergency calls: results of a Canadian Delphi study. Canadian Journal of Emergency Medicine Canada Kilner 2004 Desirable attributes of ambulance technician, paramedic, and clinical supervisor: Findings from a Delphi study. Emergency Medicine Journal UK Kilner 2004 Educating the ambulance technician, paramedic, and clinical supervisor: Using factor analysis to inform the curriculum. Emergency Medicine Journal UK Lammers, Byrwa, Fales, Hale 2009 Simulation-based assessment of paramedic pediatric resuscitation skills. Prehospital Emergency Care USA Landman, Lee, Sasson, Van Gelder & Curry 2012 Prehospital electronic patient care report systems: Early experiences from emergency medical services agency leaders. PloS one USA Larkin & Fowler 2002 Essential ethics for EMS: Cardinal virtues and core principles. Emergency Medicine Clinics of North America Not declared; USA Lazarsfeld-Jensen 2014 Telling stories out of school: Experiencing the paramedic’s oral traditions and role dissonance. Nurse Education in Practice Australia Lord, Récoché, O’Connor, Yates & Service 2012 Paramedics’perceptions of their role in palliative care: Analysis of focus group transcripts. Journal of Palliative Care Australia Margolis, Romero, Fernandez, Studnek 2009 Strategies of high-performing paramedic educational programs. Prehospital Emergency Care USA Mason, Wardrope, Perrin 2003 Developing a community paramedic practitioner intermediate care support scheme for older people with minor conditions. Emergency Medicine Journal UK Mason, Coleman, O'Keeffe, Ratcliffe & Nicholl 2006 The evolution of the emergency care practitioner role in England: Experiences and impact. Emergency Medicine Journal UK McClelland 2013 The research paramedic: A new role. Journal of Paramedic Practice UK McKean 2013 The forensic paramedic: An outline of the role and essential criteria for the job. Journal of Paramedic Practice UK Michau, Roberts, Williams & Boyle 2009 An investigation of theory-practice gap in undergraduate paramedic education. BioMedical Central Medical Education Australia Mulholland, Barnett & Spencer 2014 Interprofessional learning and rural paramedic care. Rural & Remote Health Australia Mulholland, O’Meara, Walker, Stirling & Tourle 2009 Multidisciplinary practice in action: The rural paramedic–it’s not only lights and sirens. Journal of Emergency Primary Health Care English language literature O’Meara, Tourle, Stirling, Walker & Pedler 2012 Extending the paramedic role in rural Australia: A story of flexibility and innovation. Rural and Remote Health Australia Pearson 2003 Emergency medical technician/paramedic’s role in prehospital drug delivery. Journal of Pharmacy Technology UK Petter & Armitage 2012 Raising educational standards for the paramedic profession. Journal of Paramedic Practice UK Reeve, Pashen, Mumme, De & Cheffins 2008 Expanding the role of paramedics in northern Queensland: An evaluation of population health training. The Australian Journal of Rural Health Australia Roberts & Henderson 2009 Paramedic perceptions of their role, education, training and working relationships when attending cases of mental illness. Journal of Emergency Primary Health Care Australia Ruple, Frazer, Hsieh, Bake & Freel 2005 The state of EMS education research project: Characteristics of EMS educators. Prehospital Emergency Care - Education and Practice USA Safaei 2010 A ride to care –a non-emergency medical transportation service in rural British Columbia. Rural and Remote Health Canada Tavares et al. BMC Health Services Research (2016) 16:477 Page 7 of 16 Table 3 Literature review results (Continued) Shields & Flin 2013 Paramedics’non-technical skills: A literature review. Emergency Medicine Journal UK; English language literature Silversides 2009 Canada’s ability to respond to a national health crisis hampered by jurisdictional issues, untested emergency plans. Canadian Medical Association Journal Canada Singh, MacDonald, Bronskill & Schull 2007 Interfacility transport of acutely-ill patients: Incidence of intransit critical events. American Journal of Respiratory Critical Care Medicine USA Singh, Ferguson, MacDonald, Stewart & Schull 2009 Ventilation practices and critical events during transport of ventilated patients outside of hospital: A retrospective cohort study. Prehospital Emergency Care Canada Smart 2009 The role of the paramedic in health promotion. Journal of Paramedic Practice UK Stevens &Alexander 2005 The impact of training and experience on EMS providers’ feelings towards pediatric emergencies in a rural state. Pediatric Emergency Care USA Stevens, Jones, Smith, Nelson, Agho, Taylor & Raphael 2010 Determinants of paramedic response readiness for CBRNE threats. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science Australia Studnek, Fernandez & Margolis 2009 Assessing continued cognitive competence among rural emergency medical technicians. Prehospital Emergency Care USA Tam, Maloney, Gaboury, Verdon, Trickett, Ledu & Poirier 2009 Review of endotracheal intubations by Ottawa advanced care paramedics in Canada. Prehospital Emergency Care Canada Tavares & Mausz 2013 Assessment of non-clinical attributes in paramedicine using multiple mini-interviews. Emergency Medicine Journal Canada Tohira, Williams, Jacobs, Bremner & Finn 2013 The impact of new prehospital practitioners on ambulance transportation to the emergency department: A systematic review and meta-analysis. Emergency Medicine Journal UK; English language literature Trede 2012 Becoming professional in the 21 st Century. Australasian Journal of Paramedicine None stated Trojanowski & MacDonald 2011 Safe transport of patients with acute coronary syndrome or cardiogenic shock by skilled air medical crews. Prehospital Emergency Care Canada Vilensky & MacDonald 2011 Communication errors in dispatch of air medical transport. Prehospital Emergency Care Canada Vopelius-Feldt, Wood & Benger 2014 Critical care paramedics: Where is the evidence? A systematic review. Emergency Medicine Journal UK; International literature Wang & Yealy 2006 Human patients or simulators for teaching endotracheal intubation: Whom are we fooling? Academic Emergency Medicine USA Wang & Yealy 2006 How many attempts are required to accomplish out of hospital endotracheal intubation? Academic Emergency Medicine USA Williams, Onsman & Brown 2010 Paramedic education: The significance of graduate attributes. Journal of Paramedic Practice Australia Williams, Onsman & Brown 2012 A Rasch and factor analysis of a paramedic graduate attribute scale. Evaluation & the Health Professions Australia Willis, Pointon, O’Meara, McCarthy & Lazarsfeld-Jensen 2009 Paramedic education: Developing depth through networks and evidence-based research –Executive summary. Australasian Journal of Paramedicine Australia Woollard 2006 The role of the paramedic practitioner in the UK. Journal of Emergency Primary Health Care UK Wyatt 2003 Paramedic practice –Knowledge invested in action. Journal of Emergency Primary Health Care Australia Youngquist, Henderson, Gausche-Hill, Goodrich, Poore & Lewis 2008 Paramedic self-efficacy and skill retention in pediatric airway management. Academic Emergency Medicine USA Grey Literature: 22 Bigham, Brooks, Maher 2010 Patient safety in emergency medical services: Advancing and aligning the culture of patient safety in EMS. Canadian Patient Safety Institute Canada Tavares et al. BMC Health Services Research (2016) 16:477 Page 8 of 16 range of problems to be managed without hospital visits.”[P-AL] Even when engaged in emergency response this shift included empowering paramedics to provide more patient centered dispositions. Shifts in physical workspace and models of care, novel contributions to health care and more patient centered care collectively served as one framing concept that helped to provide context for some of the roles described below. Embedded relationships A second framing concept involved paramedic clinical practice as being embedded in a number of relationships. Examples included relationships with patients, their family, their health history and existing care plans (if any) [30], with other healthcare team members (directly or indirectly) [1, 3, 30–32], their (i.e., both patients and paramedics) position in the larger healthcare system as well as social and/or cultural context [33]: “paramedics are part of a systems approach to health care, so a community system of care, an out of hospital system of care, and a hospital system of care, and they overlap.”[P-02] Others have discussed how inter-dependencies between the health care services have created a need for paramedicine to foster strong linkages with other stakeholders, including Table 3 Literature review results (Continued) Clarke, Harris, & Cowland 2010 Ethics and law for the paramedic. Blaber, A. (2008). Foundations for Paramedic Practice. 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Med Teach. 2013;35(11):949–55. • We accept pre-submission inquiries • Our selector tool helps you to find the most relevant journal • We provide round the clock customer support • Convenient online submission • Thorough peer review • Inclusion in PubMed and all major indexing services • Maximum visibility for your research Submit your manuscript at www.biomedcentral.com/submit Submit your next manuscript to BioMed Central and we will help you at every step: Tavares et al. BMC Health Services Research (2016) 16:477 Page 16 of 16