Abstract
In the United States (U.S.), the Subcommittee on Adaptability and Innovation of the National Emergency Medical Services Advisory Council (NEMSAC) recently recommended that a clinically focused Master of Science in Paramedicine (MSP) be developed as the standard minimum academic degree to meet the educational needs of paramedic practitioners in the U.S. 1 The subcommittee came to this position in recognition of the emergence of new roles such as community paramedicine calls for a clinical career ladder and the evidence linking the lack of postgraduate educational opportunities with Emergency Medical Service (EMS) personnel attrition. 2 Coupled with this recommendation were funding and regulatory adjustments to enable advanced paramedic practitioners to sustainably practice to their full professional capabilities as health professionals.
Giving support to this call for the expansion of paramedic clinical and leadership roles, the introduction of postgraduate education for paramedics, and changes to regulatory and fiscal policies to facilitate real and sustainable change appears straightforward and logical. It provides a modest step toward the dual vision to modernise EMS agencies and professionalise paramedicine. The bigger challenge is to understand why these initiatives are not already in place almost three decades after the release of the EMS Agenda for the Future.3,4 These recommendations are consistent with initiatives in countries that have already embarked on system modernisation and paramedic professionalisation.5–8 Failure to progress these recommendations may raise concerns internationally when the U.S. paramedic system is sometimes touted as the benchmark by some policy makers and stakeholders.9,10
These NEMSAC recommendations have met with fierce opposition from fire agencies and associations, some employer groups and surprisingly the National Association of Emergency Medical Technicians, some of whom oppose entry-to-practice bachelor degrees for paramedics. 11 This negative stance toward the evolution of paramedic education illustrates the fractured position amongst stakeholders in relation to the professionalisation of paramedicine. There exist structural and cultural characteristics in the U.S. that inhibit paramedic professionalisation, such as fragmentation across different agency types (hospital, fire, and third service), fragile funding, and limited integration into the health system. With almost half of EMS agencies operating as departments of fire services, where a fire/rescue philosophy is likely to be dominant, it is unsurprising that EMS agencies and their staff battle to have a strong professional identity and that their ability to collectively construct a future as health professionals is constrained.12,13
The U.S. is an outlier amongst high-income countries using the Anglo-American prehospital model, where paramedics and emergency medical technicians battle to achieve tangible professional esteem, are often poorly remunerated in uncertain employment, and have minimal control over their own occupation.13–18 The professional recognition of paramedics in the U.S. is comparatively poor, with paramedics often self-identifying as public safety providers, they are rarely educated alongside other health professionals, and lack the professional autonomy associated with co-regulation. These factors impact on opportunities for career progression within the profession, access to advanced and continuing education, competitive remuneration, and staff retention.19,20
While it is evident that the U.S. has not embraced higher education for paramedics, 21 there is also little paramedic-led research, and paramedics have limited professional autonomy.22,23 Their professional aspirations are frustrated by antiquated regulatory structures and an occupational culture that limits efforts to professionalise. This lack of professional agency is arguably a result of a discourse that is dominated by stakeholders other than paramedics, who have stymied efforts to professionalise through the transfer of paramedic education to higher education institutions, the growth of strong professional organisations, and the establishment of co-regulatory mechanisms. 13 It has been argued that paramedics in the U.S. often feel they have no right to have a seat at the table, even when their own practice is discussed and decisions are made about their education, scopes of practice, and fitness to practice. 24 They have been said to not own their profession. 25
This lack of professional agency is further complicated when there remain arguments about the nomenclature of EMS personnel and questions of whether they are fundamentally public safety providers or health professionals. 13 This inability to form and sustain a professional identity in the absence of agreed titles and roles is a significant barrier to paramedic professionalisation.25,26 Despite recommendations for change that date back decades, little has changed in the professional status of paramedics.3,4,27,28
The NEMSAC recommendations calling for the development and encouragement of postgraduate education for paramedics aspiring to practitioner roles is a step toward improving the clinical leadership capabilities of paramedics and supports other initiatives to professionalise paramedicine in the U.S. Other countries are progressing these aims through the mandating of Bachelor degree-level education for new entrants into the profession as registered health professionals, as well developing postgraduate-level education programmes for those paramedics moving into advanced practice and consultant roles.29,30
Success in comparable countries demonstrates that being accepted as health professionals and being afforded professional autonomy is dependent on enhanced educational opportunities, robust co-regulatory frameworks, and having a professional self-identity based on a unique paramedicine discourse. 6 In the absence of significant change, such as the embrace of a clinically focused Master of Science in Paramedicine (MSP), paramedics in the U.S. are unlikely to have sufficient professional agency to achieve the level of professionalisation that paramedics in comparable countries take for granted.
While there are strategies that paramedics, peak bodies, and EMS agencies in the U.S. are taking toward EMS modernisation and paramedic professionalisation, tangible progress is slow and has barely moved beyond identifying the issues and articulating a long-term vision. 27 System fragmentation makes it unclear where the responsibility for action lies, 31 with EMS agencies, medical directors, and government regulators holding the power to act. These recommendations are a significant effort to break this logjam by suggesting a set of initiatives that have the potential to garner widespread support within EMS agencies and amongst paramedics that will better align paramedicine values and practice with the health system and other health professionals.