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Georgette Eaton shares an overview of her research as part of her NIHR Doctoral Research Fellowship focusing on the employment of paramedics in primary care.

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As part of Advanced Practice week in November 2021, Georgette Eaton was invited to run a workshop at The Centre for Advancing Practice Conference based on the research she had undertaken as part of her NIHR Doctoral Research Fellowship, which focusses on the employment of paramedics in primary care. This blog gives an overview of the workshop, a recording of which can be found here.

To understand the ways in which paramedics impact (or not) the primary care workforce, we undertook an evidence synthesis on the potential implementation of paramedics into primary care. From this research, we have produced the following guide to support the implementation of an educational framework for paramedics rotating into primary care.

Documents supporting design

When considering the employment of paramedics in primary care, there are several key documents that are worth highlighting:

These tools clearly outline the expected role of the paramedic in primary care and should be considered in the initial design phase when thinking about employment.

These tools clearly outline the expected role of the paramedic in primary care and should be considered in the initial design phase when thinking about employment.

What is the difference between a Paramedic and Advanced Paramedic?

Although this is alluded to in the College of Paramedics’ document, what the other documents perhaps fail to consider is what a paramedic is.

Generally, paramedics perceive themselves as generalist clinicians who, by virtue of their work within ambulance services, need to respond to all types of patients, across all ages, with any presenting complaint. Sometimes, the paramedic is viewed as a ‘jack of all trades’, with connotations that they are master of none. However, what is often missing from this is the full phrase – ‘oftentimes better than master of one’. The phrase means that a person is a generalist rather than a specialist, and we see this with paramedics who are versatile and adept at approaching the undifferentiated, undiagnosed, patient.

Paramedics may be considered as pluripotential –something that has no fixed developmental potential - which is a useful addition for primary care teams, where paramedics have the capabilities to deal with a breadth of issues, as well as being developed to a narrower focus as the setting demanded.

 Crucially, advanced paramedics will work to the common level of advanced practice - educated to Master’s level and have developed the skills and knowledge to allow them to take on expanded roles and scope of practice caring for patients.

Why do you want a paramedic in primary care?

We know why paramedics may be suitable for primary care but thinking back to the design, an important consideration is; Why do you want a paramedic in primary care? What’s important to you?

Whatever the reason, considering why you want a paramedic in primary care is important to ensure they transition well from their previous employment into primary care:

  • Do you need a paramedic or an advanced paramedic?
  • If you need a paramedic to plug gaps in your workforce, then what supervision will you be able to give them as they enter their new role?
  • If their job is about widening patient access, what patient groups are you expecting the paramedic to see, and how will you agree that?
  • If you want to create a multidisciplinary workforce, what are the views of the other professionals in that team?

We found evidence that paramedics transition well into primary care (particularly to advanced practice roles) when supported by primary care – and this centred around education, supervision and experience.

Education

The need to build upon existing skills and competencies for paramedics and advanced paramedics to be more effective in primary care was considered across many of the case study and evaluation literature. The clinical gaps that need to be filled for successful transition to primary care centred around biochemistry (for the understanding and interpretation of blood tests), pharmacotherapy (to support independent prescribing for long term conditions or complex patient groups), and some technical skills such as wound care, urinalysis and imaging.

Throughout the literature, higher levels of paramedic education was associated with a higher level of pay and an increased scope of practice and clinical responsibility. Such attainment was used as marker to differentiate between advanced paramedic roles at Master’s level education and other paramedic roles. 

Supervision

The success of the transition to primary care from ambulance services was linked to provision of supervision to support paramedic clinical development. Clinical supervision enabled paramedics and advanced paramedics to feel supported as they adjusted their skill set to a new clinical setting and gave them confidence and satisfaction in their new role. Supervision also enabled GPs to build up trusting relationships with the paramedics, who could then be accepted into the primary care team.

Where clinical supervision was not provided, or where there were difficulties in the supervisory relationship, paramedics and advanced paramedics reported feelings of isolation and lower satisfaction with the work in their role, opting to return to ambulance service employment.

Experience

Throughout the literature across all countries, an arbitrary five years of post-registration experience within the ambulance service was considered a requirement for paramedics entering primary care roles. This is also supported by policymakers, such NHS England and Health Education England. However, there was no evidence to support why this length of experience was expected.

However, role consolidation was important for employers and paramedics, who made links between the length of exposure to patients as an autonomous clinician within the ambulance service and successful transition into primary care.

Implementation

There are four ingredients to consider for their first day in primary care to be successful:

  1. For patients, uncertainty exists when the role of the paramedic is not made clear or their expectation is not met if they attend an appointment with a paramedic when they believed they were seeing their usual GP. Patients can view the paramedic role favourably following communication from the practice, or their GP – both of which are considered ‘trusted sources’.

  2. Integration into the primary care team is crucial to avoid role duplication. Duplication is less likely to occur when the professional role boundaries of the paramedic or advanced paramedic in primary care do not overlap with existing healthcare professionals. However, where role boundaries became blurred, resistance can occur from other healthcare professionals due to a lack of confidence in the capabilities of the paramedic or feelings of threat in terms of their own job security.

  3. Whilst there was much positivity when considering the paramedic and advanced paramedic in primary care from the perspective of the GP, in some reviewed literature GPs saw paramedics as offering an ‘eyes and ears’ approach only. Using them for assessment-only roles, paramedics were not regarded as autonomous clinicians who would be able to diagnose and manage patients on their own, and thus required clinical oversight from a GP. Deployment of paramedics in such a way was unlikely to free up GP time and often led to unintended consequences such as patient frustration in the unnecessary duplication of consultations. Additionally, using advanced paramedics for assessment only roles does not relate to the criteria outlined for practice at an advanced level.

  4. General housekeeping in the practice is important, particularly understanding the documentation system, if the paramedic or advanced paramedic is going to work effectively. Writing patient clinical records will not be new to the paramedic, but understanding how the computer system works is one of the most important factors to aid transition. Spending time with the paramedic or advanced paramedic on the first day, reviewing their note keeping, outlining options for referral pathways, understanding basic blood requests and sample processing are all good foundations to ensure the paramedic can embrace their new role.

Barriers to implementation

  • Continuing Professional Development
    Lack of development post-registration or post-Master’s degree will be a barrier. This was found in an evaluation that looked at the design and implementation of an education framework for Advanced Paramedics in WAST. Schemes such as Red Whale and BMJ Learning offer additional tools for paramedics to develop their knowledge and support their ongoing integration into primary care, and may be useful to bridge the theory/practice gap.

  • Novice to Expert
    Paramedics may be an expert ambulance paramedic, but on completion of their Master’s degree and moving into primary care, they are novice – transitioned into a role where there are further opportunities to develop, but therefore greater opportunities for unconscious/conscious incompetence. Despite its name, it’s unlikely that a Master’s degree will make a paramedic with mastery in advanced practice or primary care – it’s one third of the overall picture when we take into account the need for supervision and clinical experience. There is a real danger with perceiving completion of the Master’s degree as the panacea – where this is really the starting point for consolidation.

  • Patient opposition
    There needs to be patient acceptance of the paramedic role in primary care if they are to be used effectively.

  • Provision of feedback
    A lack of feedback is typically compounded by a lack of resources, such as time to support supervision and time to support integration into primary care. In addition to this is the skills of GPs to support supervision and the development of the paramedic to advanced practice level (if wanted).

  • Recording Development
    In England, Health Education England’s Roadmap provides forms for the completion of Stage 1 and Stage 2 for First Contact Practitioners, with the aim that these forms will continue to be used for Advanced Practitioners as they move into primary care. These forms will make up the portfolio for submission to the Centre for Advancing Practice.

In one evaluation, there was poor uptake amongst advanced paramedics and GPs in recording development of paramedics in primary care. When probed about this, issues relating to time for completion, the complexity of the form and the collecting of other data were all barriers the advanced paramedics faced in the completion of these documents.

Overcoming barriers

Overcoming these barriers to integration will rely on addressing some components from the design stage:

  1. Clarity regarding scope of role. What do you want the paramedic to do? How do they fit into the team? This should be transparent and clear, with a clear understanding within the practice team regarding what a paramedic is there to do, and the development needs for the paramedic to continue to grow and develop.

  2. Involvement of the patient participation group prior to recruitment – they will be pivotal in helping to guide how the role the paramedic undertakes is communicated within the practice.

  3. Use the primary care network to standardize recruitment and set the scope of role the paramedic or advanced paramedic is expected to undertake. This is especially important if patients are expected to move between different practices within the network. The PCN can also share the responsibility for education and development of the paramedic – using the skills of GPs already there, for example those with speciality interests or GP trainers.

  4. Lastly, clinical progression – how will the progression of the paramedic post-Master’s be supported? What areas are open for them to develop? If the paramedic is employed by the ambulance service and rotating into primary care, who will assume responsibility for the progression of the paramedic – and how will this ensure the time invested into them from primary care isn’t wasted?

Implementation framework

Based on this realist review, the employment and integration of paramedics into primary care should consider the following, outlined in the framework to support implementation below:

 

 Figure5Frameworktosupportimplementation10241024_1.jpg

 

This considers the characteristics of the paramedic working in primary care and then the integration of the paramedic into the team – considering the transition, socialisation within the practice, clarity of role and patient acceptance.

 

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