Post on 18-Apr-2020
AUSTRALASIAN PARAMEDIC ATTITUDES AND PERCEPTIONS ABOUT CONTINUING
PROFESSIONAL DEVELOPMENT.
Lisa Rose HobbsBachelor of Science – Psychology
Diploma of Paramedical Science – Ambulance
Graduate Certificate Clinical Education
Graduate Diploma Health Management – Disaster Management
Submitted in fulfilment of the requirements for the degree ofMaster of Philosophy
School of Clinical SciencesFaculty of Health
Queensland University of Technology2019
“To know that you do not know is the best.
To think you know when you do not is a disease.
Recognising this disease as a disease is to be free of it.”
Lao-Tzu
Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development. i
Keywords
Ambulance; Ambulance Education; Compliance Training; Continuing
Professional Development; Lifelong Learning; Mandatory Training; Paramedic;
Paramedic Training; Professional Development.
ii Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development.
Abstract
The paramedic role is rapidly evolving commensurate with the emergence of the
paramedic profession. Historically, the model of continuing professional development
(CPD) rested solely with the completion of mandatory programs required to facilitate
changes in scope of practice or policy. These mandatory programs were developed
within services and were specific to the individual workforce. The evolution of
paramedic education and CPD has progressed parallel to the role of a paramedic,
moving away from an in-house apprenticeship style of vocational training to a model
of tertiary education.
Professional registration of Australasian paramedics commenced 1st December
2018, through the Australian Health Practitioner Regulation Agency (AHPRA). The
registration date for New Zealand Paramedics is not yet confirmed. Like existing
registered health professionals, paramedics will be required to adhere to common
professional registration standards including participation in and, the maintenance of
CPD. However, a gap in the literature exists in relation to paramedic attitudes and
engagement in CPD opportunities.
This study applied the CPD framework proposed by Kennedy (2014); a model
of professional development plan (PDP); and the CPD framework proposed by Filipe,
Golnik & Mack (2018) to existing paramedic literature and participant paramedics.
This study, which was qualitative in its focus, was guided by constructivist grounded
theory methodology as proposed by Kathy Charmaz (2014). Constructivist grounded
theory is a robust methodology which has been utilised successfully in numerous
studies within the fields of nursing, education and psychology (Mills, Bonner &
Francis, 2006). Furthermore, the reflexivity of the researcher as a paramedic, senior
clinical educator, officer-in-charge and academic supports the Constructivist
Grounded Theory methodology and adds to the validity of this research.
Qualified, working paramedics (N=10) from Australia and New Zealand were
interviewed for this study. The study participants completed their paramedic
qualification either through post-employment in-house Vocational Education and
Training (VET) or completed a pre-employment university degree. Participants had
worked as a paramedic for a period ranging from two to 31. Thus, a number of different
Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development. iii
enculturation factors were encountered by participants, and they had varied
experiences with CPD. The differences in experiences provides a rich view of the
Australasian paramedic demographic.
The research study enabled the creation of a new framework of paramedic CPD,
which includes CPD models; Professional Development Plans (PDP); reflective
practices; and Lifelong Learning (LLL). The framework acknowledges professional,
industrial, social, personal, political, organisational and economic factors which
influence or change engagement in CPD. The study found it is not a considerable step
up for paramedics to engage in CPD and LLL, although some older paramedics are
expressing fear about it; and education is now forming a new hierarchical
stigmatisation, demonstrating a shift in paramedic culture.
iv Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development.
Table of Contents
Keywords .................................................................................................................................. i
Abstract .................................................................................................................................... ii
Table of Contents .................................................................................................................... iv
List of Figures ........................................................................................................................vii
List of Tables.........................................................................................................................viii
List of Abbreviations............................................................................................................... ix
List of Abbreviations................................................................................................................ x
Publications and Presentations Stemming from this Study....................................................xii
Statement of Original Authorship .........................................................................................xiii
Acknowledgements ............................................................................................................... xiv
Chapter 1: Introduction ...................................................................................... 1
1.1 Paramedics and Paramedicine........................................................................................ 1
1.2 Overview of Ambulance Services in Australasia........................................................... 1
1.3 The History of Paramedic Continuing Professional Development (CPD)..................... 3
1.4 The Progression of Paramedic Registration and CPD ................................................... 4
1.5 Relevance of this Study.................................................................................................. 6
Chapter 2: Literature Review ............................................................................. 9
2.1 Search Strategy .............................................................................................................. 9
2.2 Paramedic CPD Literature ........................................................................................... 12
2.3 Continuing Professional Development: Broad Definition in the Literature................. 15
2.4 Education and Training of Paramedics ........................................................................ 16
2.5 Ambulance Culture, History, Transition and CPD ...................................................... 22
2.6 Transition of Practice: Emergence of the Paramedic Profession ................................. 24
2.7 Upskilling Paramedics: Expanding Paramedic Scope of Practice ............................... 29
2.8 CPD in Allied Health Professions................................................................................ 30
2.9 CPD and Imminent Registration of other Health Professionals................................... 31
2.10 Lessons of Engagement ............................................................................................... 33
2.11 Summary: Gaps in the Literature ................................................................................. 36
Chapter 3: Theoretical Background................................................................. 37
3.1 Definition ..................................................................................................................... 37
3.2 Adult Learning Theories in Medical Education........................................................... 37
3.3 Paramedic Journey to Accepting Personal Responsibility for CPD and LLL ............. 41
3.4 Models of Continuing Professional Development ....................................................... 43
3.5 Conclusion ................................................................................................................... 53
Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development. v
Chapter 4: Methodology.................................................................................... 55
4.1 Qualitative Research.....................................................................................................55
4.2 Methodological Framework..........................................................................................57
4.3 Ontology and Epistemology .........................................................................................59
4.4 Reflexivity ....................................................................................................................60
4.5 Methods ........................................................................................................................62
4.6 Recruitment ..................................................................................................................63
4.7 Inclusion and Exclusion Criteria ..................................................................................64
4.8 Justification of Cohorts.................................................................................................66
4.9 Research Questions.......................................................................................................67
4.10 Ethics ............................................................................................................................68
4.11 Data Collection .............................................................................................................68
4.12 Data Analysis................................................................................................................70
4.13 Summary.......................................................................................................................79
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD ............................................................................................ 81
5.1 Introduction ..................................................................................................................81
5.2 Understanding Associate Diploma and Diploma Trained Paramedics.........................84
5.3 Tertiary Qualified Paramedics......................................................................................89
5.4 Understanding Paramedic Facilitators and Barriers of CPD ........................................93
5.5 Opportunities and Modalities for Paramedics to Engage in CPD Activities ..............103
5.6 Perceived Difference between LLL and Mandatory Training....................................113
5.7 Perceived Implications Paramedic Registration .........................................................117
5.8 Expectations................................................................................................................120
5.9 Summary.....................................................................................................................125
Chapter 6: Conclusions ................................................................................... 126
6.1 Summary of the Research Findings ............................................................................126
6.2 Key Conclusions and Implications for the Future ......................................................133
6.3 Limitations of this Study ............................................................................................134
6.4 Influencers of Change.................................................................................................135
6.5 Conclusion ..................................................................................................................137
Bibliography ........................................................................................................... 139
Appendices .............................................................................................................. 161
Appendix A Research Questions (utilised in semi-structured interviews) ...........................161
Appendix B Research Ethics, Integrity and Safety Modules 1 and 2 ...................................163
Appendix C QUT University Human Research Ethics Committee Approval ......................164
Appendix D Approach Emil to Participants .........................................................................166
vi Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development.
Appendix E Letter to ANZCP Research Committee............................................................ 167
Appendix F Letter to Paramedics Australasia ...................................................................... 170
Appendix G Participant Information.................................................................................... 171
Appendix H Consent Form................................................................................................... 173
Appendix I Glossary of Terms and Assumptions made available to participants before and during the interview.............................................................................................................. 174
Appendix J Transcription Confidentiality Agreement ......................................................... 175
Appendix K Progression to Date.......................................................................................... 176
Appendix L Resources and Funding .................................................................................... 178
Appendix M Researcher Timeline........................................................................................ 179
Appendix N Paramedic CPD Post Professional Registration............................................... 182
Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development. vii
List of Figures
Figure 1. The multi-theories model of adult learning................................................ 40
Figure 2. Spectrum of continuing professional development models ....................... 49
Figure 3. The PDP cycle............................................................................................ 50
Figure 4. The CBCPD cycle ...................................................................................... 52
Figure 5. Concept map representing the structure of this thesis................................ 56
Figure 6. CPD concept map: Links established in extant literature and links discovered during this study ........................................................................ 83
Figure 7. Proposed paramedic CPD framework ...................................................... 132
viii Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development.
List of Tables
Table 2.1 Paramedic CPD Literature ........................................................................ 13
Table 2.2 CPD Research Determinants ..................................................................... 14
Table 4.1 Inclusion and exclusion criteria................................................................. 66
Table 4.2 Example of Theoretical Sampling .............................................................. 72
Table 4.3 Example of coding process......................................................................... 75
Table 4.4 Example of Memo....................................................................................... 78
Table 4.5 Example of Field Note................................................................................ 79
Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development. ix
List of Abbreviations
ACP Advanced Care Paramedic
ACTAS Australian Capital Territory Ambulance Service
AHPRA Australian Health Practitioner Regulation Agency
AHWMC Australian Health Workforce Ministerial Council
ANZCP Australia and New Zealand College of Paramedicine
AT Ambulance Tasmania
AV Ambulance Victoria
CAA Council of Ambulance Authorities
CCP Critical Care Paramedic
CPD Continuing Professional Development
ECP Extended Care Paramedic
EMS Emergency Medical Service
EMT Emergency Medical Technician
HREA Human Research Ethics Application
HPCA Health Practitioners Competence Assurance Act 2003
LLL Life-long Learning
NRAS National Registration and Accreditation Scheme
NSWA New South Wales Ambulance
PA Paramedics Australasia
ParaBA Paramedicine Board of Australia
RTO Registered Training Organisation
QAS Queensland Ambulance Service
SAAS South Australian Ambulance Service
VET Vocational Education and Training
x Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development.
List of Abbreviations
Australasia For the purposes of this study, Australasia is defined as
any States or territories of Australia and New Zealand.
Constructivist
Grounded Theory
This approach analyses actions and processes instead of
structures and themes. It emphasises the engagement of
the researcher in both the construction and the
interpretation of the data (Charmaz, 2014).
Continuing
Professional
Development
For the purposes of this study, CPD is described as
commitment to the process of both formal and informal
life-long learning (LLL) opportunities that are linked to
clinical advancements, practitioner competence and
professionalism, and the delivery of gold standard
patient care (Macdougall, Epstein & Highet, 2017;
Martin, 2015; Filipe, Silva, Stulting & Golnik, 2014;
Kemp & Baker, 2013).
Critical Care
Paramedic
Pre-hospital emergency health care specialist with
advanced knowledge, skills and protocols to provide
expert pre-hospital interventions in accordance with
organisational protocols (Von Vopelius-Feldt &
Benger, 2013).
Engagement The act of being committed or involved in a particular
process. Engagement in CPD includes motivators,
facilitators, barriers, attitudes and opportunities.
Epistemology Examines the essence of knowledge: how knowledge is
generated, learned and transferred (Chernikova &
Chernikova, 2016).
Extended Care
Paramedic
An experienced paramedic working in a specialised role
which allows them to respond to both traditional
paramedic cases, and to perform additional treatment
options (Long, 2017).
Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development. xi
Life-long
Learning (LLL)
Formal and informal learning opportunities that assist
the continued acquisition, development and
improvement of knowledge, skills or abilities that can
be utilised in both the learners’ personal or professional
life (Jaiswal, 2017; Sockalingam et.al, 2017; Soykan &
Anderson, 2015; Kemp & Baker, 2013; Currie, Lockett,
Finn, Martin & Waring, 2012; Wyatt, 2003). LLL can
be considered a 'philosophy of practice' & the skills
associated with it can be learned.
Ontology The nature of being, or the study of what constitutes
“reality” (Scotland, 2012).
Organisation The paramedic employer. Including both private and
public or State ambulance services.
Paramedic Pre-hospital emergency health care specialist (CAA,
2009; Paramedics Australasia, 2012a). In Australia, the
title of paramedic is protected under the Health
Practitioner Regulation National Law Act 2009 for use
by qualified, registered paramedic professionals.
Qualitative
Research
Allows researchers to seek knowledge in areas of
interest about the human lived experience that have
previously had little or no exploration. It is performed
without the use of statistical measures, empirical
analytical conventional research methods, or other
types of quantification. The underlying philosophy of
qualitative research is that people formulate their
perception of reality, based on what they perceive to be
true (Silverman, 2016; Hallberg, 2006).
Vocational
Education and
Training
Workplace specific training and education that is
competency based around industrial knowledge and
workplace-specific skills.
xii Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development.
Publications and Presentations Stemming from this Study
Hobbs, L., Devenish, S., Clark, M. & Tippett, V. Clinical Skills Degradation in
Paramedicine Specific to Trauma Management: A Critical Review of the Literature.
Australian Journal of Paramedicine. 2015, 12(5)
Paramedics Australasia International Conference, Melbourne 24-26 November
2017. Hobbs, L., Devenish, S., & Tippett, V. Mandatory Continuing Professional
Development (CPD) requirements for professional health registration: Paramedic
Implications.
Paramedics Australasia International Conference, Adelaide Convention
Centre 1-3 October 2015. Hobbs, L., Devenish, S., Clark, M. & Tippett, V. Clinical
Skills Degradation in Paramedicine Specific to Trauma Management: A Critical
Review of the Literature.
Non-Peer Reviewed Presentations
Student Paramedic Union Conference, Queensland University Technology,
Kelvin Grove Campus June 2016. Topic: Paramedic Professional Registration and
Continuing Professional Development.
Three Minute Thesis Presentations, Queensland University Technology,
Gardens Point Campus 3rd December 2015. Topic: Paramedic Professional
Development: What does it look like in evolving professions?
Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development. xiii
Statement of Original Authorship
The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the best
of my knowledge and belief, the thesis contains no material previously published or
written by another person except where due reference is made.
Signature:
Date: September 24th, 2019
QUT Verified Signature
xiv Australasian Paramedic Attitudes and Perceptions about Continuing Professional Development.
Acknowledgements
This journey into the academic wilderness could not have been started, let
alone finished, without the inspiration, motivation and support of the following people:
First, the wonderful paramedic participants, who gave of themselves so freely.
Thank you for your open and authentic interviews. I sincerely appreciate everyone one
of you. I would also like to acknowledge my amazing supervisors, Dr Scott Devenish,
Professor Vivienne Tippett and Dr David Long, who went above and beyond to advise
and assist me to complete this research. They inspired me and rode the highs with me;
walked beside me and guided me when I thought I was lost; comforted and motivated
me when I need it; and reminded me that they had my back along the way. I have
appreciated working with you and thank you for giving of your time, knowledge and
yourselves so freely.
Thank you to my long-suffering family and friends. To my mother, Marlies
who continued to ask, “How hard can it be?” – The answer is, it wasn’t easy, but it
was worth it. Thank you Eila, you were such an inspirational person and the world was
made a better place to have had you in it; we miss you every day. Thanks to my lovely
neighbours, Steve and Joe, who cooked meals, made me litres of coffee, and allowed
me to talk incessantly about CPD when they wanted to talk about anything else. Thank
you to the incredible Steve, Ellie and Mark, who edited this dissertation; my “Bhutan
Bunch” because if you can climb to the Tiger’s Nest, you can do this; and anyone
else who gave me input or motivation along the way.
Chapter 1: Introduction 1
Chapter 1: Introduction
This chapter outlines the background of paramedicine, Ambulance Services in
Australasia, and the history of paramedic CPD. The chapter also describes the
significance and scope of this research and provides definitions of terms used. Finally,
it includes an outline of the remaining chapters of the thesis.
1.1 PARAMEDICS AND PARAMEDICINE
Paramedics are pre-hospital emergency health care specialists that provide both
scheduled and unscheduled lifesaving medical interventions, stabilisation and
transportation of the sick and injured (CAA, 2009; Paramedics Australasia, 2012a).
Paramedicine is an evolving profession which continues to build its research base
(Maguire, O'Meara & Newton, 2016). Research that exists within the paramedic
paradigm has been described “undeveloped” and “under-utilised”, as it struggles to
progress and expand upon research opportunities for prehospital practitioners (Batt &
Knox, 2017). The majority of paramedic research focuses on clinical care interventions
pertaining to skills, procedures and pharmacology (Campeau, 2015; Williams, Brown
& Onsman, 2012). An identifiable gap remains in the literature surrounding some
facets of paramedic education, particularly in the area of paramedic attitudes and
perceptions about Continuing Professional Development (CPD). For the purpose of
this thesis, CPD is described as commitment to the process of both formal and informal
life-long learning (LLL) opportunities that are linked to clinical advancements,
practitioner competence and professionalism, and the delivery of gold standard patient
care (Macdougall, Epstein & Highet, 2017; Martin, 2015; Filipe, Silva, Stulting &
Golnik, 2014; Kemp & Baker, 2013).
1.2 OVERVIEW OF AMBULANCE SERVICES IN AUSTRALASIA
In Dunedin, New Zealand, the first St John Ambulance Brigade was formed in
1892 (St John NZ, 2017). On the 1st of April 1895, the first officially recognised
Australian ambulance service was established in New South Wales (NSW Ambulance,
2017b). In 1927, Mayor Charles Norwood assisted in the development of the
Wellington Free Ambulance Service (WFA, 2019). In just 127 years, Paramedicine in
Australasia has evolved from canvas stretcher-bearers to pre-hospital emergency
2 Chapter 1: Introduction
health care specialists who provide unscheduled lifesaving medical interventions,
stabilisation and transportation of sick and injured members of the community (NSW
Ambulance, 2017b; St John NZ, 2017; Paramedics Australasia, 2012a).
In Australia, eight State/Territory Government operated or contracted
ambulance services and numerous private sector services providing emergency and
pre-hospital care to the Australasian population (Paramedics Australasia, 2017b). Each
of these services operates within their own organisational boundaries and are governed
by State/Territory Ambulance Acts. At present, paramedics mostly work within the
organisational guidelines, procedures, protocols and policies. The skills and
procedures that Australian paramedics are permitted to perform can differ between
services as there are no national clinical practice guidelines such as those which exist
in the United Kingdom (Joint Royal Colleges Ambulance Liaison Committee,
Association of Ambulance Chief Executives, 2017). Paramedics in Australia may be
required to undertake further education, training and assessment through an orientation
program if they want to move and work in another Australasian state, territory or island
(ACT Ambulance, 2017; NSW Ambulance, 2017a; Ambulance Tasmania, 2017;
Ambulance Victoria, 2017; South Australian Ambulance Service, 2017; St John NZ,
2017; St John WA, 2017; Queensland Ambulance Service, 2017). An exception to this
occurs where one service may be requested to cross the border and assist another
service for operational or emergency reasons such as required for a natural disaster
like floods or bush fires. In this case, ambulance services operate under a
Memorandum of Understanding (MOU), and paramedics at an incident over the border
will continue to work under their services practice guidelines, protocols and
procedures (QLD Government, 2017; NSW Government, 2017b).
In Australia, the majority of Ambulance services are state funded. In New
Zealand, the Northern Territory and Western Australia, government contracts are held
by Non-government Organisations (NGO) to provide the community with ambulance
services. There are also other private sector ambulance service providers in operation
throughout Australasia. Operationally, paramedics usually respond in a configuration
of two paramedics per vehicle. However, single officer responses can occur due to:
• rank (e.g. Officer In-Charge (OIC); Operations Supervisor)
• specialisation (e.g. Critical Care Paramedic (CCP), Extended Care Paramedic
(ECP), Specialist Operations)
Chapter 1: Introduction 3
• operational ability (e.g. Rural/Remote Officers working in single officer
stations or on mining sites)
• roster issues (e.g. extra staff rostered on, or a staff member has not
attended/completed a shift and has been unable to be replaced).
In 2015-16, a total of 15,263 (FTE) operational staff from the public and private
sectors responded to the out of hospital needs of 3,715,564 patients in Australasia (The
Council of Ambulance Authorities, 2016). The demand for ambulance service
provision within the Australasian community has increased dramatically over the last
decade. The current rate of population growth suggests that the utilisation of
ambulance services will continue to grow (Joyce, Wainer, Piterman, Wyatt & Archer,
2009). Paramedics are continually voted by the community as being the most trusted
profession (NSW Government, 2017a; Paramedics Australasia, 2014; St John WA,
2012). It is conceivable that this “trust” is built on the back of several factors such as:
• the reliability and dedication of paramedics;
• rapid response capacity and perceived contributions to public safety;
• their care of people are at their most vulnerable; and
• the countless hour’s paramedics invest into their training and education.
1.3 THE HISTORY OF PARAMEDIC CONTINUING PROFESSIONAL DEVELOPMENT (CPD)
The traditional model of pre-hospital emergency care was provided by pre-
vocationally and later, vocationally trained Ambulance Officers (Hou, Rego &
Service, 2013; Lord, 2003). The vocational education and training of paramedics was
generally facilitated by the ambulance service/employer (Gregory, 2012; Cooper &
Grant, 2009; Joyce, Wainer, Archer, Wyatt & Pitermann, 2009; Cooper, O’Carroll,
Jenkin & Badger 2007). In Australia, and specifically Queensland, paramedic CPD
was broadly constructed to complement vocational qualifications, by the ambulance
service educators and administrators, was supported by the union and reinforced by a
Parliamentary Committee of Enquiry (G. Fitzgerald, personal communication,
November 30, 2017).
Prior to the implementation of undergraduate degree qualifications in
paramedicine and professional registration, paramedic CPD resided in the realm of
4 Chapter 1: Introduction
clinical development and education packages and programs, which dealt more with
specific knowledge of pharmacology, paramedic procedures and interventions, as
opposed to development of staff members (G. Fitzgerald, personal communication,
November 30, 2017). An analysis of future directions for education within the
Queensland Ambulance Service (QAS) in 2005 claims to “focus” on “professional
development”, yet does not qualify what professional development is (QAS, 2005). It
merely outlines certifications and courses. The majority of paramedic professional
development has been denoted in the same way, regardless of clinical level, and future
paramedic CPD may possibly continue at the same level to have a focus on mandatory
training and clinical rank. It is hoped that paramedicine will continue to adopt a
lifelong learning (LLL) approach like other health professions, and thus highlights the
importance of this study.
1.4 THE PROGRESSION OF PARAMEDIC REGISTRATION AND CPD
Australian paramedics were able to apply for paramedic registration with the
Paramedicine Board of Australia (ParaBA) from September 3rd, 2018. Professional
registration then came into effect December 1st, 2018 (AHPRA, 2018d). However,
paramedic registration had been pursued for many years prior. In 2010, the Australian
Health Workforce Ministerial Council (AHWMC) began investigating a proposal to
include paramedicine as a profession and regulate paramedics in all Australian States
and Territories through a professional registration process (Australian Health
Ministers’ Advisory Council, 2012). In 2015, Australian Health Ministers agreed to
progress paramedic inclusion under the National Registration and Accreditation
Scheme (AHPRA, 2017a; Paramedics Australasia, 2017c). Registration as a
paramedic enables the officer to practice in all Australian states and territories
(AHPRA, 2017b). Since 1st December 2018, registered paramedics in Australia, have
been named on a public register managed by the Australian Health Practitioner
Regulation Agency (AHPRA) and the National Registration and Accreditation
Scheme (NRAS). Paramedic registration is imminent in New Zealand and is to be
managed through the Ministry of Health. Once Paramedics in Australia and New
Zealand have achieved professional standing, the paramedic profession will then align
with other allied health professions (Paramedics Australasia, 2017c; COAG Health
Council, 2016; Paramedics Australasia, 2016).
Chapter 1: Introduction 5
AHPRA stipulates strict adherence to five common registration standards by the
professions it covers (AHPRA, 2017a; Jones, Shaban & Creedy, 2015). The standards
that paramedics need to achieve for registration in Australian are mandated and have
been developed via approval from the Ministerial Council, to set requirements for:
• continuing professional development (CPD)
• english language skill registration
• recency of practice
• criminal history registration, and
• professional indemnity insurance registration (AHPRA, 2017b).
In New Zealand the Health Practitioners Competence Assurance (HPCA) Act
2003, currently regulates more than twenty health professions (O'Meara & Duthie,
2018; Tunnage, Swain & Waters, 2015). Paramedic registration in New Zealand will
be recognised under the HPCA Act by the Ministry of Health and overseen by Health
Workforce New Zealand (Paramedics Australasia, 2016). In New Zealand, the relevant
authorities undertake responsibility for three principal functions under the HPCA Act
2003:
• qualification – (scope of practice, CPD and reaccreditation);
• competency – (clinical); and
• complaint management (Tunnage, Swain & Waters, 2015).
Professional registration is likely to change the way that paramedics engage with
CPD, in that an increase in personal onus will be required to maintain professional
status. Conversely, the paramedic industry and the paramedic employer may need to
facilitate changes in levels of support for individual paramedics to engage in CPD. For
example, paramedics work in a 24/7 rostered environment and most CPD providers
operate within normal business hours. Therefore, models of CPD delivery may need
to change reflect the needs of participants. In this context, an exploration of
Australasian paramedic attitudes and perceptions about CPD, is both justified and
timely.
6 Chapter 1: Introduction
1.5 RELEVANCE OF THIS STUDY
To date, little research has been undertaken on the complexities of CPD within
the paramedic profession. Martin (2015) suggests that for paramedic CPD to be
utilised effectively by the profession, four principles should be embraced by the
paramedic community. These are:
• the individual is responsible for their own learning and development;
• CPD is based upon and feeds back into practice;
• employers creating optimal environments for CPD; and
• learning and development can be derived from an extremely wide and diverse
range of both formal and informal activities (Martin, 2015).
Martin (2015) proposes that these four CPD principles are not without their own
complications. Taking personal responsibility for individual learning and development
may be a new concept for some of the paramedic population who have previously had
all training mandated, organised and provided by their employer (Martin, 2015).
Research has identified that the basis of CPD is driven by the individual practitioners’
desire to develop and maintain a skill set that is beneficial to the patient (Gent, 2016;
Coventry, Maslin-Prothero & Smith, 2015; Martin, 2015). The challenge for
paramedic employers, educators and managers is to facilitate ways that paramedics
can take individual responsibility for their engagement in CPD (Martin, 2015). The
literature suggests that employers can do this by ensuring that CPD opportunities are
systematic, goal orientated and designed to encourage improvement in the
practitioner’s individual practice (Macdougall, Epstein & Highet, 2017; Gent, 2016;
Walsh & Craig, 2016; Martin, 2015). While influencing factors about individual
engagement in CPD have been investigated in other health professions such as
medicine and nursing (Sockalingam et.al, 2017; Bressan et. al., 2016; Jones, Shaban
& Creedy, 2015; Filipe, Silva, Stulting & Golnik, 2014) there is limited literature
within the paramedic field on this topic.
A greater understanding of Australasian paramedic attitudes and perceptions
about CPD is required to discover what drives paramedics to seek out further CPD
opportunities; or merely “jump the hoops” required to maintain clinical and
operational currency. A clear understanding of CPD, lifelong learning (LLL) and
compliance training are required to build experience and evidence in this field. The
Chapter 1: Introduction 7
exploration of the attitudes and perceptions of paramedics in relation to their
interaction with CPD may lead to a better understanding of how paramedics can find
more self-directed opportunities for active participation in CPD activities.
The findings of this research study have contributed to the current body of
knowledge, which may assist educators and paramedic professionals to position
themselves for LLL. This research generates new knowledge about current attitudes,
perceptions and theories regarding individual paramedic understanding of and
engagement in CPD. As a result, it is anticipated that paramedic self-directed CPD will
have the same benefits as seen in the literature for other health professions, namely an
increase in participation and positive correlations with professional standing,
contributions to research, and improved patient outcomes.
1.5.1 Overview of this Study
The aim of the study is to examine Australasian paramedic attitudes and
perceptions, in order to develop a conceptual understanding of how and where CPD
currently fits into paramedic practice in Australasia. A qualitative approach based on
constructivist grounded theory methods (Charmaz, 2014) is applied to this research.
Attitudes and perceptions are likely to be influenced by many factors. These influences
may include: macro (organisational, health systems) and micro (individual) level
determinants of participation in CPD and LLL. These influences are explored in depth
to provide a framework within which to develop a rich understanding of paramedic
attitudes and perceptions about CPD. Practitioners taking self-onus of their CPD is an
important part of the professionalisation of paramedicine. The aims of this research
are to investigate:
• Australasian paramedic attitudes and perceptions about CPD;
• The relationship between CPD and paramedic professional practice in the
Australasian paramedic context; and,
• How this relationship could be influenced now that paramedic professional
registration has commenced in Australia and is imminent in New Zealand.
1.5.2 Significance of this Study
As Australia now requires paramedics to be nationally registered, and New
Zealand is moving towards paramedic registration, Australasian paramedic attitudes
8 Chapter 1: Introduction
and perceptions about CPD may now be subject to internal and external influences,
which may have previously received less emphasis within the profession. The
exploration of the attitudes and perceptions of paramedics in relation to their
engagement and experience with CPD may lead to a better understanding of how
paramedics can find more self-directed opportunities for active participation in CPD
activities. The literature for other health professions cites that increased participation
with self-directed CPD is positively correlated with professional standing,
contributions to research and improved patient outcomes (Macdougall, Epstein &
Highet, 2017; Walsh & Craig, 2016; Filipe, Silva, Stulting & Golnik, 2014). It is
predicted that more paramedic engagement in self-directed CPD will demonstrate
similar benefits in the paramedic profession.
1.5.3 Overview of this Dissertation
The subsequent chapters are organised as follows. Chapter Two contains a
review of the literature about CPD. Chapter Three discusses the theoretical background
for this dissertation and examines relevant evaluation models of workplace training
programs and CPD. Chapter Four discusses the methodological approach, reflexivity
of the researcher, the research methods and participant recruitment. Chapter Five
presents results analysis. Chapter Six completes the document with a conclusion of the
study and proposed starting points for further investigations. A reference list and
appendices can be found at the end of this thesis.
Chapter 2: Literature Review 9
Chapter 2: Literature Review
“Everyone involved in health and social care provision is well aware that the
practice world is constantly changing. We live in an environment where dynamic
sociological, political and economic factors have a major impact in what we do. As
they change, so practice changes. We have to stay in tune with the nature of practice
and its wider environment in order to understand health care provision, the direction
that it is taking and consequences for ourselves as health care professionals.”
(Alsop, 2000, pp. vii-viii)
The relevant literature about paramedic Continuing Professional Development
(CPD) is presented in this chapter and the search strategy described. First, the gap in
the literature is identified. Then the literature on ambulance education is discussed to
provide an overview of the background of paramedic education and training. The
cultural and organisational history of Australasian ambulance services regarding CPD
is also briefly examined, highlighting the dearth of research focusing on the on-going
education of paramedics after they complete their paramedic qualification. The review
of the literature assists in demonstrating the links between the paramedic (individual),
the paramedic profession (industry), and, the organisation (employer) that can affect
paramedic attitudes and perceptions about CPD.
The second part of this chapter examines the CPD literature from cognate health
professions, as these health disciplines have made the transition to ‘health professional
status’ before paramedicine and have encountered similar challenges to those the
paramedic profession now faces. One of these challenges is possibly the move, both
conceptually and actively, of practitioners taking onus for the momentum and direction
of their CPD. It is useful to examine the attitudes and perceptions of like-health
professionals about CPD in this context.
2.1 SEARCH STRATEGY
The search strategy included both published and unpublished studies. It
incorporated literature from: books, journals, government and ambulance service
publications, conference presentations and thesis submissions. A three-step search
strategy was utilised in this review. An initial limited search of MEDLINE and
10 Chapter 2: Literature Review
CINAHL followed by analysis of the text words contained in the title, abstract, and of
the index terms used to describe articles was undertaken. A second search using all
identified keywords and index terms was then commenced across all included
databases. Third, the reference list of all identified books, reports and articles was
searched for additional studies. Thus, creating a robust research framework, as shown
Table 2.3 on the following page.
Cha
pter
2:L
itera
ture
Rev
iew
11
Tabl
e 2.
3 In
form
atio
n so
urce
s acc
esse
d fo
r the
lite
ratu
re re
view
Peer
Rev
iew
ed
Dat
abas
es S
earc
hed
Non
-Pee
r Rev
iew
ed/G
rey
Dat
abas
es S
earc
hed
Roo
t Sea
rch
Term
s & M
esh
Term
s
Aus
trala
sian
Jour
nal o
f Par
amed
icin
eA
HPR
A w
ebsi
te w
ww
.ahp
ra.g
ov.a
uA
mbu
lanc
e Ed
ucat
ion
Cam
brid
ge Jo
urna
lsA
NZC
P w
ebsi
te w
ww
.anz
cp.o
rg.a
uA
mbu
lanc
e O
ffic
er/E
MT
CIN
AH
LEt
hos
Clin
ical
Edu
catio
n
ERIC
Goo
gle
Scho
lar
Clin
ical
Ski
lls R
eten
tion
Info
rma
Med
nar
Con
tinui
ng P
rofe
ssio
nal D
evel
opm
ent
Med
line
AN
ZCP
web
site
ww
w.a
nzcp
.org
.au
Educ
atio
n
Ovi
dO
pen
Gre
yEn
gage
men
t
ProQ
uest
PA w
ebsi
te w
ww
.par
amed
ics.o
rgH
ealth
Pro
fess
iona
l
PubM
edPr
oQue
st T
hesi
s and
Dis
serta
tions
Man
dato
ry
Scop
usQ
AS
web
site
and
doc
umen
tatio
n
ww
w.a
mbu
lanc
e.ql
d.go
v.au
Para
med
ic
Wile
y O
nlin
e Li
brar
y Q
UT
Libr
ary
cata
logu
ePa
ram
edic
Edu
catio
n/tra
inin
g
Trov
ePa
ram
edic
Pro
fess
iona
l Dev
elop
men
t
Para
med
ic R
egis
tratio
n
Prof
essi
on/a
l/ism
Prof
essi
onal
Dev
elop
men
t/reg
istra
tion/
regu
latio
n
12 Chapter 2: Literature Review
The search of the literature considered studies that included predominately
health disciplines, but also other professionals required to participate in mandatory
CPD activities as part of their professionalism and/or professional regulation. Studies
investigating influences of participant and employer engagement in CPD, including:
facilitators and barriers, organisational compliance training, and mandatory CPD as
stipulated by professional regulatory authorities were also considered. The search of
the literature considered the availability of, and influences on paramedic educational
pathways, including Parliamentary Inquiries, organisational policies and politics. It
considered studies that focus on qualitative data including, but not limited to, designs
such as phenomenology, grounded theory, ethnography and action research. The
search of the literature dated back 10 years apart from seminal research work, and only
studies published in English were considered for inclusion in this literature review.
2.2 PARAMEDIC CPD LITERATURE
To ensure that the literature utilised in this study was as current as possible, the
literature was searched multiple times during the course of this research. Despite
regular searches, a major element consistently identified as missing from the literature
is a robust body of knowledge relating to paramedic engagement in CPD. A systematic
review of CPD for paramedics was conducted by Gent in 2016. The systematic review
contributes to the body of knowledge however, it overstates the scope of paramedic
CPD in relation to this study. The inclusion of four of the articles reviewed by Gent
(2016) is questionable as they examine CPD only in relation to specific clinical skills
or interventions. Therefore, those four articles were excluded from this literature
review as they do not focus on paramedic attitudes and perceptions about CPD. Thus,
current peer-reviewed literature on CPD in ambulance is limited to the work of the
following authors listed in Table 2.1, on the following page.
Chapter 2: Literature Review 13
Table 2.1 Paramedic CPD Literature
Author/Year Summary/Relevance to Paramedic CPD
Cooper (2005) The study evaluated the education and training with
the Westcountry Ambulance NHS Trust (WAST) and
some regional Accident and Emergency Departments,
through a series of focus groups and interviews with
paramedics and stakeholders.
Brink, Bäck-Pettersson
& Sernert (2012)
The small study examined group supervision of
emergency medical technicians (N=4) as a means of
providing professional development for non-clinical
skills such as compassion and confidence.
Knox, Cullen & Dunne
(2014)
The study examined delivery of CPD to Irish
paramedics (N=49).
Martin (2015) Discussion piece regarding the benefits of paramedic
CPD.
In the absence of this knowledge from the paramedic paradigm, CPD literature
from allied disciplines must be examined. Prominent authors from allied health, and
seminal research work, have contributed to the study of CPD with the following
insights.
14 Chapter 2: Literature Review
Table 2.2 CPD Research Determinants
CPD demonstrates a commitment to lifelong learning (LLL) and, is linked to clinical
advancements, practitioner competence, professionalism, and the delivery of gold
standard patient care (Macdougall, Epstein & Highet, 2017; Jaiswal, 2017; Kemp &
Baker, 2013; Currie, Lockett, Finn, Martin & Waring, 2012; Wyatt, 2003).
Facilitators of CPD include; the desire to improve patient outcomes; cultural aspects
of the profession; environmental factors (i.e. employer support); personal enjoyment
in undertaking the CPD activity; the motivation level of the health professional and
their understanding of how CPD programs and activities can improve both health
care practices and patient outcomes (Walsh & Craig, 2016; Coventry, Maslin-
Prothero & Smith, 2015; Légaré, Ratté, Gravel, & Graham, 2008).
Barriers to CPD reported by allied professionals to include: organisational
confusion; time constraints; lack of knowledge of the facilitator or presenter; lack
of confidence of the participant/practitioner; financial and/or personal cost; lack of
training resources; suspicion of the organisational motives for providing learning
activities and lack of strategic leadership (Bressan, et al, 2016; Mather & Seifert,
2014; Légaré, Ratté, Gravel, & Graham, 2008).
The determinants in Table 2.2 may have crossovers to paramedic practice. The
aim of this research is to examine whether these insights are applicable to
paramedicine and to develop new knowledge about paramedic CPD in the context of
paramedic practice.
Chapter 2: Literature Review 15
2.3 CONTINUING PROFESSIONAL DEVELOPMENT: BROAD DEFINITION IN THE LITERATURE
The context of CPD can have different meanings depending on the profession it
relates to. In medicine, CPD is directly linked to the development of practitioner
competence through the acquisition of knowledge, skills and active participation in
realistic workplace activities (Eppich, et.al. 2016). The literature describes CPD as the
development of knowledge, skills and reflective practices which serve to improve
professional practice and the quality of patient care outcomes (Miraglia & Asselin,
2015). In physiotherapy, CPD is central to the maintenance, extension and enrichment
of expert knowledge and professional competence (Leahy, Chipchase & Blackstock,
2017). In other health disciplines such as medicine and nursing, CPD is best described
as a commitment to the process of both formal and informal LLL opportunities which
are linked to clinical advancements, practitioner competence and professionalism, and
the delivery of gold standard patient care (Macdougall, Epstein & Highet, 2017;
Martin, 2015; Filipe, Silva, Stulting & Golnik, 2014; Kemp & Baker, 2013). CPD can
be utilised as a structure of learning and development which can contribute to the
proficiency of practitioner skills (Kemp & Baker, 2013).
Therefore, it is reasonable to generalise the goal of CPD for health professionals
is the acquisition, maintenance and enhancement of the skills and knowledge which is
considered essential to continue to perform their role in an ever-advancing industry
(Haywood, Pain, Ryan & Adams, 2012). There are consistent commonalities between
these disciplines, which include:
• the development and maintenance of skills;
• the formulation of a professional development plan (PDP);
• participation in life-long learning (LLL);
• improving the standard/s of service delivery; and
• advancement of the profession in general.
Of specific interest to this study was the interaction between the organisation,
the profession, the individual, and the concept of LLL. There are many descriptions of
LLL in the literature, perhaps one of the most significant in the health literature is that
‘learning leads to more learning’ and integration of newly acquired knowledge into
clinical practice (Dent, Harden & Hunt, 2017). A dearth of literature on this topic
16 Chapter 2: Literature Review
demonstrates that further investigation is required to explore and confirm if this is also
the case for the paramedic profession, and if the drive for LLL comes from the
individual; the profession; the organisation; or a combination of each.
For the purposes of this study, CPD is defined as any activity which enhances
the development or maintenance of knowledge, skills, competence or the expertise of
a paramedic throughout their professional career (Mills, Bonner & Francis, 2006).
These activities also contribute to LLL; which can be considered a 'philosophy of
practice' that occurs through formal and informal learning opportunities designed to
assist in the acquisition or improvement of skills, knowledge or abilities (Jaiswal,
015; Tofade, Duggan,
Rouse, & Anderson, 2015; Kemp & Baker, 2013; Currie, Lockett, Finn, Martin &
Waring, 2012; Wyatt, 2003). The skills associated with LLL can be learned and
developed. Engaging in CPD activities can occur independently or as a part of a
Professional Development Plan (PDP). Active practitioner engagement in CPD assists
in the demonstration of commitment to the delivery of gold-standard patient care, and
the advancement of the paramedic profession.
2.4 EDUCATION AND TRAINING OF PARAMEDICS
This section discusses the literature relating to ambulance education to provide
an overview of the background of paramedic training, specifically: ambulance
education models, transition to paramedic practice, and ambulance culture in transition
and upskilling paramedic scope of practice. It encompasses attitudes and perceptions
to CPD of the paramedic industry, the paramedic employer and the individual
paramedic. Cultural, political and organisational influences related to CPD are also
discussed before moving on to the second section of the literature review.
2.4.1 Transition to Tertiary Education
University education of paramedics has been canvased in the literature. The
transition of paramedic education from post-employment vocational education and
training (VET) models to pre-employment university-based models in Australasia, is
comparable to the transformation that occurred within the nursing paradigm (Brooks,
Grantham, Spencer & Archer, 2018; O’Brien, Moore, Dawson & Hartley, 2014). As
the nature of pre-hospital emergency care began to include a wider scope of practice
and critical reasoning, a progression towards tertiary education and professionalisation
Chapter 2: Literature Review 17
was the logical outcome (Brooks, Grantham, Spencer & Archer, 2018; Johnston &
Acker, 2016; Hou, Rego & Service, 2013; Joyce, Wainer, Piterman, Wyatt & Archer,
2009). The journey towards professional degree qualifications for Australian
paramedics is relatively new, commencing at Charles Sturt University, New South
Wales in 1994 (Brooks, Grantham, Spencer & Archer, 2018; Hou, Rego & Service,
2013; Lord, 2003). Undergraduate degrees in paramedic science are now available all
over Australasia (Brooks, Grantham, Spencer & Archer, 2018).
Tertiary education for paramedics contains both challenges and advantages
(O’Brien, Moore, Dawson & Hartley, 2014; Hou, Rego & Service, 2013). One
advantage of tertiary education for paramedics is the natural progression towards
professionalisation, as demonstrated in other health professions, such as chiropractic
and nursing (Brooks, Grantham, Spencer & Archer, 2018; Johnston & Acker, 2016;
O’Brien, Moore, Dawson & Hartley, 2014; Emms & Armitage, 2010; Joyce, Wainer,
Archer, Wyatt & Pitermann, 2009; OMeara, 2009). Although undergraduate course
requirements may differ between universities, the establishment of industry specific
accreditation standards from 1996-2010, ensures some consistency in graduates across
the country (Brooks, Grantham, Spencer & Archer, 2018).
Major requirements of paramedic education currently include ensuring effective
training in practical skills; interprofessional communication and clinical decision
making which are required to perform the role of a paramedic upon graduation
(Johnston, MacQuarrie & Rae, 2014; O’Brien, Moore, Dawson & Hartley, 2014). Of
interest, one study found “statistically significant negative correlations” between
degree level of education and organisational commitment of the paramedic to the
ambulance service (Alexander, Weiss, Braude, Ernst & Fullerton-Gleason, 2009
p.830). The study of 375 paramedics found a reduced level of organisational
commitment from paramedics with higher education qualifications and concluded that
this was correlated to those paramedics participating in education for personal
satisfaction and LLL, rather than just for occupational reasons (Alexander, Weiss,
Braude, Ernst & Fullerton-Gleason, 2009). There is currently no such study on
Australasian paramedics found in the literature.
2.4.2 History of Ambulance Education and CPD
Paramedic education models have been examined in the literature. Scenario
based simulation exercises have been utilised in both VET and undergraduate degree
18 Chapter 2: Literature Review
education, as an effective paramedic training tool for many years (Brooks, Grantham,
Spencer & Archer, 2018; Kennedy, Cannon, Warner & Cook, 2014; Von Wyl,
Zuercher, Amsler, Walter & Ummenhofer, 2009; Rumball, Macdonald, Barber, Wong
& Smecher, 2004). Paramedic education has continued to evolve, especially over the
last 20-25 years (Brooks, Grantham, Spencer & Archer, 2018; Hou, Rego & Service,
2013). Prior to the 1970’s paramedic education and training in Australia and New
Zealand was virtually non-existent, as there was no formalised vocational process to
commence a career as an ambulance officer or ambulance attendant (G. Fitzgerald,
personal communication, November 30, 2017). During this time, State or Territory
ambulance services conducted in-service training schools that delivered unaccredited
pre-hospital training and programs (Brooks, Grantham, Spencer & Archer, 2018). The
development of government medical advisory committees led to vocational education
and training for ambulance officers to commence in 1974, while curriculum was
ultimately overseen by these committees (Brooks, Grantham, Spencer & Archer,
2018), CPD was primarily managed by the organisation or employer (NZ Govt, 2017;
First, Tomlins, & Swinburn, 2012; Williams, Brown & Onsman, 2012). In 2000, the
Australian College of Ambulance Professionals was formed to represent ambulance
personnel and support emerging CPD interest and establish the Journal of Emergency
Primary Health Care (Marr, 2003). Australian census information shows a dramatic
rise in the educational qualifications held by paramedics in comparison to other
comparable groups (ABS, 2012a). In 2006, 24% of paramedics held a Bachelor degree
and 5% held post-graduate qualifications (ABS, 2012a). Ten years later, the 2016
census data indicated that there are 13,725 ambulance officers and paramedics in
Australia, 46% of which now have completed a Bachelor degree and 7.5% have post
graduate qualifications (ABS, 2017).
Historically, paramedic CPD opportunities have been organisationally driven by
the desire to improve patient safety and outcomes (G. Fitzgerald, personal
communication, November 30, 2017; Martin, 2015; Ferreira & Hignett, 2005).
Competent and clinically appropriate decision-making strategies which support
paramedic practice are paramount to providing holistic healthcare for patients (Nixon,
2013). As paramedic training and education progressed from a vocationally based
model to tertiary studies, the concept of CPD has been increasingly emphasised in
undergraduate paramedic programs through the introduction of self-directed learning
Chapter 2: Literature Review 19
(Williams et al., 2012) and LLL enculturation (Lim, Hou & Tippett, 2016). Paramedic
professional organisations such as Paramedics Australasia (PA) and the Australia and
New Zealand College of Paramedicine (ANZCP) have demonstrated interest in
paramedic CPD and are offering professional development programs and activities to
qualified paramedics and undergraduate student paramedics.
Mandatory CPD or compliance training, has been utilised to varying degrees in
paramedicine and numerous other health professions. There is limited research
available that examines the effectiveness of participation in mandatory CPD programs
and activities (Filipe, Silva, Stulting & Golnik, 2014). Research suggests that it is
essential that CPD is fed back into paramedic practice (Martin, 2015). However, there
is a gap in paramedic literature regarding the decision process about what type of CPD
was the best fit for paramedics previously. Presumably there were factors that related
to organisational culture and socialisation that stipulated what paramedics needed to
learn; and, may have been influenced by government policy, or the initiation of a new
drug/skill authorised by the medical director (G. Fitzgerald, personal communication,
November 30, 2017).
Previously, paramedic educational needs were met by the organisation through
occupational training; in-service education programs, mandatory CPD, skills
certification and recertification (Brooks, Grantham, Spencer & Archer, 2018; G.
Fitzgerald, personal communication, November 30, 2017; Kilner, 2004). That is to
say, paramedic education initiatives were directly linked to paramedics maintaining
the authority to practice bestowed by the employer. These programs were generally
designed to focus on a specific procedure, drug or piece of equipment, and not the
actual development of staff (G. Fitzgerald, personal communication, November 30,
2017). Therefore, paramedic CPD usually focused on a single aspect of the
requirements of the job as opposed to assisting the individual to embrace new
knowledge and participate in LLL.
Formal learning is described as an organised and systematic educational process
that leads to formal qualifications (Mahajan, 2017) which is influenced by the
organisation through employment opportunities becoming more and more dependent
on tertiary qualifications (ACT Ambulance Service, 2017; Ambulance NSW, 2017a;
Ambulance Tasmania, 2017; Ambulance Victoria, 2017; South Australian Ambulance
Service, 2017; Queensland Ambulance Service, 2017; St John NT, 2017; St John WA,
20 Chapter 2: Literature Review
2017). Informal learning can be described as learning through informal processes, such
as casework, personal experience and the experiences of others (Mahajan, 2017).
Informal learning processes have previously been utilised in ambulance in-service
educational packages by way of regional training; simulation exercises and clinical
debrief.
One of the major barriers to employees actively engaging in CPD reported
throughout the literature relates to how, when or why compulsory CPD is provided by
an employer or organisation (Duncombe, 2018; Maher, et.al, 2017; Stevens & Wade,
2017). Compulsory CPD is generally viewed by employees, with a level of suspicion
that participating is just a “points-gathering” or a tick and flick type of exercise to
indicate compliance with workplace policies which were susceptible to fabrication and
falsification of CPD records (Mather & Seifert, 2014). Anecdotally, there have been
instances where staff found paperwork in their pigeon-hole advising that they had been
signed off as competent or had completed mandatory education programs, packages
or activities that they had not actually attended. This suspicion is supported by the
contention that attendance at a CPD activity does not necessarily improve professional
practice (Haywood, Pain, Ryan & Adams, 2012).
As the role of a paramedic has developed into that of a clinician, paramedic
training and education has moved almost completely to the tertiary sector in response;
and, paramedic registration in Australasia has now commenced in Australia and is
imminent in New Zealand (AHPRA, 2017b; Gent, 2016; Tunnage, Swain & Waters,
2015; First, Tomlins, & Swinburn, 2012; Williams, Brown & Onsman, 2012). As a
result, the concept of paramedic CPD is beginning to align with other registered health
professions and move towards being self-directed, with less input from the
organisation, and more input from the paramedic industry and the individual
paramedic. Nonetheless, employers will still be required to continue to provide some
workplace education through both formal and informal learning, and CPD activities
(Macdougall, Epstein & Highet, 2017; Sutherland Olsen, 2016; Filipe, Silva, Stulting
& Golnik, 2014).
Since the end of 2018, Australian paramedics have become nationally regulated
and registered under AHPRA (AHPRA, 2017b; Gent, 2016). The Paramedicine Board
of Australia has stipulated CPD requirements for the maintenance of paramedic
registration at all paramedic levels (AHRPA, 2018a). The Paramedicine Board of
Chapter 2: Literature Review 21
Australia operates in conjunction with AHPRA to regulate Australian paramedics
under the National Registration and Accreditation Scheme (NRAS), and to ensure a
consistent CPD approach for all registered Australian paramedics (AHPRA, 2018b;
Senate Legal and Constitutional Affairs Committee, 2016). New Zealand is also in
the process of implementing national paramedic registration which will be recognised
under the HPCA Act by the Ministry of Health and overseen by Health Workforce
New Zealand (Paramedics Australasia, 2016). The implications of mandatory CPD
and paramedic registration will be discussed later in this chapter.
Paramedics provide pre-hospital patient care by utilising technical skills and
clinical judgement, however they also call upon a variety of “soft skills”1 and positive
personal attributes when providing care to their patients (Ross & Kabidi, 2017). The
Council of Ambulance Authorities (CAA) Paramedic Professional Competency
Standards document states that personal attitudes and characteristics including values
and beliefs, are integral towards the development of well-rounded professional
paramedics (CAA, 2013). These attributes include: demonstrating honesty, integrity,
respect, non-discrimination and professionalism at all times; and respecting the rights,
values, dignity, and autonomy of patients (CAA, 2013). Personal attributes such as
these encapsulate a culture of prosocial behaviour and are highly valued by paramedic
employers (Bolino & Grant, 2016). By nature of the job, and the soft skills required to
do it effectively, paramedics demonstrate prosocial behaviours daily. Soft skills and
prosocial behaviours are encouraged in numerous paramedic undergraduate programs
(Ross & Kabidi, 2017; Williams et.al. 2017; CAA, 2013). Evidence also suggests that
paramedics will continue to promote and demonstrate these attributes and behaviours
in their non-working life as paramedics perform volunteer work in the community on
average, more than the comparable employed Australian general population (ABS
Census, 2017). Further examination of Australasian paramedics may confirm if these
attributes can either directly or indirectly influence engagement in CPD and LLL in
Australasian paramedics.
One of several models that has been investigated regarding paramedic clinical
judgement and practice is that of tacit knowledge (Shaban, Considine, Fry & Curtis,
1 Soft skills can be defined as a combination of attitudes, personality traits, values and beliefs which promote harmonious and positive interpersonal communication and interactions (Matteson, Anderson & Boyden, 2016).
22 Chapter 2: Literature Review
2017). Tacit knowledge is described as a type of intuition that expert practitioners
utilise when making decisions or judgements in their professional practice to assist in
the improvement of the quality of patient care (Panahi, Watson & Partridge, 2016;
Ranucci & Souder, 2015; Wyatt, 2003). Tacit knowledge is acquired through
interactions, not formal learning theories (Garrick, 2018) and is a good fit with any
paramedic education model due to the real-world relatability of clinical experiences in
critical situations, which focus on what actually works, as opposed to “how things
should work” (Panahi, Watson & Partridge, 2016, p.344). Regardless of the model of
paramedic education in use at any specific ambulance service or university, an
essential component of the education process identified is that programs need to
transition from training to education and be supportive of all types of LLL (Michau,
Roberts, Williams & Boyle, 2009; Donaghy, 2008). Elements of paramedic training
and education that have been identified as lacking in the literature, include: LLL, self-
development, evidence-based practice, tacit knowledge and cultural awareness
(Hoffmann, Bennett & Del Mar, 2017; Weldon & Weldon, 2016; Kilner, 2004).
Therefore, this study attempts to fill some of these gaps by examining components of
LLL and self-development from the viewpoint of the Australasian paramedic
participants.
Compulsory and/or mandatory training is also influenced by the political
environment and its priorities, and the legal responsibilities of the organisation to
provide a safe working environment for employees (Tavares & Boet, 2018; Haywood,
Pain, Ryan & Adams, 2012; Mahony, 2003). Generally, organisational compliance or
effectiveness is the goal of the employer as part of an organisational development plan
to meet KPI’s or improve worker performance (Macdougall, Epstein & Highet, 2017;
Mather & Seifert, 2014). However, this is only one element of CPD; it is equally vital
to develop capabilities and competencies in methods that are personally meaningful to
the participant (Macdougall, Epstein & Highet, 2017; Filipe, Silva, Stulting & Golnik,
2014).
2.5 AMBULANCE CULTURE, HISTORY, TRANSITION AND CPD
The impact of organisational culture on CPD has been discussed in the literature.
Given the complexity, unpredictability and at times volatility of the pre-hospital
environment, acceptance and adherence to ambulance culture has the potential to
influence a paramedics’ attitude towards CPD (Devenish, 2014). The intricacies of
Chapter 2: Literature Review 23
ambulance organisational culture can either positively and negatively impact service
delivery (Knowles, Ahmed, Bishop-Edwards & O’Cathain, 2017; McCann, Granter,
Hassard & Hyde, 2015; Devenish, 2014). Investigations of the organisational culture
of several English ambulance services and the South Australian Ambulance Service,
found that ambulance culture is more complex than frontline operations alone
(Knowles, Ahmed, Bishop-Edwards & O’Cathain, 2017; Reynolds, 2008). Culture can
be defined as a common identity that is shared between different individuals and the
socially-constructed link between collective and individual behaviour patterns
(Carlström & Ekman, 2012; Wankhade, 2012). Literature regarding organisational
culture and health care suggests that ambulance services consist of various sub-
cultures which all interact with industrial performance, quality improvement, and a
sense of identity with its own occupational language, formalities and beliefs (Scott,
Mannion, Davies & Marshall, 2018; Devenish, 2014; Wankhade & Brinkman, 2014;
Wankhade, 2012). It has been suggested that within the healthcare sector, culture
represents the collective, accepted opinion and that if new members of the collective
want to improve their chances of being accepted into the culture, they need to go along
with the collective beliefs and behaviours (Devenish, 2014; Carlström & Ekman,
2012).
Paramedics and emergency service workers self-report attraction to the role
because of the dynamic, confronting, action oriented and exciting environment that
continues to test their knowledge, skills and abilities (Klee & Renner, 2013; Wagner,
Martin & McFee, 2009; Ahl, et al., 2005). Humour, often gallows humour, has also
been found to be a part of paramedic culture (Clompus & Albarran, 2016; Launer,
2016; Charman, 2013; Rowe & Regehr, 2010). Research demonstrates that paramedic
culture displays these traits and many others including: professional pride, high
personal standards; resilience, tolerance and identity (Klee & Renner, 2013; Rowe &
Regehr, 2010; Wagner, Martin & McFee, 2009; Ahl, et al., 2005). These traits have
been identified as being driven by the unique working conditions of pre-hospital care,
where paramedics are reliant on their collective competency, knowledge and ability to
work in both common and uncommon situations with a sometimes seemingly wordless
communication (Ahl, et al., 2005; J. O’Neil, personal communication, October 10,
2016). The data from this study revealed some of the cultural traits of Australasian
paramedics that appear to draw a parallel with paramedic personality traits discussed
24 Chapter 2: Literature Review
in the literature. Chapter Five considers these during the discussion of Australasian
paramedics and their drivers of engagement with CPD opportunities.
2.6 TRANSITION OF PRACTICE: EMERGENCE OF THE PARAMEDIC PROFESSION
The transition to paramedic practice has been discussed in the literature by many
authors. Literature in this space has examined the professionalisation of paramedicine
to assist the development of theory and research about the whole practice of
paramedicine (Long, 2017; Johnston & Acker, 2016; Campeau, 2015; O’Brien,
Moore, Dawson & Hartley, 2014). The transition from paramedic skills being heavily
encased in protocols and algorithms, to clinical reasoning and evidence-based pre-
hospital emergency care has been discussed in the literature (OMeara, 2009).
However, few authors have commented on how and where CPD fits into this transition.
The transition of the ambulance industry into a paramedic profession also
involves organisational and operational change (Wankhade, Heath & Radcliffe, 2017;
Wankhade, 2012; Mahony, 2003). It has been suggested that there are differences
between clinician and managerial understanding of the complexity of healthcare
(Oliver et.al, 2014; Plsek & Wilson, 2001). Some authors advocate for organisations
to use more adaptive management systems, which result in a more productive service,
and have a direct relationship with improving patient outcomes, meeting KPI’s and the
CPD (Knox, et.al, 2016; Plsek and Wilson, 2001). Commonly in the organisational
culture of ambulance, budget constraints result in cuts to funding, education and
training opportunities for employees, as management concentrates on operational
requirements of the front-line (Parker, 2008). Generally, this results in many
organisational education opportunities becoming mandatory compliance training
packages. A tendency towards negative consequences of cultural changes within
ambulance services occurs when ambulance management fails to account for the
impact of managerial changes affecting the CPD of employees (Wankhade and
Brinkman, 2014). Further investigation is warranted to explore the relationship
between ambulance culture; the individual (paramedics), the organisation (ambulance
services) and the context of paramedic practice in relation to CPD.
To date, the majority of paramedic research is focused on clinical care
interventions pertaining to skills, procedures and pharmacology (Campeau 2015;
Williams, Brown & Onsman, 2012). In recent years changes and participation in
Chapter 2: Literature Review 25
clinical practice, training, education and research has assisted in bolstering the
emergence of the paramedic professional identity (Maguire, O'Meara & Newton,
2016). It has been proposed that CPD can assist in maintaining the status of a
profession (Cruess, Cruess & Steinert, 2016). Many authors describe paramedicine as
an evolving profession still building its research base (Burford, et al., 2014; Emms, &
Armitage, 2010; Donaghy, 2008). It is argued, that a paramedic, who has a wealth of
experience, also has the ability to do more to save the life of their patient than any
other health worker and is therefore justified in fighting for professional status
(Mahony, 2003). As this is now part of the transition in Australasia, it is also time for
paramedic researchers to take a closer look at the symbiotic relationship between CPD
and paramedic professionalisation.
The professional socialisation processes experienced by novice paramedic
practitioners have been explored in the literature. One study concluded that university
educated paramedics experience significant professional socialisation challenges,
including marginalisation and stigmatisation during their transition phase to paramedic
practice (Devenish, 2014). Another study in Ireland that concluded intern/student
paramedics could successfully transition to competent autonomous practitioners when
supported through clinical training and appropriate supervision from senior colleagues
(Bury, Janes, Bourke & O’Donnell, 2007). How a paramedic makes the transition into
practice is relevant to paramedic CPD and this study because this is the time in the
novice practitioners’ career where they are attempting to merge pre-conceptions and
the reality of paramedicine (Devenish, 2014), with organisational culture and the
realisation that ongoing learning will be required.
The terms profession, professional (behaviour and identity), and
professionalisation are themes which are discussed in the literature (Cruess, Cruess &
Steinert, 2016; Taylor, 2015; Trede, 2009; Mahony, 2003). When striving for
professional status, it is important for practitioners to protect their individualistic
occupational and organisational territory (Dew, 2017). This concept can now be seen
among Australasian paramedics. The literature recognises Australian paramedics as a
contemporary example of the evolution of pre-hospital emergency care becoming
recognised as a profession (Knox, et.al, 2016). Paramedics have also long been
recognised as being experts in resuscitation and emergency obstetrics in the pre-
hospital environment (Mahony, 2003).
26 Chapter 2: Literature Review
2.6.1 Profession, Professionalism, Professional Practice
The evolution of the paramedic profession is influenced by clinical governance;
tertiary models of education and training, as is the case for all health professionals; a
code of ethics; professional association and registration; professional development;
autonomy and patient safety outcomes (Taylor, 2015; Knox, Cullen, & Dunne, 2014;
Hou, Rego, & Service, 2013; Williams, Brown & Onsman, 2012; Alexander, Weiss,
Braude, Ernst, & Fullerton-Gleason, 2009). It is important to note the difference
between the terms: profession, professionalism and professional practice. The term
profession can be described as an occupation, which generally is supported or
regulated by professional autonomy and accountability; a code of conduct and ethics
that is abided by; status within the community; shared professional skills and
knowledge; and, a tertiary education (Cruess, Cruess & Steinert, 2016; Trede, 2009).
Each of these elements are found within the paramedic profession. Professionalism
can be described as the characteristics, including self-regulation, professional
competence and integrity, that a practitioner is expected to display as a member of a
profession (Cruess, Cruess & Steinert, 2016; Edgar, 2014) which are also apparent
within the paramedic profession. Finally, professional practice encompasses both the
profession and professionalism of the practitioner. Professional practice is socially
constructed and encompasses the role that the practitioner plays within the health
continuum (Cruess, Cruess & Steinert, 2016; Trede, 2009), including how the
professional has interacted with practitioner competences and adherence rates, clinical
process outcomes and error rates, patient satisfaction, and patient outcomes (Reeves,
Perrier, Goldman, Freeth & Zwarenstein, 2013). As of the end of 2018, in Australia
official recognition of paramedicine as a profession has occurred through the
instigation of professional registration (AHPRA, 2018b), thus acknowledging
paramedics as being official stakeholders in the progression of the healthcare
continuum.
2.6.2 Paramedic Professional Registration in Australasia
At the time of writing this literature review, within Australasia, each ambulance
service seemingly has different perceptions of the role and responsibilities of a
paramedic, thus making it difficult to elicit a single definition of the Australasian
paramedic profession (O’Brien, Moore, Dawson & Hartley, 2014). There is an
expectation that this may begin to change since the implementation of paramedic
Chapter 2: Literature Review 27
registration in December, 2018. Notwithstanding this, in recognition of no national
regulation, Paramedics Australasia (PA) developed a set of clinical practice guidelines
in 2012, which defines standards and scope of practice for Australasian paramedics
(Paramedics Australasia, 2012b).
The Paramedicine Board of Australia has clearly outlined the professional
expectations of paramedics to meet the CPD standard. Paramedics must complete a
minimum of 30 hours of CPD per year and retain documents pertaining to their CPD
activities in a portfolio (AHPRA, 2018e). Furthermore, the 30 hours of annual CPD
must: seek improvement of patient experiences and outcomes; utilise appropriate
evidence, which is well-established and accepted knowledge and supported by peer-
reviewed research where possible, to inform good practice and decision-making; build
on existing knowledge of the learner; directly contribute toward the development or
improvement of practitioner competence (behavioural and clinical performance) that
is appropriate for the paramedic scope and setting of practice; and, include a minimum
of eight hours of CPD that interacts with other practitioners (AHPRA, 2018e).
Paramedics in New Zealand are awaiting professional regulation (Paramedics
Australasia, 2016). In New Zealand the Health Practitioners Competence Assurance
(HPCA) Act 2003, regulates more than 20 health professions (Tunnage, Swain &
Waters, 2015). Paramedic registration in New Zealand will be recognised under the
HPCA Act by the Ministry of Health and overseen by Health Workforce New Zealand
(Paramedics Australasia, 2016). In New Zealand, the relevant authorities undertake
responsibility for three principal functions under the HPCA Act 2003, including
engagement in CPD (Tunnage, Swain & Waters, 2015).
2.6.3 Paramedic Professional Registration: International Examples
It is mandatory in countries such as Canada, the UK and the USA for paramedics
to complete a statutory minimum number of hours participating in CPD activities, and
these CPD activities are required to be recorded in a folder of evidence (Macdougall,
Epstein & Highet, 2017; Haywood, Pain, Ryan & Adams, 2012). As such, a model of
paramedic registration already occurs and functions in other countries. There are
currently 24,722 paramedics in the UK registered under the Health and Care
Professions Council (HCPC, 2017a). To maintain registration with the HCPC,
paramedics must continue to meet the standards set for the profession. One of these
standards is that of CPD, which the HCPC defines as a range of learning activities
28 Chapter 2: Literature Review
which paramedics need to maintain and develop throughout their career ensuring that
they continue to practice safely, effectively, and legally, within their evolving scope
of practice (HCPC, 2017b). Clearly demonstrating that CPD is an important part of a
Paramedic’s continuing registration with the HCPC. Paramedics are expected to
continue to develop their knowledge and skills while they are registered to satisfy the
HCPC that they can practice safely and effectively. The HCPC standards for CPD state
that a registrant must:
• maintain an up-to-date and accurate record of CPD activities;
• demonstrate that their CPD activities are a mixture of learning activities
relevant to current or future practice;
• seek to ensure that their CPD has contributed to the quality of their practice and
service delivery;
• seek to ensure that their CPD benefits the service user; and finally,
• if requested, be able to present a written profile (which must be their own work
and supported by evidence) explaining how they have met the standards for
CPD (HCPC, 2017b).
Conversely, Canada is made up of ten provinces and three territories, and does
not have a uniform system for certifying paramedics (Government of Canada, 2017).
The National Occupational Competency Profile (NOCP) defines specific clinical
skills, knowledge, and abilities as equal with a given level of paramedic practice, but
each province retains its authority in legislating emergency services that are
represented within its boundaries (Paramedic Association of Canada, 2017a). Most of
the provinces are moving toward recognising the NOCP definition of the profession,
which will allow paramedics from different provinces to work in other provinces,
regardless of their clinical level (Paramedic Association of Canada, 2017a).
Under the NOCP framework, paramedic practice consists of eight competency
areas; and it is through incorporation with the Canadian Medical Association that the
NOCP establishes the required minimum learning outcomes of accredited education
programs at the PCP, ACP and CCP levels (Paramedic Association of Canada, 2017b).
Programs are free to create their own curricula and learning activities to enable
graduates to achieve the learning outcomes. Programs are also able to generate
Chapter 2: Literature Review 29
learning outcomes that exceed the competencies and CPD is embedded into both
programs and learning outcomes (CMA, 2011).
2.6.4 Paramedic Professional Registration in Summary
Professional registration of paramedics (including CPD) is not a new
phenomenon in other Commonwealth countries such as Canada and the UK. When
lobbying on behalf of its members to AHPRA in the consultation process prior to
professional registration, the Network of Australasia Paramedic Academics (NAPA),
a sub-group of the peak professional body Paramedics Australasia, investigated these
other systems (Paramedics Australasia, 2017d). While these regulatory systems work
well for the host country, it must be noted that these systems are influenced by the
governance of each countries’ health care system and the funding available to it. Either
system could have been implemented into Australia and New Zealand. However, the
Paramedicine Board of Australia has implemented a system which is aligned with
other Australian health professions that are professionally registered with AHPRA.
The Paramedicine Board of Australia has stipulated professional paramedic
registration requires; a minimum of 30 hours CPD, eight of which must be interactive,
and all must be recorded in an evidence portfolio that can be produced on audit
(AHPRA, 2018e). The CPD standard is a condition for Australian paramedics to
maintain their registration with AHPRA. Many ambulance services already
requirement paramedics to develop a Professional Development Plan (PDP) specific
to their scope of practice and organisational level, which is a part of CPD and similar
to the requirements of other health professions. Appendix N depicts the expected
movement of the onus of CPD within the paramedic paradigm, post-professional
registration.
2.7 UPSKILLING PARAMEDICS: EXPANDING PARAMEDIC SCOPE OF PRACTICE
Extended paramedic scope of practice has been a contentious topic in the
literature. Perhaps because most paramedic scope of practice can expand into both
high and low acuity genera. In the literature, expanding paramedic scope of practice
has been an overarching term that covered paramedic classifications such as:
Emergency Care Practitioner, Paramedic Practitioner, Extended Skills Paramedic, and,
most recently, Community Paramedic (Bigham, Kennedy, Drennan & Morrison,
2013).
30 Chapter 2: Literature Review
A review of the literature and specific studies have revealed that extended
paramedic scope of practice has had an overall positive impact on, and significantly
contributed towards, the patient care continuum (Bigham, Kennedy, Drennan &
Morrison, 2013; Cooper & Grant, 2009; Reynolds, 2008). Yet, it is unknown what part
CPD has played in this, despite the presumption that formal and informal learning
contributed to these paramedics extending their knowledge, skills and clinical scope
of practice. Community paramedicine programs in Australia, Canada and the UK have
been cited as proving paramedics can operate safely under an extended scope of
clinically focused professional practice and can improve patient outcomes (Long,
Clark, Lim & Devenish, 2016; Bigham, Kennedy, Drennan & Morrison, 2013; Cooper,
O’Carroll, Jenkin & Badger, 2007; Mason, Coleman, O’keeffe, Ratcliffe & Nicholl,
2006). This is relevant to the current study as it demonstrates that previous paramedic
CPD has assisted in the actual development of the clinician and resulted in positive
patient outcomes. Currently paramedics with extended scopes of practice are not
required by AHPRA to engage in extra CPD. However, this may change to align with
other professions such as nursing (AHPRA, 2017c).
2.8 CPD IN ALLIED HEALTH PROFESSIONS
In the absence of literature about paramedic CPD, it is appropriate to review the
relevant research about CPD from other health professionals, such as the disciplines
of medicine, nursing, dentistry and allied health. These health professions have
previously transitioned to health professional status and as such, have encountered and
overcome challenges similar to those which the paramedic profession now faces.
AHPRA CPD guidelines for these professions will be discussed, as similar guidelines
have now been recommended by the Paramedicine Board of Australia for Australian
paramedics (AHPRA, 2018a).
Research into CPD of other health professions has determined that many
different factors, including professional goals or status, financial benefits, personal
morals, employment obligations and patient safety can influence the motivational level
of a person working in healthcare to participate in CPD programs and activities
(Burstow & Winch, 2014; Haywood, Pain, Ryan & Adams, 2012; Kilner, 2004). The
literature suggests that CPD should be an activity which holds personal value which
enables the participant to then engage in deep learning, resulting in improved patient
care, reflective practices and professional accountability (Macdougall, Epstein &
Chapter 2: Literature Review 31
Highet, 2017). There are also ethical motivators, including maintaining a high
standard of professional competence and delivering the gold standard of care to
patients (Haywood, Pain, Ryan & Adams, 2012). Within the allied health literature
some other motivators are discussed namely: professional image; improved patient
outcomes; improved knowledge sharing; greater authority to practice; financial and
career prospect benefits; peer pressure and professional obligation (Duncombe, 2018;
Macdougall, Epstein & Highet, 2017; Filipe, Silva, Stulting & Golnik, 2014;
Haywood, Pain, Ryan & Adams, 2012; Kilner, 2004).
2.9 CPD AND IMMINENT REGISTRATION OF OTHER HEALTH PROFESSIONALS
A major influence on CPD was highlighted in a study of physiotherapists, noting
that when statutory registration was imminent, health professionals were expected to
maximise their CPD involvement and opportunities (Wotherspoon & McCarthy,
2016). The same concept is a common theme in medicine, nursing, pharmacy,
podiatry, social work, physiotherapy, occupational therapy, dietetics, dentistry,
psychology, speech pathology, radiography, optometry, psychotherapy, medical
science, audiology and medical imaging (Cleary, Horsfall, O’Hara-Aarons, Jackson &
Hunt, 2011; Stagnitti, Schoo, Reid & Dunbar, 2005; Ryan, 2003; Brown, Belfield &
Field, 2002). Since December 1st, 2018, in Australia, professional registration for
paramedics is a requirement of National Law (AHPRA, 2018b). In New Zealand,
paramedic professional registration is imminent but not yet required (Paramedics
Australasia, 2016). It is reasonable to conclude that at this time, the discipline of
paramedicine may not be totally prepared for the transition. An example is the
paramedic profession demonstrating a lack of preparedness for professional regulatory
standards was seen in the United Kingdom in 2012-2013 (Eburn & Townsend, 2014).
Due to a general lack of understanding regarding self-reporting and complaints, the
HCPC investigated 262 cases alleging breaches of regulatory requirements (Eburn &
Townsend, 2014). Anyone who has a reasonable belief that a registered health
professional has breached the Health Practitioner National Law Act (2009), can make
a complaint about professional misconduct or unprofessional conduct.
Self-onus towards CPD is an important part of the professionalisation process
(Macdougall, Epstein & Highet, 2017). CPD is mandatory and registration
requirements demand it. This is evident in health professionals such as doctors, nurses,
32 Chapter 2: Literature Review
pharmacists, and psychologists which require a CPD plans or portfolios to be
submitted as part of their professional registration (AHPRA, 2017a). These
requirements differ between the allied health professionals. An example of this is seen
in the nursing profession where there is an expectation that individuals will complete
at least 20 hours within predetermined timeframes post registration (AHPRA, 2017c).
Furthermore the 20 hrs of CPD per year, has to be ‘new learning’, that is relevant to
the individuals’ practice (AHPRA, 2017c). For example, an Emergency Department
(ED) nurse cannot do a course on theatre nursing because it would not count towards
ED work, unless the individual has a professional development plan that includes a
desire to move from working in the ED to theatre. Furthermore, if a nurse were to
specialise, in an extension of general nursing such as midwifery, they would have to
complete another 20 hours of CPD on top of the normal 20 hours for nursing (AHPRA,
2017c).
Nursing courses and conferences indicate how much the event is worth in either
CPD hours or points. Options such as short courses or writing journal articles are
available for utilisation by the individual to make up time or point requirements (S.
Webster, personal communication, November 5, 2017). Self-directed CPD evidence
records must be maintained for a period of five years (AHPRA, 2017c). AHPRA
conducts CPD portfolio audits of approximately 10% of nurses in any year (AHPRA,
2017c). If audited, the individual is required to supply CPD evidence records for the
previous five years (AHPRA, 2017c). Nurses are not required to supply evidence of
CPD unless audited, however they must make an annual declaration that they have
done the required number of hours every year to renew their registration (AHPRA,
2017a). The regulatory system appears to be flawed in regard to classifying the value
of a CPD event. The value (in hours or points) is subjective and applied by the CPD
provider/organiser, meaning that the provider can decide what the activity they are
providing is worth (AHPRA Call Centre Representative 1300419495, personal
communication, January 3, 2019). Furthermore, CPD providers are not governed,
audited or dealt with by AHPRA, leaving the onus of documenting an accurate
representation of CPD with the practitioner, and not the provider (AHPRA Call Centre
Representative 1300419495, personal communication, January 3, 2019). These issues
with CPD recording highlight a vulnerability in the system which realistically could
Chapter 2: Literature Review 33
enable individuals to falsify their CPD records and not fulfil the minimum standards
required.
A similar model had been instigated by AHPRA for paramedics (AHPRA,
2018a). Therefore, paramedics need to look at other professionals who have already
integrated registration requirements and CPD and evaluate them to see if they can
contribute to or enhance our knowledge. The evidence supports the authors claim that
CPD can be individually driven via choices that are open to individual practitioners,
such as specific types of conference attendance. Personal preferences dictate that some
CPD programs or activities will be individually preferred overs. This can affect how
we, as paramedics and in fact, as individuals, interact with and engage in CPD. A major
influence on CPD was highlighted in a study of physiotherapists, noting that when
statutory registration was imminent, health professionals were expected to maximise
their CPD involvement and opportunities (Wotherspoon & McCarthy, 2016). The
same concept is a common theme in medicine, nursing and allied health professions
(Cleary, Horsfall, O’Hara-Aarons, Jackson & Hunt, 2011; Stagnitti, Schoo, Reid &
Dunbar, 2005; Ryan, 2003; Brown, Belfield & Field, 2002). However, a gap in the
literature exists in relation to the expectations put on Australasian paramedics and their
engagement in CPD prior to the implementation of professional registration.
2.10 LESSONS OF ENGAGEMENT
Participation in a variety of CPD activities and reflective practices are key to
improving patient care (Macdougall, Epstein & Highet, 2017; Wotherspoon &
McCarthy, 2016). However, there is more to CPD than just striving for improving
patient care. Engagement in CPD can be directly influenced by: the professions’
requirements to acquire and/or develop skills; professional recognition; possibility of
career or professional advancement; mandatory requirements/professional
registration; social support; opportunity; personal and/or financial costs (Jaiswal,
2017; Coventry, Maslin-Prothero & Smith, 2015; Filipe, Silva, Stulting & Golnik,
2014; Ikenwilo & Skåtun, 2014; McArdle & Coutts, 2010; Munro, 2008). It has been
suggested that regardless of the health care discipline, or any external pressures on the
individual; there is a social expectation that professional currency needs to be
maintained, and providing quality patient care and continuing to update clinical
knowledge are common personal motivators of individuals who choose to actively
34 Chapter 2: Literature Review
participate in CPD activities (Filipe, Silva, Stulting & Golnik, 2014; Ikenwilo &
Skåtun, 2014; Chong, Sellick, Francis, & Abdullah, 2011; Ahl, et al., 2005).
2.10.1 Facilitators of CPD
Research demonstrates that it is beneficial if CPD activities are enjoyable for
practitioners to participate in and to continue engaging with in the future (Macdougall,
Epstein & Highet, 2017; Filipe, Silva, Stulting & Golnik, 2014). A study of 50 mental
health nurses concluded that participants not only favoured CPD activities which
focused on the enhancement of patient-centred clinical skills, but that the majority of
participants actively sought out further opportunities to participate in CPD activities
(Cleary, Horsfall, O’Hara-Aarons, Jackson & Hunt, 2011). The most commonly
reported facilitators of CPD include; cultural aspects of the profession; environmental
factors (i.e. employer support); the motivation level of the health professional and their
understanding of how CPD programs and activities can improve both health care
practices and patient outcomes (Walsh & Craig, 2016; Coventry, Maslin-Prothero &
Smith, 2015; Légaré, Ratté, Gravel, & Graham, 2008). At this time, there is little in
the literature that links Australasian paramedics’ attitudes towards facilitators of their
understanding of and engagement in CPD.
2.10.2 Barriers of CPD
Similarly, there has been limited investigation of Australasian paramedics’
attitudes about the perceived barriers to their engagement in CPD. CPD is often linked
to professional regulations and registration and as such, enjoyment may not always
coincide with professional obligation (Filipe, Silva, Stulting & Golnik, 2014; Ikenwilo
& Skåtun, 2014). The literature states that CPD has been perceived by some
professionals as confusing or ambiguous, which initially resulted in limited research
about the barriers preventing professionals from actively participating in CPD
activities and programs (Friedman & Phillips, 2001). As further research occurred,
common barriers to CPD have become apparent. Barriers often reported by other
professionals to include: time constraints; information overload; lack of knowledge of
the facilitator or presenter; lack of confidence of the participant/practitioner; personal
and/or financial cost; family commitment; continuing lack of training resources; staff
shortages; insufficient study leave; fatigue and/or lack of motivation to engage in the
CPD activity; and lack of strategic leadership or definition as to if the onus for
engagement in CPD belonged to the individual or the organisation (Bressan, et al,
Chapter 2: Literature Review 35
2016; Filipe, Silva, Stulting & Golnik, 2014; Ikenwilo & Skåtun, 2014; Légaré, Ratté,
Gravel, & Graham, 2008; Gallagher, 2006; Friedman & Phillips, 2001).
2.10.3 Lessons for Paramedicine
The discipline of Paramedicine is still professionally evolving (Long, 2017; Batt,
Morton, Kloepping, Buick & Todd, 2015; Hou, Rego & Service, 2013; Ahl, et al.,
2005). Tertiary education for medicine and other health professions began being
offered in Australasian universities from the mid 1800’s, in comparison to
paramedicine which has only been available since 1994 (O’Brien, Moore, Dawson &
Hartley, 2014; Hou, Rego & Service, 2013; Lord, 2003). The legitimacy of a
profession is contributed to through the move of education models moving from VET
to university (O’Brien, Moore, Dawson & Hartley, 2014). Paramedicine is in its
infancy of being recognised as a profession (Johnston & Acker, 2016; Williams,
Brown & Onsman, 2012). Continuing improvements in technology; health and safety;
and the application and provision of patient care have influenced the way that CPD
occurs (Sockalingam et.al, 2017; Hill, Beisiegel & Jacob, 2013; Ross & Anderson,
2013; Currie, Lockett, Finn, Martin & Waring, 2012). Some researchers believe that
exploration into the field of CPD is now at a crossroad, and some CPD programs have
not contributed to, or enhanced our knowledge of effective program characteristics
(Hill, Beisiegel & Jacob 2013). The conclusion of this hypothesis is that practitioners
now have little insight into what best practice actually looks like (Hill, Beisiegel &
Jacob, 2013). There is no research in the Australasian paramedic paradigm to confirm
or disprove this theory.
As advancements in healthcare continue, it is imperative that health care
professionals also move forward with these improvements in their individual
disciplines (Macdougall, Epstein & Highet, 2017). Since so little research has been
undertaken on CPD and its role in the discipline of paramedicine, it is useful to
examine cognate fields such as medicine; nursing; allied health professions and
education. Literature relating to allied health professions has investigated professional
and personal attitudes as well as some of the perceived barriers to, and facilitators of
engagement in CPD (Bressan, et al, 2016; Filipe, Silva, Stulting & Golnik, 2014;
Ikenwilo & Skåtun, 2014; Haywood, Pain, Ryan & Adams, 2012; Légaré, Ratté,
Gravel, & Graham, 2008).
36 Chapter 2: Literature Review
The review of the literature revealed limited contributions from the paramedic
profession relating CPD. It was noted that few studies examined the barriers to and
facilitators of CPD within the paramedic paradigm, especially in Australasia.
Similarly, there has there been little examination of paramedic perceptions or attitudes
about CPD in the paramedic profession. Thus, a gap exists in the literature which
highlights the necessity for a thorough investigation of Australasian paramedic CPD
practices. National paramedic professional registration commenced in Australia in
December 2018 and is imminent and New Zealand. This will influence the course of
CPD for Australasian paramedics. Therefore, it is timely to investigate paramedic
attitudes and commitment to CPD within the field of paramedicine in Australasia.
2.11 SUMMARY: GAPS IN THE LITERATURE
There is evidence that a gap exists regarding Australasian paramedic CPD in the
context of paramedic practice. A greater understanding of paramedic drivers to seek
out further CPD opportunities; or merely maintain clinical and operational currency,
will significantly contribute the current body of knowledge. It is envisioned that this
research into Australasian paramedics may generate new knowledge, validate or
disprove unsubstantiated rumours and theories regarding individual paramedic and
ambulance services’ understanding of CPD. A richer understanding of paramedic
attitudes and engagement in CPD also has the potential to have a measurable impact
on paramedic education; national regulation, patient care and clinical outcomes. Thus,
this timely study to investigate Australasian paramedic attitudes and perceptions about
CPD, can provide insight into the implications of existing research and policy on
mandatory CPD for healthcare professionals as it applies to paramedicine. The study
also explores the requirement for a shift in the drivers for engagement in CPD from
the employer to the individual.
Chapter 3: Theoretical Background 37
Chapter 3: Theoretical Background
Chapter Three discusses the theoretical background for this dissertation. It
examines relevant adult learning theories and provides an evaluation of models of
workplace training courses, programs and Continuing Professional Development
(CPD). Where possible, paramedic literature has been utilised to inform the theoretical
background. However, as a gap in the literature exists, other transferable health and
educational literature is examined in this chapter to inform the theoretical background
to this thesis. The application of a model to measure the effectiveness of a CPD activity
is vital in healthcare, since the outcome of any CPD program or activity can directly
affect the population health status (Filipe, Silva, Stulting & Golnik, 2014). While it is
beyond the scope of this dissertation to provide a comprehensive appraisal of models
and theory relating to CPD evaluation, this chapter examines the relevant literature,
theoretical constructs and several key models that have shaped CPD in health and other
disciplines.
3.1 DEFINITION
CPD has many definitions in the literature as outlined in Section 2.3. For the
purposes of this research CPD has been defined as any activity (either self-directed or
mandatory) which enhances LLL, and the development or maintenance of knowledge,
skills, competence or expertise of a paramedic throughout their professional career.
LLL can be considered a 'philosophy of practice' & the skills associated with it can be
learned. Furthermore, engaging in CPD can occur independently or as a part of a
professional development plan (PDP). It may demonstrate commitment to the delivery
of gold-standard patient care, and/or advancement of the paramedic profession, and/or
a commitment to LLL.
3.2 ADULT LEARNING THEORIES IN MEDICAL EDUCATION
There are numerous theories of education in the literature (Olson, 2015). Each
theory provides an explanation of the different ways learning occurs (Olson, 2015;
Taylor & Hamdy, 2013). It is generally accepted that the term pedagogy refers to
teaching children, and the term andragogy is utilised to describe adult learning (Olson,
2015). Malcolm Knowles is one of the most prolific researchers into andragogy, with
38 Chapter 3: Theoretical Background
publications spanning from 1950 to 2014, expanded into six assumptions of adult
learning (Ozuah, 2016). These assumptions are:
• The Need to Know – prior to commencing educational activities, adult learners
need to know the value of what it is that they will learn;
• The Learners Self-Concept – adult learners are independent and prefer learning
to be self-directed;
• The Role of Experience – the richest resource in adult learning is experience.
Analysis of experience is the core methodology of adult learning;
• The Readiness to Learn – having assessed the value and relevance of the topic,
adult learners will then ready themselves to undertake the learning journey;
• The Orientation to Learning – adult learning is ‘life-centred’ or situational in
context.
• The Motivation to Learn – adults will be motivated to learn to satisfy needs and
interests that arise.
(Knowles, Holton & Swanson, 2014).
The multi-theories model of adult learning, developed by Taylor & Hamdy,
(2013) are applied to this research. The justification being that there are many ways
through which adults learn. One single theory does not explain the learning process or
apply that process, for every learner (Olson, 2015; Taylor & Hamdy, 2013). It is also
not always easy for educational institutions to connect adult learning theory with
professional practice (Taylor & Hamdy, 2013). Research into the ways that healthcare
professionals learn, led to the development of the multi-theory model, which
incorporates andragogy and positions that learning consists of three domains:
knowledge, skills and attitudes (Taylor & Hamdy, 2013). The model proposes that
there is an overlap between adult learning theories, which allows them to be grouped
into categories. These are:
• Instrumental learning theories (including cognitive and behaviouralist learning
theories) - which focus on the experience of the individual;
• Social learning theories – emphasising communities of practice to encourage
and guide the learner;
Chapter 3: Theoretical Background 39
• Humanistic learning theories – promote individualistic, self-directed, internally
motivated learning;
• Transformative learning theories – are an exploration of the learner,
encouraging reflective learning practices;
• Motivational models – based on intrinsic motivation and personal reflection,
leading to successful learning; and,
• Reflective models – feedback and reflection lead to actions, which assist in the
development of autonomous learning.
(Taylor & Hamdy, 2013).
The multi-theories model (Figure 1) on the following page, incorporates the
knowledge of adult learning theories and based on these theories, revolves around the
experience of the learner.
40C
hapt
er 3
:The
oret
ical
Bac
kgro
und
Figu
re 1
. The
mul
ti-th
eorie
s mod
el o
f adu
lt le
arni
ng
Rep
rinte
d fr
om “
Adu
lt le
arni
ng th
eorie
s: Im
plic
atio
ns fo
r lea
rnin
g an
d te
achi
ng in
med
ical
edu
catio
n: A
MEE
Gui
de N
o. 8
3,”
by D
. C. T
aylo
r &
H. H
amdy
, 201
3, M
edic
al T
each
er, 3
5(11
), e1
566.
Cop
yrig
ht [2
013]
by
Tayl
or &
Fra
ncis
. Rep
rinte
d w
ith p
erm
issi
on.
Chapter 3: Theoretical Background 41
The learner moves through five phases: dissonance, refinement, organisation,
feedback and consolidation during their learning experience (Taylor & Hamdy, 2013).
The model can be applied in numerous ways, and proposes specific roles during each
phase, for the learner and the teacher (Taylor & Hamdy, 2013). The journey to improve
knowledge, skills and attitudes can take many routes, this model provides the map for
both educators and learners to utilise and ensure that learning outcomes are co-
constructed, making it relevant to the discipline of paramedicine.
Having defined paramedic education and adult education, the remainder of this
chapter is constructed in the following way. Section 3.4 outlines the journey that
paramedics must now take to accept some personal responsibility for their CPD and
LLL; with comparisons made against other healthcare professionals. Section 3.5, then
brings together the multi-model theory with paramedicine, to investigate theories and
models of CPD. It is in section 3.5, that the reader can appreciate why a single theory
for adult learning could not be utilised effectively for this study.
3.3 PARAMEDIC JOURNEY TO ACCEPTING PERSONAL RESPONSIBILITY FOR CPD AND LLL
Education can be a personal journey which a learner engages in with certain
goals in mind. Since the early 1990’s doctors engaging continuing education and CPD
have been encouraged to assess their personal learning needs and then to implement a
plan on how they will best meet those needs (Macdougall, Epstein & Highet, 2017;
Nicholls, 2014). Both education and nursing disciplines report that interactive and self-
directed learning and development activities can be integral to establishing good CPD
practices (Manley, Martin, Jackson & Wright, 2018; Kemp & Baker, 2013). From a
paramedic perspective, when individuals commenced a career in paramedicine, they
underwent vocational education and training which was typically facilitated by the
ambulance employer (Hou, Rego & Service, 2013; Gregory, 2012; Cooper & Grant,
2009; Cooper, O’Carroll, Jenkin & Badger 2007). As the role of paramedics
progressed from technicians in Basic Life Support (BLS), to Advanced Life Support
(ALS) and more recently independent clinicians, the level of education and
qualification required has increased correspondingly (Batt, Morton, Kloepping, Buick
& Todd, 2015; Hou, Rego & Service, 2013; First, Tomlins, & Swinburn, 2012;
Williams, Brown & Onsman, 2012). Thus, paramedic training and education moved
to the tertiary sector, and the concept of CPD is moving away from being
42 Chapter 3: Theoretical Background
organisationally mandated and towards being self-directed by the individual
paramedic.
Paramedics have demonstrated a commitment to LLL and the concept of self-
onus of at least some of their CPD. A cross-sectional study by Alexander, Weiss,
Braude, Ernst & Fullerton-Gleason (2009) investigated the educational backgrounds
of 375 paramedics and found that 27.3% held a bachelor’s degree and 8.1% held a
Graduate degree. While no similar study could be found on Australasian paramedics,
information from the Australian Bureau of Statistics (ABS) reveals a similar
commitment to LLL and an increase in self-directed CPD by paramedics in Australia.
In 2006, 24% of paramedics held a Bachelor degree and 5% held post-graduate
qualifications (ABS, 2012a). A decade later in 2016, from a reported 13,725
ambulance officers and paramedics in Australia, 46% self-reported to have held a
Bachelor degree and 7.5% completed post graduate qualifications (ABS, 2017).
Research indicates that when an individual participates in an LLL activity they
are more likely to transfer learned skills into practice, and to be motivated to then
engage in subsequent activities (Macdougall, Epstein & Highet, 2017; Dent, Harden
& Hunt, 2017; Filipe, Silva, Stulting & Golnik, 2014). Both formal and informal
learning can facilitate LLL (Manuti, et.al, 2015; Gallagher, 2007). Formal learning is
an education process connecting learner, teacher and institution (Mahajan, 2017).
Evidence that Australasian paramedics are taking a self-onus of their formal learning
is provided by information from the ABS which can be further broken down to
investigate field of study undertaken by paramedics. These fields of study extend
beyond an undergraduate degree in paramedicine to post-graduate paramedicine
qualifications in critical care, research and aeromedical (ABS, 2018). Therefore,
providing data which indicates paramedics do engage in self-directed, formal learning
which contributes to their LLL, and/or the development of paramedic specific
knowledge, skills, or expertise.
3.3.1 Informal Learning and Tacit Knowledge
Informal learning is a style of education which complements formal education
(Mahajan, 2017). Informal learning may take many forms, one form relates to the
benefits of professional knowledge and experience which results in the formation of
tacit knowledge, which may also be described as intuition (Mostafa & Klepper, 2018;
Turner, 2018). Research has identified that within the realm of healthcare, tacit
Chapter 3: Theoretical Background 43
knowledge can significantly contribute to quality patient outcomes, because of the
clinical experiences, know-how or know-who that clinicians share (Panahi, Watson &
Partridge, 2016). Tacit knowledge is also recognised in nursing literature as resulting
in a positive influence on processional practice (Hayes, Fox, Scott-Thomas & Graham,
2018). Furthermore, tacit knowledge is often connected to experiential learning and
the ability to think and act in the moment (Hayes, Fox, Scott-Thomas & Graham,
2018). It is reasonable to surmise that tacit knowledge parallels some aspects of
paramedic practice and could be relatable to both VET educated paramedics and
tertiary trained paramedics, since paramedics and paramedic educators will often refer
to intuition that assists them in pre-hospital emergency care (J. O’Neil, personal
communication, October 11, 2018).
The literature pertaining to other healthcare professions described tacit
knowledge in the context of assisting employers to recruit the best suited candidates;
or assisting healthcare professional in their reflective processes (Hayes, Fox, Scott-
Thomas & Graham, 2018; Pringle, 2017). There is however, a dearth of literature
expressly investigating how the concept of tacit knowledge fits into the paramedic
CPD context. Nurses utilise reflective practices in conjunction with tacit knowledge to
self-evaluate knowledge, skills and practitioner confidence (Pringle, 2017). Which
assists in bridging the dissonance between theoretical and practical knowledge
(Benner, 1984). However, no study could be found investigating if this is the case with
paramedics. As professional registration now requires paramedics to incorporate
reflective practices into their CPD, the relationship between tacit knowledge and
practitioner development from novice to expert has become apparent, suggesting that
tacit knowledge could possibly be better incorporated into paramedic CPD.
3.4 MODELS OF CONTINUING PROFESSIONAL DEVELOPMENT
CPD is discussed extensively in the literature, which has resulted in the
development and discussion of various CPD models. Section 3.4 discusses the models
of CPD that were included in this study, with one exception. The Deficit Model is
briefly outlined in as it is included in a CPD framework developed by Kennedy (2005).
It is included in the study as this model as historically, this type of model was favoured
by ambulance education units, as a reflection of the hierarchical paramilitary culture
at the time (Devenish, 2014). Due to organisational socialisation, aspects of this model
are still encountered in ambulance services. However, it is recommended that
44 Chapter 3: Theoretical Background
utilisation of this model be limited, or ceased due to its application not being in
alignment with best practice principles. The other seven models from the framework
proposed by Kennedy (2005) are considered by the author to be more appropriate for
the progression of paramedic CPD.
The eight models identified and placed within a CPD framework, by Kennedy
in 2005 and re-evaluated against more contemporary literature in 2014 (Kennedy,
2014). Thus, demonstrating the framework developed by Kennedy was robust and
remains contemporary. The eight models identified from the literature are: training
models; award-bearing models; deficit models; cascade model; standards-based
models; coaching/mentoring models; community of practice models; and,
collaborative professional inquiry models (Kennedy, 2014). The framework developed
by Kennedy (2005) organises CPD models for teachers, along a spectrum
demonstrating the capacity for transformative practice and professional autonomy
within each of the models. When examining existing health disciplines, these models
also begin to reveal themselves through the relevant literature, training programs,
organisational policy and professional standards. The following sections 3.4.1 through
to 3.4.8 with briefly examine each of these models, section 3.4.9 discusses how the
models fit within the framework proposed by Kennedy.
3.4.1 The Training Model
The training model of CPD provides the participant with learning activities
designed to impart new knowledge, or update professional knowledge or skills (Glen,
2017; Kennedy, 2005). The learner is then required to demonstrate the skill under some
form of assessment criteria which can then assess competence (Shaw, Barnet,
Mcgregor & Avery, 2015). The training model of CPD is a transmissive model
generally following a didactic pedagogy in which the teacher is the expert and the
learner remains a passive participant of the education the process (Kennedy, 2014).
Another key point made by Kennedy (2005) in relation to the training model involves
dominant stakeholders wielding almost absolute power to limit or control the training
agenda. The relationship between paramedicine and this training model is very clear
and dates beyond the time vocational education and training (VET) of paramedics
being facilitated by the ambulance service/employer through paramedic educators and
guest educators (e.g. doctors) which superior clinical knowledge, skills and
Chapter 3: Theoretical Background 45
competence (Gregory, 2012; Cooper & Grant, 2009; Joyce, Wainer, Archer, Wyatt &
Pitermann, 2009; Cooper, O’Carroll, Jenkin & Badger 2007).
3.4.2 The Award-Bearing Model
These types of CPD models are curriculum-focused, inquiry-based and require
the completion of an award-bearing course or programme of study that is usually
tertiary-based or validated by a funding stakeholder (King, Ní Bhroin & Prunty, 2018;
Kennedy, 2005). Tertiary based courses of study provide quality assurance and
external validation of the award (Kennedy, 2005). The award-bearing model of CPD
sits within the ‘malleable’ category because there is both a transmission of knowledge
and support for the learner to increase autonomy (King, Ní Bhroin & Prunty, 2018).
Within the Australasian paramedic paradigm, use of the award-bearing model has been
demonstrated through both VET and tertiary education of paramedics. An example of
VET award-bearing CPD was demonstrated by the employer (ambulance services)
funding the course of study (diploma qualification) and held control over the validation
of the assessment items and the completion of the award. In 1994 Australasian
universities commenced offering undergraduate degrees in paramedicine (O’Brien,
Moore, Dawson & Hartley, 2014; Hou, Rego & Service, 2013; Lord, 2003), which
enabled the provision of quality assurance and external validation of the (degree)
award (Kennedy, 2005). Similarly, now that the majority of paramedic qualifications
come from the university sector, completion of an undergraduate program is awarded
with a degree.
3.4.3 The Deficit Model
The deficit model enables the CPD to be directed towards rectifying an identified
deficit and bringing about a behavioural change in the performance of the learner
(Lowe, 2016; Kennedy, 2005). One of the largest criticisms of this model of CPD is
that it may also blend into a framework of performance management (Davis &
McMahon, 2018). Kennedy (2005) warns against the utilisation of the deficit model
of CPD to ignore the collective responsibilities of each stakeholder and attribute blame
for poor performance solely to the learner. Rather than assigning punitive measures
disguised as CPD to remedy perceived performance weakness, collective competence
must be defined and then assessed (Kitto & Grant, 2014). There are three elements that
compose effective collective competence: constructing a collective sense of workplace
events; development and utilisation of the collective knowledge base; and
46 Chapter 3: Theoretical Background
development of a sense of interdependency (Kennedy, 2005). Historically, paramedic
CPD has shared an informal interchangeability within some context of performance
management. Arguably CPD in such instances was driven by the desire to ensure
patient safety and patient outcomes (Martin, 2015). Regardless of the motive, the
recognition of collective responsibility is forfeited when underperformance is blamed
only on the individual (Kennedy, 2005). For the purposes of this study, the deficit
model is possibly not best practice and it is therefore, recommended that paramedic
CPD programs avoid utilising this particular model, wherever possible.
3.4.4 The Cascade Model
The cascade model is sometimes referred to as a ‘train the trainer’ model, it is
both cost effective and transmissive in nature (Howell & Sayed, 2018). An example of
the cascade model is demonstrated when an individual attends some type of CPD
event, and then disseminates information relevant to the new knowledge acquired to
other staff members (Lowe, 2016). The cascade model has been utilised in numerous
ambulance in-service training and/or education packages. Several weaknesses must be
carefully evaluated prior to engaging in this model of CPD. One possible drawback of
the cascade model is that values and attitudes appear not to be given as much priority
as knowledge and skills (Kennedy, 2005). A second consideration is that the CPD
interventions are not typically retained by subsequent staff because ‘the trainers’ do
not always possess the requisite skills to ensure quality transfer of relevant content and
evidence-based information (Howell & Sayed, 2018).
3.4.5 The Standards-based Model
The standards-based model centres around the learner undertaking training or
education which results in them being able to demonstrate specific skills at an imposed
standard (Lowe, 2016). This model represents a form of competency-based training
that has been utilised in ambulance education for many years. The standards-based
model of CPD has been criticised in the literature for imposing inspection and quality
assurance rather than respecting the learner’s ability for analytical inquiry, self-
reflection and practice-based learning (Kennedy, 2014; Silva et.al, 2011). Despite
criticism in the literature, the standards-based model does enable professional
development to be scaffolded (Kennedy, 2019), which may assist novice practitioners
to transition into professional practice. For this reason, it has been included in this
study.
Chapter 3: Theoretical Background 47
3.4.6 The Coaching/Mentoring Model
The coaching/mentoring model covers a variety of CPD activities based on many
philosophical concepts (Kennedy, 2005). It lends itself to the paradigm of
paramedicine since it is designed as a one-to-one relationship occurring between two
practitioners, in which support can be given one-way or mutually (Lowe, 2016;
Kennedy, 2005). The coaching/mentoring model can be hierarchical, where a qualified
paramedic inducts a novice paramedic into the profession by assisting them to navigate
cultural norms and grow in self-efficacy. It may also be collegial between qualified
paramedics who equally challenge and support each other, so that learning can occur
in both directions with minimal power distance (Lancer, Clutterbuck & Megginson,
2016). The coaching/mentor model depends less on the type of relationship (e.g.
experienced/novice, or mutual) and more on the quality of the interpersonal
relationship between practitioners (e.g. professional friendship based in well-
developed interpersonal communication skills) to ensure successful learning outcomes
(Lancer, Clutterbuck & Megginson, 2016; Kennedy, 2005).
3.4.7 The Community of Practice Model
The community of practice model is also referred to as the teacher learner
community model and is generally considered to be group-based coaching/mentoring
in nature (Lowe, 2016). The main differences between the coaching/mentoring model
and the community of practice model are that there are generally more than two
individuals involved in the community of practice model, and there is less stipulation
for confidentiality to be sustained throughout the learning process (Kennedy, 2005). It
is an inexpensive method for innovation; the transfer of knowledge and influence
professional behaviours (Aveling, Martin, Herbert & Armstrong, 2017). Boreham
(2000) proposed that within the medical profession:
“When the professional activity is collective, the amount of
knowledge available in a clinical unit cannot be measured by
the sum total of the knowledge possessed by its individual
members. A more appropriate measure would be the
knowledge generated by the richness of the connections
between individuals.” (p.505)
48 Chapter 3: Theoretical Background
Thus, a community of practice model of CPD can shape the value and depth of
knowledge transfer which occurs within any learning community.
3.4.8 The Professional Inquiry Model
The professional inquiry model engages the learner to collaborate with peers and
external experts into a common problem of practice (DeLuca, Bolden & Chan, 2017).
In this model participants conduct research within their own professional setting
(Lowe, 2016; Kennedy, 2014). There are many opportunities for practitioner
development utilising this model of CPD within the field of paramedicine. Indeed,
these opportunities are continuing to develop as the paramedic paradigm evolves.
3.4.9 Summary
The different models of CPD outlined by Kennedy (2014) reflect training models
previously utilised by ambulance employers to train paramedics. The functionality of
the models were possibly utilised by ambulance educations without the depth of
understanding of the underpinning philosophies. Therefore, these models hold
relevance to the field of paramedic CPD. Furthermore, these models will be utilised as
sensitising concepts in the formulation of a new paramedic CPD framework resulting
from this study. Interestingly, these models progress along a continuum of increasing
professional autonomy (Kennedy, 2014), which has similarities to the progression of
paramedic professionalisation. Section 3.4.10 examines the framework proposed by
Kennedy (2014).
3.4.10 The Framework
The CPD framework proposed by Kennedy (2014) allows for the examination
and comparison of the different models of CPD. The models within the framework
have different strengths, weaknesses and characteristics for the transference of
knowledge. The model utilised may differ dependant on the purpose of the CPD and
whether it is transmissive, malleable or transformative in nature (Kennedy, 2014). The
framework categorises models along a spectrum of increasing professional autonomy
demonstrated in the Figure 2 on the following page.
50 Chapter 3: Theoretical Background
individual reviews again, thereby engaging in a cycle which should span their
professional career. A limitation of the PDP is that, like the deficit model of CPD, it
can be co-opted by the employer as a tool of performance management. The PDP cycle
is depicted below in Figure 3.
Figure 3. The PDP cycle
Reprinted from “Preparing a personal development plan for all members of the dental
team,” by W. Maguire & A. Blaylock, 2017, British Dental Journal, 223(6), 248.
Copyright [2017] by Springer Nature. Reprinted with permission.
The addition of the PDP cycle enhances to the framework proposed by Kennedy
(2014), however does not complete it. When examining the theoretical background of
CPD for healthcare professionals, the following considerations were also made.
• relevance to the profession;
• effective learning models/interventions;
• regulatory requirements and auditing;
• mandatory/self-directed;
• competency-based;
• lifelong learning.
Filipe, Golnik, & Mack, (2018) propose a framework that contends political, social,
economic and professional influences have led the progression of continuing medical
education (CME) to CPD, competency-based CPD (CBCPD) and mandatory systems
of CPD (Figure 4). The framework incorporates the traditions of LLL, the concept of
CME and styles of CPD and CBCPD, to form a matrix which can be utilised by
Chapter 3: Theoretical Background 51
educators and learners to achieve a main goal of improvement of patient care (Filipe,
Golnik, & Mack, 2018). Figure 4: The CBCPD Cycle, is located on the following page.
52C
hapt
er 3
:The
oret
ical
Bac
kgro
und
Figu
re 4
. The
CB
CPD
cyc
le
Rep
rinte
d fr
om “
CPD
? W
hat h
appe
ned
to C
ME?
CM
E an
d be
yond
,” b
y H
. P. F
ilipe
, K. C
. Gol
nik
& H
. G. M
ack,
201
8, M
edic
al T
each
er, 4
0(9)
, 91
5. C
opyr
ight
[201
8] b
y Ta
ylor
& F
ranc
is. R
eprin
ted
with
per
mis
sion
.
Chapter 3: Theoretical Background 53
The concept of CBCPD is constructed on five measurable LLL domain key
competencies for clinical practice (Filipe, Golnik, & Mack, 2018). These competencies
have similarities to the PDP process, and are also organised in a cycle:
• self-awareness in personal practice. In this phase of the cycle the practitioner
identified their personal learning priorities;
• scanning the environment. Where the practitioner will identify and compare
gaps by accessing new evidence to integrate into their professional practice;
• manage learning in practice: Knowledge is managed through the development
and monitoring of a PDP;
• raise and answer questions: In this phase the practitioner can formulate clinical
questions, then analyse and critical appraise the literature or appropriate
evidence to answer the questions raised; and
• assess and enhance practice. Which is done by measuring personal
performance. (Filipe, Golnik, & Mack, 2018).
The progression to CBCPD was driven by: political factors, such as professional
qualifications and/or the authentication of educational activities; social influences,
such as changes in societal expectations and patient demographics; economic reasons,
such as ensuring that learning activities are cost effective; and professional factors,
such as professional regulation (Filipe, Golnik, & Mack, 2018). Each of these elements
are relevant to the field of paramedicine and thus are also considered in this study.
Within the framework proposed by Filipe, Golnik, & Mack (2018) appears the
acronym SCAR. This component advocates formalisation of CPD activities and
programs through a method that is systematic, comprehensive, utilises adult learning
principles and is properly regulated (Filipe, 2016). This component is simple yet
eloquent as it draws together the essence of the CPD framework. Thus, making it an
appropriate framework to apply to this study.
3.5 CONCLUSION
Having examined the relevant theoretical background, the frameworks discussed
in Chapter Three were found to be the most appropriate to guide the analysis of the
thesis. The models developed by Filipe, Golnik & Mack (2018) and Kennedy (2014),
when linked to the PDP Cycle, help to formulate a clearer understanding of ‘CPD best
54 Chapter 3: Theoretical Background
practice’. Many of the concepts linked to these CPD models and tools have been
utilised within the paramedic paradigm, although not every element is a perfect fit for
paramedicine. As the study evolved it became evident that a paramedic specific CPD
framework could be developed to direct formal and informal learning opportunities
towards models which assist paramedics to engage in LLL, demonstrate the capacity
for professional autonomy and strive towards gold standard of patient care. The
proposed paramedic CPD framework is discussed further in Chapter Six, section 6.2.
Chapter 4: Methodology 55
Chapter 4: Methodology
The research explores Australasian paramedic attitudes and perceptions about
CPD through a constructivist grounded theory methodology (Charmaz, 2014). Chapter
Four discusses the study’s proposed methods, including the research questions and
how the data were collected and analysed. A diagram depicting the research process is
provided in Figure 5 on page 91. To best explore the methodological framework for
this study, a brief explanation about qualitative research is provided below. The
justification for the use of constructivist grounded theory is also provided.
4.1 QUALITATIVE RESEARCH
Qualitative research invests in meanings and allows researchers to seek
knowledge in areas of interest about the human lived experience that have previously
had little or no exploration before (Hallberg, 2006; Silverman, 2011; Silverman, 2016).
Qualitative research does not use statistical measures, empirical analytical
conventional research methods, or other types of quantification (Khan, 2014; Hallberg,
2006; Richardson & Kramer, 2006; Strauss & Corbin, 1990). Instead, analysis of the
research data occurs through interpretative processes, because the goal of the research
is to make sense of the world, its connections and contradictions in a meaningful way
(Charmaz, 2014; Strauss & Corbin, 1990).
56 Chapter 4: Methodology
Figure 5. Concept map representing the structure of this thesis
Chapter 4: Methodology 57
There are five common characteristics of qualitative research defined by
Silverman, 2011:
1. Qualitative research is frequently instigated with a single phenomenon
which has been selected by the researcher either due to interest or
convenience.
2. Qualitative research usually investigates phenomena through observation
and analysis, in the context through which they arise.
3. Hypothesises are rarely stated at the inception of the investigation, rather
they are generated from the analysis of the data.
4. Qualitative research does not have a single research model. There are
multiple research models available, such as grounded theory, ethnography,
discourse analysis, phenomenography or constructionism.
5. Statistical correlations and tests are not generally utilised, rather the use of
numbers is limited to simple formulations which are utilised to detect
divergent cases. (Silverman, 2011)
By utilising qualitative research, the researcher attempts to understand the
experiences, thought processes, emotions or feelings of their subject(s) through a
paradigm that assumes that the world consists of multiple realities which interlink the
subject and the researcher (Khan, 2014; Hallberg, 2006). The underlying philosophy
of qualitative research is that people formulate their perception of reality, based on
what they perceive to be true. A persons’ perspective on anything is shaped by their
ontology and epistemology. These two concepts are discussed later in this chapter.
4.2 METHODOLOGICAL FRAMEWORK
The aim of this research is to investigate, through a constructivist methodology,
Australasian paramedic attitudes and perceptions about CPD. Examining the
paramedic CPD experience can provide insight into current paramedic professional
practice. Constructivist grounded theory approach analyses actions and processes
instead of structures and themes. It emphasises the engagement of the researcher in
both the construction and the interpretation of the data because constructivism
advocates that it is through our cognitive experience(s) that we as individuals construct
a realm of understanding (Charmaz, 2017; Charmaz, 2014; Young & Colin, 2004).
58 Chapter 4: Methodology
Qualitative research utilised in this study is guided by Constructivist Grounded
Theory methodology as proposed by Charmaz (2014). Charmaz contends that
constructivist grounded theory is an appropriate qualitative research methodology
because “data do not provide a window on reality. Rather, the ‘discovered’ reality
arises from the interactive process and its temporal, cultural, and structural contexts”
(Charmaz, 2000, p.524). The constructivist approach adopts a view that instead of only
one true reality, there are multiple realities occurring simultaneously in the social
world (Hallberg, 2006; Young & Colin, 2004). Constructivist grounded theory is a
robust methodology which has been utilised successfully in numerous studies within
the fields of nursing, education and psychology (Mills, Bonner & Francis, 2006).
This research methodology applies the stratagems of the traditional approach to
Grounded Theory, allowing the researcher to build a research theory from the ground
up (Charmaz, 2014; Liamputtong, 2013). Grounded theory was developed from the
research of Glaser and Strauss (1967), who argued that theories about social processes
should not be hypothesised and tested against data, but rather be discovered from the
data (Noble & Mitchell 2016; Charmaz, 2014; Liamputtong, 2013; Suddaby, 2006).
Grounded theory begins with inductive data then utilises repeated rounds of analysis
and comparative methods, to keep the researcher involved and interacting with the data
(Charmaz, 2014; Suddaby, 2006; Glaser, 2002).
Grounded theory research aims to develop a theoretical framework which can
reveal what is taking place within an area of interest, in a meaningful way to the people
concerned (Ramalho, Adams, Huggard & Hoare, 2015; Liamputtong, 2013).
Grounded theory research differs from other qualitative methods because it emphasises
a practical method of explaining social processes, actions and interactions, instead of
providing a description of what is happening (Noble & Mitchell 2016; Liamputtong,
2013; Suddaby, 2006). This is achieved through the use of abductive and deductive
logic to create abstract analytical categories (Charmaz, 2014). The process includes
using theoretical sampling, which can be described as data collection that is used to
develop the theory (Draucker, Martsolf, Ross & Rusk, 2007). Memo writing, is also
utilised to link researchers writing and analysis to the coding of the data (Charmaz,
2014). The process of theoretical sampling and memo writing in constructivist
grounded theory allows the researcher to simultaneously collect and analyse the data.
Constructivist Grounded Theory goes beyond this by the researcher immersing
Chapter 4: Methodology 59
themselves in the data, seeking meaning about ideologies, values and beliefs from the
data (Mills, Bonner & Francis, 2006) through co-construction of the data with the
research participants (Charmaz, 2014).
Constructivist Grounded Theory was chosen as the most appropriate
methodology to systematically examine the Australasian paramedic attitudes and
perceptions about CPD because constructivism offered the researcher the ability to
utilise a subjectivist epistemology (Chernikova & Chernikova, 2016). That is,
knowledge could be discovered from a subjectivist standpoint. The subjectivist
epistemology in this instance implies that the values of rational belief from an
individual paramedic are shared within the paramedic community (Chernikova &
Chernikova, 2016).
Constructivist Grounded Theory has been proven an effective research
methodology in both health and education disciplines (Mills, Bonner & Francis, 2006).
These allied disciplines bring a level of familiarity to paramedicine thereby supporting
the use of the chosen methodology. Furthermore, this methodology is in keeping with
like studies completed in the paramedic paradigm. A Constructivist Grounded Theory
methodology highlights the importance of the reflexivity of the researcher and a
subjective representation of the research participants’ views and responses to specific
situations (Charmaz, 2014). Consequently, the knowledge unearthed was then a co-
construction between the researcher and the participants which was then interpreted
by the researcher. The researcher’s reflexivity is addressed further in this document
under the heading Reflexivity.
4.3 ONTOLOGY AND EPISTEMOLOGY
“It is difficult to isolate the researcher from the research.
Whatever the researcher believes or assumes about the world,
and about research, will inevitably put colour and scent to his
or her research activities and findings.”
(Klakegg, 2015 p. C5)
Ontology can be described as the nature of being, or the study of what constitutes
“reality” (Scotland, 2012). It is imperative that researchers advocate and remain true
to their own reality, that is, “their perceptions of how things really are and how things
really work” (Scotland, 2012, p.9). The researcher has chosen a constructivist
60 Chapter 4: Methodology
orientation, rather than objectivist approach to align with the researchers’ ontology,
discussed later in this chapter. Constructivism is considered the most appropriate
strategy to formulate methodology as it places the researcher as an active participant
of the research (Liamputtong, 2013). The researcher is able to analyse the qualitative
data through the lens of their own reality but must exclude personal bias which can
have the potential to influence the participants to respond in predetermined ways. This
approach ensures a high degree of trustworthiness (Klakegg, 2015).
Epistemology examines the essence of knowledge; how knowledge is generated,
learned and transferred (Chernikova & Chernikova, 2016; Scotland, 2012).
Epistemology explores the relationship between the researcher: what is known, the
research participants, and what can be learned (Chernikova & Chernikova, 2016;
Scotland, 2012). Epistemological assumptions are important because they influence
how the researcher will code data, write memos, and conduct theoretical sampling and
sorting (Charmaz, 2017). Subjectivist epistemology delves into the relationship
between the ‘knower’ and the ‘known’, and thereby promotes authenticity (Manning,
1997). It is using a subjectivist epistemology, the researcher can explore the values of
rational belief from an individual and theorise that these beliefs are shared by the
community (Chernikova & Chernikova, 2016).
The concepts of ontology and epistemology are paramount to this research given
the individual researchers’ perception of reality and knowledge underpins the approach
taken in the research. It enables the researcher to design a robust research strategy
(Klakegg, 2015). Every phenomenon is based on its own ontological and
epistemological assumptions which are the philosophical underpinnings of the
research and individual to every researcher, because assumptions are based on
speculation and cannot be, proven or disproven empirically (Scotland, 2012).
Therefore, it is necessary to state this researchers’ reflexivity and their perception of
reality and knowledge.
4.4 REFLEXIVITY
Reflexivity considers that knowledge cannot become separated from the
researcher. Reflexivity is an important tenant of Constructivist Grounded Theory
because the researcher must be mindful that they are not actually neutral, they are in
fact, a human being whose ontology and epistemology may influence their research
Chapter 4: Methodology 61
(Ritchie, Lewis, Nicholls & Ormston, 2013). To ensure reflexivity, the researcher
must consider their own assumptions, behaviours, personal and social factors
throughout the research process (Finlay & Gough, 2008). Therefore, it is imperative
that the researcher acknowledges their own ethos regarding the research topic being
examined, and ensures that personal beliefs do not interfere with data collection and/or
data interpretation.
As an experienced clinician who has held senior paramedic roles, I have been
involved in many different facets of paramedic CPD. For example, I have participated
in CPD sessions as part of my ongoing paramedic recertification; as an educator; and
as a workplace supervisor. I have also developed training and education packages and
ensured paramedics completed mandatory and advanced training, as required by the
organisation. This experience has been invaluable in providing me with an
appreciation of the different attitudes and approaches to CPD by paramedics at all
clinical levels, and has fuelled my quest to investigate this topic further.
Working in ambulance education has provided an awareness of the diversity of
paramedic experience and opinion regarding CPD. Historically, the only way to
become a paramedic in Queensland was to complete vocational training (apprentice
style) to obtain an Associate Diploma, or later a Diploma, of Paramedical Science. As
time progressed, a tertiary model of paramedic training was developed. During this
transition phase there was an overlap of “Diploma Students”, “Graduate Paramedics”
and “Qualified Paramedics” being upskilled to degree level (G. Fitzgerald, personal
communication, November 30, 2017). New staff members employed by the
Queensland Ambulance Service (QAS) are now either graduate paramedics or
qualified paramedics from another ambulance service.
In the context of the proposed research study and considering the history of the
researcher, it is important to continuously assess and reassess any influence that my
expectations and experiences could place upon this research. The study cannot be
tainted by my personal thoughts regarding how paramedics should interact with CPD
opportunities and activities. My experience can assist in enhancing the understanding
of paramedic culture, language, and professional pressures in relation to CPD; thus,
ensuring that the study is authentic and organic so that it produces an honest
representation of Australasian paramedics. To be authentic to the constructivist theory
– and indeed, the research, reflexivity will be used to facilitate greater insights when
62 Chapter 4: Methodology
collecting and analysing data whilst not attempting to utilise the participants to
construct data that aligns with my personal beliefs.
To date, most paramedic CPD research appears to concentrate on specific
clinical skills and critical interventions such as advanced airway management and
cardiac arrest (Yang et. al., 2012; Rumball, Macdonald, Barber, Wong & Smecher,
2004; Adams, Sirel, Marsden & Cobbe, 1997). However, concentrating research on
topics such as clinical skills or pre-hospital interventions merely investigates one
thread of paramedic CPD. Currently a gap in the literature exists surrounding
paramedic attitudes and perceptions about CPD. The knowledge that could be
discovered through this investigation will provide an understanding of paramedic
engagement in CPD. That is to say, the research will illuminate how paramedic
engagement in CPD is facilitated or hindered. Therefore, an investigation of
Australasian paramedic attitudes and perceptions about CPD is justified.
A comprehensive investigation of paramedic CPD must examine its relationship
with the concept of clinical competence. Therefore, possible correlation/s between a
paramedic’s education and level of personal engagement in professional development,
must also be considered. A comprehensive study should also consider the possible
influences that: efficacy; economy; and, the level of consultation occurring within the
current CPD framework used by ambulance services and professional bodies in the
Australasian paramedic context. When looking at the current literature regarding
paramedic CPD, it is reasonable to conclude that to date, there has been insufficient
exploration conducted into Australasian paramedic attitudes and perceptions about
their professional development.
4.5 METHODS
This section outlines the proposed methods utilised in this study. It describes
how the participants were chosen, outlines the study and research questions. The
inclusion and exclusion criteria, data collection and analysis methods are also
discussed.
4.5.1 Determining the Sample Size
The proposed sample size for this study (N=10-15), was chosen after a review
of the literature (Mason, 2010). Sample size in qualitative research is often an area of
contention (Liamputtong, 2013; Dworkin, 2012; Mason, 2010; Morse, 1995). When
Chapter 4: Methodology 63
using qualitative methods, the sample size is smaller than what would be considered
desirable for quantitative research (Charmaz, 2014; Dworkin, 2012). This is because
qualitative researchers are typically more focused on meaning and understanding the
lived experience (Charmaz, 2014). Consequently, there is conjecture about estimating
an appropriate sample size for conducting qualitative research and the concept of
saturation. It is argued by many scholars that when deciding on sample size,
researchers should consider the concept of saturation (Liamputtong, 2013; Dworkin,
2012; Mason, 2010). Corbin and Strauss (2008) define saturation as the point at which
additional data reveals no fresh, new or relevant theoretical insight(s).
Other researchers argue against saturation, citing that the richness of the data
comes from the detailed analytical processes, not from the number of times that a
particular statement is made (O’Reilly & Parker, 2013; Dworkin, 2012; Morse, 1995).
Therefore, a researcher can conclude data collection at the point that they believe they
have sufficiently rich data to build a comprehensive and substantial theory (Dworkin,
2012). Qualitative researchers must consider their study on an individual basis and
determine an appropriate sample size for their specific study. The sample size (N = 10)
for this study was determined based on a goal to obtain richness of data rather than
attempting to determine when data saturation may have occurred. The richness of data
was achieved by going beyond the superficial layers of paramedic social and subjective
life, to gather detailed and focused participant views, feelings, intentions and actions
(Charmaz, 2014).
4.6 RECRUITMENT
Following ethics approval from the Queensland University of Technology’s
(QUT) Human Research Ethics Committee (HREC) approval number 1800000232,
approval to recruit participants was requested through the websites for Paramedics
Australasia (PA) and the Australia and New Zealand College of Paramedicine
(ANZCP). The recruitment campaign also utilised forward passive snowballing
(referrals from other participants or interested paramedics to their peers about the
study).
The study investigated Australasian paramedics’ attitudes and perceptions about
CPD. As this is an Australasian study, the research participants included paramedics
who currently work in any State ambulance service or private provider within Australia
64 Chapter 4: Methodology
or New Zealand. Initially, recruitment was targeted at qualified paramedics who are
members of either PA or ANZCP. A secondary strategy included forward snowballing
of participants. The strategy was decided upon for due to the following:
• ANZCP: The Australian and New Zealand College of Paramedicine reported
2,621 members as at 30th June 2016 (ANZCP, 2017). Membership is open to: qualified
paramedics; full-time university student paramedics; trainee/intern paramedics and
volunteers in the field of paramedicine (ANZCP, 2017). Notification of ethics approval
was provided to ANZCP in conjunction with a request from the researcher to advertise
for study participants on the ANZCP webpage.
• PA: In 2017, Paramedics Australasia reported a membership of 2,235
(Paramedics Australasia, 2017a). Membership is open to: qualified paramedics;
students enrolled in approved undergraduate programs and graduate paramedics
(Paramedics Australasia, 2017a). There are also membership options for: associate
members; retired paramedics; life members; fellows and honorary fellows (Paramedics
Australasia, 2017a). Notification of ethics approval was provided to PA in conjunction
with a request from the researcher to advertise on the PA webpage. A secondary option
of requesting recruitment in Response (a printed publication from this organisation)
for study participants, remained a possibility until enough participants were recruited.
Limitation – Membership to PA and ANZCP is not restricted to qualified
paramedics. A paramedic degree is required to join these professional bodies as a full
member, however there is a grandfather clause to enable vocationally trained
paramedics to become members. Neither associate members nor student members
were recruited to take part in this study. It should also be noted that paramedics are
able to obtain membership for both PA and ANZCP. It is unknown how many qualified
paramedics are active members of these associations. Thus, forward snowballing from
participants was also encouraged.
4.7 INCLUSION AND EXCLUSION CRITERIA
The study proposed an exploration of CPD in the context of paramedic practice.
Table 4.1, on the following page, outlines the inclusion and exclusion criteria. The
inclusion and exclusion criterion for this study took into consideration the amount of
time that a paramedic has worked in the profession; enculturation factors; position
within the organisation (clinical role); education and training factors. These inclusion
Chapter 4: Methodology 65
and exclusion criteria were determined, and all the data collected and analysed, prior
to paramedic registration in Australia. However, the inclusion and exclusion criteria
do fit nicely within the regulatory standards that came into effect in December, 2018.
The expectation being that these criteria will provide a balanced representation of
Australasian paramedics.
66 Chapter 4: Methodology
Table 4.1 Inclusion and exclusion criteria
Criteria Cohort: Australasian Paramedics (n = 11)2
Inclusion Vocationally trained paramedic, or a paramedic who
was employed as a paramedic with a graduate degree
in some type of paramedical science.
Has completed any probationary period or internship
and now works as an independently qualified
paramedic.
Currently works in Australia or New Zealand as a
paramedic for either a State ambulance service or a
private service provider.
Exclusion Not an independently qualified paramedic (e.g. student
paramedic or intern paramedic).
Not currently working in Australia or New Zealand as
a paramedic for either a State ambulance service or a
private service provider.
4.8 JUSTIFICATION OF COHORTS
The participants were comprised of paramedics who had either been vocationally
trained as a paramedic, or a university educated paramedic who had completed any
employer required induction, internship or probationary period. This justification of
the inclusion criteria fits with post-registration National standards of paramedics
requiring an approved, accepted or equivalent paramedic qualification. The
paramedics in this cohort must have been working as an Emergency Medical
Technician (EMT) or paramedic in either the public or private sector, at the time of
data collection. The criterion was specified for several reasons:
2 One of the 11 paramedics recruited dropped out of the study, and only qualified paramedics and graduate paramedics who had completed their internship were recruited for this study.
Chapter 4: Methodology 67
• Prior to 1994, the only way to commence a career in ambulance in
Australasia, was to complete Vocational Education Training (VET),
diploma and associate diploma.
• It was desirable to attempt to capture and examine the professional
practice of paramedics with vocational training who did not have tertiary
qualifications prior to becoming paramedics, but who may have acquired
further qualifications after completing VET.
• It enabled the investigation of any influences that may have driven the
participants to undertake or not to undertake: tertiary study; further
clinical qualifications; or implement a CPD plan.
• Investigation of influencing reasons afforded the potential to align with
literature from allied health professions (i.e. LLL, career development,
financial impact).
4.9 RESEARCH QUESTIONS
The research questions are:
• How do Australasian paramedics engage with CPD?
• What factors influence CPD in the field of paramedicine?
• What do Australasian paramedics perceive to be facilitators of their
engagement in CPD?
• What do Australasian paramedics perceive to be barriers that prevent their
engagement in CPD?
These questions were further broken down into sub-questions to ensure that the
study examines paramedic CPD in the context of professional practice, including:
• What do Australasian paramedics understand the concept of CPD to entail?
• What affects paramedic attitudes towards participating in CPD?
• What expectations do Australasian paramedic have of themselves and their
colleagues?
• What is the relationship between paramedic CPD, professionalism and clinical
competence?
68 Chapter 4: Methodology
• What influence do external bodies such as AHPRA, CAA, PA and ANZCP
have on paramedic CPD?
• What do paramedics perceive to be the barriers that prevent them and
facilitators that encourage them to engaging in CPD activities?
• Does previous level of education correlate level of personal engagement in
LLL and CPD?
• What are Australasian paramedic perceptions about paramedic registration;
CPD and being professional?
4.10 ETHICS
Ethical clearance was acquired through the Queensland University of
Technology’s (QUT) Human Research Ethics Committee (HREC) approval number
1800000232. Following ethics approval, endorsement was then sought from: ANZCP
and PA, by way of permission to advertise for participants in the publications and
websites managed by these organisations. The study was classified as low risk as it is
investigating paramedics’ perception of; attitudes toward; and engagement in CPD.
low risk is the appropriate category as the only risk to participants was that they were
required to give up time to attend the interview. Therefore, participation in the study
did not constitute any further risk than day to day living. An expression of interest
notice (Appendix D) and letters of introduction (Appendix E and F) advertised for
participants. Potential recruits were provided with participant information (Appendix
G), a glossary of terms that were pertinent to the study (Appendix I) and a consent
form (Appendix H). Participation in the study was voluntary and participants were able
to withdraw from the study at any time during the process. The privacy of participants
is paramount, and anonymity was maintained, by participants being provided with a
code pseudonym name which will be used for the lifetime of the study and any outputs
related to it. Consent forms and data were stored as per QUT requirements.
4.11 DATA COLLECTION
Data collection occurred using face-to-face, semi-structured interviews
whenever it was possible. Where face-to-face interviews were not a viable option due
to time restraints, allocated resource limitation, or the participants location (e.g. remote
location) the interview occurred via Zoom. Semi-structured interviews were utilised
Chapter 4: Methodology 69
as they follow an interview guide but allow sufficient room for the researcher and
participant to delve into rich concepts and theoretical points of interest (Minichiello,
Aroni & Hays, 2008). Interviews were conducted by means of a method that was
convenient for the individual participants; and at a mutually agreed place and time.
Interviews at the paramedic workplace were avoided which enabled the study to
maintain confidentiality and maintain the ethics parameters of the study, which might
be inferred by paramedics discussing their attitudes and perceptions of paramedic CPD
in the workplace. That is to say, interviewing participants at work would have
potentially compromised the anonymity of the participant. Telephone interviews were
completely avoided as it has been suggested in the literature that qualitative interviews
conducted via phone are generally shorter, more difficult for the participant and
generally do not produce the depth of data than face-to-face interviews (Irvine, Drew
& Sainsbury, 2013).
Qualitative data were collected through voice recorded semi-structured
interviews which enabled participants to be as open and authentic as possible during
the interview process (Charmaz, 2014; Silverman, 2011). The interviewing process
began with passive listening, followed by theoretical sampling; and the development
of more focused questions based on emergent categories was then implemented into
the interviews (Hallberg, 2006). The duration of the interview ranged from 45 minutes
to 1.5 hours. While the interview guide was followed (Appendix A), participant
experiences, attitudes and perceptions varied which impacted the time taken to
complete an in depth semi-structured interview (Minichiello, Aroni & Hays, 2008).
Field notes were taken, and a reflective journal kept to assist with the data collection
and analysis process. Research suggests that the best way to enhance the quality of
data management is for qualitative researchers to utilise a combination of field notes,
transcripts and tape recordings (Tessier, 2012). Prior to conducting the interview, a
consent form was presented to each participant advising them about the study
(Appendix H). The consent form advised the participant that they will remain
unidentified throughout the study and for the lifetime of the data storage. The consent
form also requested the consent of the participant to allow the researcher to contact
them for a subsequent interview regarding any emergent areas of possible theoretical
interest.
70 Chapter 4: Methodology
Following the interview, the voice recordings were transcribed verbatim, either
by the researcher or a professional service. With regard to the data that was
professionally transcribed, the transcriber was required to sign a confidentiality
agreement prior to the release of the voice recording to them. The electronic data from
the voice recordings was stored as per Queensland University of Technology Manual
of Policies and Procedures (MOPP). Pursuant to the Management of Research Data
MOPP, a research data management plan was also developed.
4.12 DATA ANALYSIS
NVivo (QSR International) is software for the storage of qualitative data which
was used for data management in this study. Data analysis occurred by reviewing the
transcripts through coding, which is a process of categorising individual and salient
segments of the data with names/titles that accounts for and summarise each piece of
the data (Saldaña, 2015; Charmaz, 2014). The data analysis commenced with first
cycle, or initial (line-by-line) coding of each transcript. Second cycle, or focused
coding allowed for further synthesis of the data into more detailed code categories. As
recommended by Charmaz (2014) and Silverman (2011) coding took place as soon as
possible after the interview which enabled early identification of focused codes, and
links to be found within the data to form emergent theories. Throughout the entire
study, the following continual processes occurred through: theoretical sampling,
comparison methods, memo writing, field notes and inter-coder agreement.
4.12.1 Theoretical Sampling and Comparison Methods
Theoretical sampling involves analysing data and collecting codes to elaborate
on and refine emergent theory as it surfaces, in this way it advances the analysis, and
assists the researcher to identify analytic problems which need to be resolved
(Charmaz, 2014). Theoretical sampling allows the researcher to sample across multiple
areas rather than focusing on a single empirical topic (Charmaz, 2014). Continual
method comparison facilitates the exploration of relationships between categories and
codes. This method of analysis allows the research to utilise inductive processes to
create abstract theories and concepts during the data analysis (Charmaz, 2014).
Comparison methods occur by “comparing data with data, data with code, code with
code, code with category, category with category and category with concept”; finally,
major categories are compared with relevant literature (Charmaz, 2014, p.342). Table
Chapter 4: Methodology 71
4.2, located on the following pages, is an example of the theoretical sampling utilised
in this study.
72C
hapt
er 4
:Met
hodo
logy
Tabl
e 4.
2Ex
ampl
e of
The
oret
ical
Sam
plin
g
Cat
egor
y:M
anda
tory
CPD
–“T
ick
and
Flic
k”
Parti
cipa
nts v
iew
som
e as
pect
s of C
PD a
s bei
ng a
rbitr
ary,
man
dato
ry, o
rgan
isat
iona
lly d
riven
“tic
k an
d fli
ck”
activ
ities
whi
ch o
ffer
them
littl
e pe
rson
al v
alue
.
Con
ditio
ns?
Org
anis
atio
nally
driv
en
Empl
oyee
s don
’t fe
el li
ke st
akeh
olde
rs
Man
dato
ry e
mpl
oym
ent c
ondi
tion
Act
ivity
lack
s enj
oym
ent
Emer
ges?
As p
art o
f the
em
ploy
men
t and
/or r
egis
tratio
n pr
oces
s.
Mai
ntai
ned?
By
polit
ics o
r org
anis
atio
nal p
olic
y
Whe
n m
ight
it c
hang
e?If
the
orga
nisa
tiona
l edu
cato
rs lo
ok a
t how
par
ts o
f man
dato
ry C
PD c
an b
e m
ade
enjo
yabl
e/or
inte
rtwin
ed w
ith e
njoy
able
act
iviti
es
If e
mpl
oyee
s em
brac
e C
PD a
s a fr
amew
ork
of m
anda
tory
and
self-
driv
en a
ctiv
ities
and
dec
ide
that
alth
ough
the
exer
cise
is m
anda
tory
, it m
ay st
ill h
ave
patie
nt-c
entre
d or
pat
ient
safe
ty o
utco
mes
.
If th
e re
gula
tory
bod
y (A
HPR
A) a
nd th
e pa
ram
edic
as a
n in
divi
dual
, bec
ome
stak
ehol
ders
in th
e ac
tivity
.
Con
sequ
ence
s?N
egat
ive
CPD
exp
erie
nce
for t
he p
aram
edic
Cha
pter
4:M
etho
dolo
gy73
Fals
e ec
onom
y of
lear
ning
out
com
esfo
r the
em
ploy
er
May
impa
ct p
atie
nt c
are
May
hav
e ne
gativ
e em
ploy
men
t ram
ifica
tions
May
neg
ativ
ely
impa
ct th
e pa
ram
edic
s’ re
gist
ratio
n ob
ligat
ions
Link
s to
othe
r cat
egor
ies?
LLL
Reg
istra
tion/
Reg
ulat
ion
Self-
deve
lopm
ent
Empl
oym
ent c
ondi
tions
or L
egis
lativ
e re
quire
men
ts
74 Chapter 4: Methodology
4.12.2 Initial Coding
The foundations of the analysis are generated through the initial coding (line-by-
line) analysis of the data (Charmaz, 2014). Utilising line-by-line coding enabled this
research study to produce: codes and categories that fit within the empirical world;
and, ensure an analytic framework that remained relevant to what was happening in
the data (Charmaz, 2014). The aim of initial coding was for the researcher to remain
close to the data, whilst exploring all the theoretical possibilities which could be
determined from it (Charmaz, 2014). Each segment of the data was viewed and the
spoken word, was then translated into an action, rather than separated into a pre-
existing category (Charmaz, 2014). Charmaz, (2014) contends that when the
researcher codes in ‘actions’ they are less likely to “code for types of people” (p.116).
This allowed the researcher to keep an open mind, divergent points of view allowed to
emerge, and enabled new ideas to develop (Charmaz, 2014).
4.12.3 Focused Coding
Focused coding took place on the completion of initial coding, to “sift, sort,
synthesize and analyse” to highlight categories that emerge from the analysis and
providing a theoretical direction for the study (Charmaz, 2014). The focused coding
assessed the initial codes, compared codes with codes, and, enabled the researcher to
scrutinize and direct codes that carried critical and/or analytical weight (Charmaz,
2017; Charmaz, 2014). An example of the coding process is found in Table 4.3, on the
following pages.
Cha
pter
4:M
etho
dolo
gy75
Tabl
e 4.
3Ex
ampl
e of
cod
ing
proc
ess
Raw
Dat
aIn
itial
Cod
ing
Focu
sed
Cod
ing
QU
ESTI
ON
:
Whe
n yo
u be
cam
e a
para
med
ic o
r thi
nk b
ack
over
you
r
para
med
ic c
aree
r, w
hat w
ere
your
per
cept
ions
abo
ut
CPD
, and
hav
e th
ey c
hang
ed?
INTE
RV
IEW
EE R
ESPO
NSE
:
To b
e ho
nest
I ha
d no
idea
wha
t my
CPD
wou
ld b
e. I
liter
ally
had
not
eve
n th
ough
t abo
ut it
, I o
nly
appl
ied
on a
whi
m. I
qui
t my
othe
r job
ver
y qu
ickl
y an
dfr
iend
s had
said
that
I'd
like
this
car
eer.
Look
ing
back
I w
as lu
cky
beca
use
I wen
t int
o th
e in
terv
iew
with
no
idea
wha
t I w
as
real
ly g
ettin
g in
to. T
hat w
as p
roba
bly
a go
od th
ing,
I
didn
't re
aliz
e ho
w so
ught
afte
r the
pos
ition
s are
ove
r her
e.
I kne
w I
had
to d
o a
univ
ersi
ty d
egre
e bu
t oth
er th
an th
at I
didn
't kn
ow w
hat m
y on
goin
g C
PD w
as a
nd I
hadn
't
thou
ght a
bout
it a
t all.
Not
thin
king
abo
ut C
PD
Jum
ping
into
the
job
No
plan
ning
for C
PD
Falli
ng in
to a
hig
hly
priz
ed p
rofe
ssio
n
Rea
lisin
g st
udy
was
requ
ired
for t
he
job
Adv
ance
men
t of s
elf
76C
hapt
er 4
:Met
hodo
logy
Raw
Dat
aIn
itial
Cod
ing
Focu
sed
Cod
ing
I don
't w
ant t
o ev
er st
op le
arni
ng, I
don
't w
ant t
o be
com
e
stal
e. A
cla
ssic
exa
mpl
e, a
nd y
ou'd
kno
w fr
om y
our t
ime
on ro
ad, i
s the
am
ount
of p
eopl
e th
at sa
y, “
Oh,
you
mus
t
see
som
e te
rrib
le th
ings
”. M
y lin
e is
, “I s
ee m
ore
good
than
bad
. I g
et to
do
a lo
t mor
e go
od th
an b
ad, b
ut w
hen
I
go to
thos
e sh
it m
ixer
jobs
it ju
st m
akes
me
wan
t to
be
bette
r at m
y ca
reer
”.M
y th
ough
ts o
n C
PD n
ow a
re
arou
nd th
at o
f jus
t alw
ays b
eing
the
best
that
I ca
n be
. As
soon
as I
find
CPD
inte
rest
ing
I don
't m
ind
the
thou
ght o
f
havi
ng it
life
long
.
Not
kno
win
g ex
tend
of C
PD
requ
irem
ents
Enga
ging
in a
nd e
njoy
ing
lear
ning
Feel
ings
of p
rofe
ssio
nal p
ride
and
oblig
atio
n to
con
tinue
lear
ning
Ref
ram
ing
nega
tive
expe
rienc
es/c
ases
Thin
king
abo
ut C
PD
Ach
ievi
ng b
ette
r out
com
es
Wan
ting
a pa
yoff
for e
ngag
ing
in
CPD
Prof
essi
onal
ism
Enga
gem
ent i
n LL
L
Chapter 4: Methodology 77
4.12.4 Inter-coder Agreement
While member checking can be utilised as a strategy to confirm consistence of
data analysis (Charmaz, 2014), this strategy was not utilised due to the potentially
sensitive information that participants revealed during the interview phase. Instead, a
different strategy employed during data analysis, was the unitisation of an inter-coder
agreement to analyse data and consistent review by supervisors. These supervisory
checks replaced member checking and continued to challenge the researchers’
assumptions. This also provided an avenue to highlight any concerns that the
supervisors had, which in-turn allowed the research to address these concerns as they
occurred. Consistency of data analysis occurred through the inter-coder agreement
with one of the study’s supervisors to analyse data. The inter-coder agreement enabled
the data to be analysed and compared, thereby increasing the reliability of the study
(Kirilenko & Stepchenkova, 2016). Through this, it allowed any potential distortions
of the data to be mitigated and ensured that the researcher has not prompted any
responses during the qualitative interviews that were not true to the participants.
4.12.5 Memo Writing and Field Notes
Memo writing enabled the researcher to utilise reflexivity to assist in theory
construction. Memo writing and keeping a methodological journal facilitated data
analysis (Charmaz, 2014; Hallberg, 2006). Memo writing ensured the researcher
remained engaged and interacting in the data, therefore speeding analytic momentum
(Charmaz, 2012). Memoing allowed the researcher to consider, question and clarify
the data from the beginning of the coding process right through to the drafting of this
thesis (Charmaz, 2012). Maintaining a methodological journal assisted in capturing
the researchers’ “methodological dilemmas, directions and decisions” and thus
enabled reflection about participants’ views, the researchers’ reflexivity and the
literature in making sense of the data (Charmaz, 2014, p.165). Thus, memo writing
assisted the analysis and conceptualisation of the data and guided this generation of an
original contribution (Charmaz, 2012) to Australasian paramedic research. An
example of a memo relating to the “cost” of CPD is located in Table 4.4, on the
following page.
78 Chapter 4: Methodology
Table 4.4 Example of Memo
Statement
from
participant
I think finances are a hindrance. I know. I was subsidised to do
my first degree. A Bachelor degree. But I paid for my Masters
and my Graduate Certificate, myself. And I put my family into a
very tight situation for probably about five years, and was about
another 3 or so years until we recovered from that. So, over a
period of about 8 years, I put my family into financial strain, in
order to be able to do my studies.
Question
from
researcher
Was there any financial gain that came out of that, once you had
the qualifications? Like pay rise or……
Statement
from
participant
No. No, it was purely, for my own professional development.
There was no pay rise associated with it. But then, there hasn’t
been any pay rise associated with any of our training either.
Note from
researcher
Financial and time related “costs” associated with attending CPD
events such as conferences, or undertaking further qualification
has been identified by numerous participants as aspects that
directly affect their willingness or ability to participate. Research
demonstrates that time and financial burdens are commonly
reported other health professionals, as barriers to engaging in
CPD (Bressan, et al, 2016; Mather & Seifert, 2014). Some
participants, such as this one, discussed feeling that their
employer had an expectation that they participate in CPD events
such as conferences; but this as assumed to be self-driven and
not necessarily directed by the organisation. Several of the
participants talked about undertaking qualifications despite
adverse financial conditions, because they felt it was important
for their personal (professional) development. This fits with the
framework proposed by Filipe, Golnik, & Mack, (2018) as these
paramedics are expressing self-awareness and identifying their
personal learning priorities.
Chapter 4: Methodology 79
Field notes were also utilised as an observational tool, to record and retain the
memory of how the participant behaved during the interview. By combining the field
notes with memos, the researcher was able to keep an account of what was happening
at the time of the interview that could be referred to during analysis. An example field
note from a participant who was so engaged in becoming the best professional
paramedic that she could, is located below in Table 4.5.
Table 4.5 Example of Field Note
WOW! That was the best interview EVER! This participant just does not let
anyone or anything stop her. I think the most profound and resonating thing that she
said was: “My knowledge can be unlimited – if I choose it to be”. That seems to
sum up how she has developed as a professional and a paramedic. She doesn’t see
the next challenge as challenging, just as the next step towards becoming a better
version of herself. This participant seems to actively engage in the Professional
Inquiry model of CPD. I love to see this in my colleagues. She has inspired me.
Photo of reflective art journal page that related back to this participant.
4.13 SUMMARY
This chapter has detailed the decision-making process which deemed
constructivist grounded theory to be the most appropriate methodology through which
80 Chapter 4: Methodology
to answer the research questions. The ontology and epistemology (perception of
reality) and reflexivity of the researcher has been disclosed, thereby indicating how
the results of this study are analysed and interpreted.
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 81
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
Chapter Five presents the results of the study and a discussion of Australasian
paramedics’ relationship with CPD. The chapter commences with an explanation of
how the categories were determined, followed by an examination of paramedic
engagement with CPD. The chapter then moves on to examine paramedic attitudes and
perceptions about CPD and their relationship with it. This is followed by results and
discussion for each phase of the research, and is completed by a summary and,
conclusions.
5.1 INTRODUCTION
Through qualitative semi-structured interview questions the study explored how
Australasian paramedics perceive and engage with CPD. Participants detailed what
they knew about CPD prior to becoming a paramedic. The point in time where
participants knew that they would have to engage in CPD as part of their career choice
to become a paramedic was identified, and influences that helped and hindered their
engagement in CPD activities, including CPD planning with their employer were
discussed. Participants in this study came from different educational pathways and
were paramedics who currently worked in both the private and public sector. They had
worked in paramedicine between 2 – 31 years and came from Australia and New
Zealand. Thus richness of data was enhanced through the diversity of participants.
The direction of this research study was also guided by the iterative processes
required of constructivist grounded theory and was advised by themes from the
literature. Figure 6, on the following page details links in the existing literature that
were relevant to this study; and it highlights the links that became evident in the
analysed findings during the process of the study. The links already established in the
literature are indicated with a solid arrow from the concept, back to CPD. It should be
noted that the study looked at assumed links and grey literature, which is indicated on
the concept map through the use of hollow arrows and small arrows. Finally, the red
82 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
arrows indicate findings from the study that either filled gaps within the literature, or
concurred with existing literature.
Cha
pter
5:R
esul
ts a
nd D
iscu
ssio
n of
the
Aus
trala
sian
Par
amed
ic R
elat
ions
hip
with
CPD
83
Figu
re 6
.CPD
con
cept
map
: Lin
ks e
stab
lishe
d in
ext
ant l
itera
ture
and
link
s dis
cove
red
durin
g th
is st
udy
84 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
Understanding Associate Diploma and Diploma Trained Paramedics
5.1.1 Results
Participants where either trained as paramedics through an in-house
apprenticeship style vocational education and training (VET), or more recently (since
the early 2000’s) through the tertiary sector. Those who trained as paramedics through
a VET pathway spoke of their experience of engaging in CPD. Their engagement in
CPD commenced early in their paramedic career, and they were aware CPD was an
expectation of their employer.
“I think from day one it was obvious…. So, the CPD was
from the outset I would say.” (Jenni)
“From the outset we were told that there would be
additional training days and so forth. We have between four
and six of those a year I think.” (Reece)
However, from the participants in this educational pathway, there was a
discussion surrounding a lack of clarity between what was defined as mandatory
training and what was defined as CPD. Some of the participants talked about
participating in mandatory training as a requirement of the job as a paramedic, but
were reluctant to take self-onus for their CPD.
“So, it’s always been a part of my job to maintain skill
levels and I always accepted it as part of the responsibility
of the job. Upgrading skills has always been accepted as
part of the job as well. Upgrading though is not the same
though as taking on further responsibility. I think that there
are certain things that for example, where new techniques
might come in which enhance what you are doing normally.
The difference is, involving a totally new level of training.
For example, PCI3, which I think was forced upon us
without too many people being comfortable about it. I am
still to do it. And am still very uncomfortable with the idea.”
(Fred)
3 PCI = percutaneous coronary intervention.
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 85
Furthermore, it was noted that some of the paramedics who had qualified through
a VET diploma program felt that once they had completed that qualification, they were
abandoned by their employer when it came to CPD.
“It has not really been discussed much until there was talk
of national registration, more so in the sense of formal CPD
that stuff was not really talked about. I suppose just rocking
up the State agency organised training sessions and doing
mandatory packages was stuff that we knew we had to do
just because the Boss said that we had to do it. But as far as
our own CPD, it has not really been discussed or brought to
our attention at all until we have been talking about national
registration where it has come to the forefront a little bit
more.” (Luke)
“I’ve been fairly disappointed over most of the years as far
as continuing ongoing education….it was more or less left
up to us to do our own skills training.” (Ted)
5.1.2 Discussion
The participants from a vocational training background were very open with
their responses about when and how they engaged in CPD. Research has demonstrated
that understanding and skills for engaging in CPD elements are built into
undergraduate paramedic degrees (Johnston, MacQuarrie & Rae, 2014; O’Brien,
Moore, Dawson & Hartley, 2014). However there is a dearth of literature regarding
how Australasian paramedics who qualified vocationally have developed a
relationship with CPD. Some participants described knowing from very early in their
career that they would have to engage in CPD as part of their career choice to be a
paramedic, for example, there was a requirement to engage in CPD from the outset of
their employment.
On further exploration, it was revealed that during the vocational Associate
Diploma (AD), time was spent in the classroom followed by working “on road” for a
period of time before coming back to the classroom. The rotation from the classroom
to the road, and back again continued until graduation. Participants gave examples of
their education and CPD surrounding the topic of preeclampsia with pregnancy.
86 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
Classroom learning can change to a new protocol within the first few days of going
out operationally on road. This participant was required to memorise new protocols
which re-enforced that there was a requirement to actively engage in CPD from the
commencement of one’s paramedic career. Of particular note, the concept of CPD for
some participants appears to revolve around compliance training, and complying with
new protocols for patient care by rote learning and accompanied by applying them in
the field. Given that the health literature clearly defines CPD as the development of
any knowledge or skills, reflective practice and professional competence that can
enhance the quality of patient care outcomes (Leahy, Chipchase & Blackstock, 2017;
Eppich, et.al. 2016; Miraglia & Asselin, 2015; Haywood, Pain, Ryan & Adams, 2012),
the initial mindset of some participants was an unexpected finding, as they had shared
details of an immense amount of CPD that they had self-initiated over their paramedic
career. This included:
• upgrading from AD to a conversion degree in paramedicine;
• upskilling from a BLS4 Officer to an ACP and later, and ECP;
• member of the thrombolysis research team for critical care paramedics, in that
she researched and wrote the literature review for the pilot study;
• completing a master’s degree in a health-related field; and,
• currently enrolled in a PhD.
Other participants, eluded to a lack of clarity between mandatory training and
CPD. For example, one participant stated that he knew from the beginning of his
paramedic career that he would have to engage in CPD, because it was specified by
the employer. At the beginning of the interview process, many of the participants felt
that CPD only referred to a professional requirement to attend mandatory training days
with the ambulance service they were employed by. All of the vocationally trained
paramedics in the study had completed all the mandatory training required by their
employer, however, some had not engaged in any self-directed CPD activities for a
number of years, or at all. Some of the participants reflected that, when they first
qualified as a paramedic, they had ambitions to either develop clinically to a higher
4 BLS Officer = Basic Life Support. This level does not have the clinical knowledge or skills to operate as an ACP
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 87
role, such as Critical Care Paramedic (CCP), and/or progress through the ranks of their
organisation. This career advancement pathway may have been blocked along the way
for reasons including lack of support from their OIC5, ambulance culture, and sabotage
by another colleague. The perceived lack of support had led to decreased level of
motivation to engage in much self-directed CPD.
There was one participant (Fred) with noticeably different views identified
during the interviews. The voice of this participant opens a theoretical avenue of
interest. The participant initially qualified with an AD and spoke of early engagement
with CPD. However their relationship with CPD appeared to take a different tone. This
was explored deeper during the process of the interview and barriers to paramedic CPD
were highlighted (which are also discussed later in this chapter). For this paramedic,
like many others interviewed, CPD was initially, only viewed as mandatory, in-service
education or compliance training packages. When explored on a deeper level, the
reasons articulated for this, were different to other participants. This could possibly
relate to his length of service in the profession, as this participant had more years of
practice as a paramedic than any other participant in this study. When he joined the
ambulance service, the only requirements were a first aid certificate and a letter
outlining his expression of interest. The participant stated that he was barely literate at
the time, and his wife wrote the application letter. He has over 30 years’ experience
and currently works at as a qualified paramedic. During his time in the ambulance
service, he has increased his literacy skills to ensure that he can complete his
paperwork appropriately and has completed all mandatory training and upskilling.
Thus, demonstrating engagement in self-directed CPD and LLL.
This participant, like many long serving paramedics, very clearly desired to do
the best for his patients but identified struggles with the increased technology now
utilised within his service (e.g. iPads and e-training). Frustration with technology
became apparent, for example e-training packages that might take a more tech-savvy
paramedic 30 minutes to complete, can take him several hours and phone calls to
Information Technology (IT) support. He said that this frustration is compounded by
the fact that IT is only open during normal office hours, which is not conducive for
paramedics who work shift work rosters.
5 Officer In Charge – the supervisor or manager of the ambulance station where the paramedic works
88 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
A time when paramedics had a far lighter workload was also highlighted in the
results, where working a shift, or block of shifts without doing a job, or attending to a
patient was not uncommon. It was during these times that in-service training packages
were completed and skills practiced on manikins in the station training room. During
this period of his service, the employer was responsible for the maintenance of his
training and training was always done on company time. For some long serving
paramedics, the concepts of taking self-onus of CPD, extending one’s scope of practice
further towards the end point of a paramedic’s career, engaging in it outside of work
hours, or paying for CPD activities, appears for some to be completely alien.
Another finding that emerged from the data came from two participants Luke
and Ted, who reflected on having put a lot of effort into personal CPD, but felt their
employer had abandoned them educationally, once they had qualified as paramedics
through a vocational pathway. While neither of these participants had been in the
service as long as some of the more senior participants, they both expressed a similar
sentiment of feeling forgotten by their employer. There appears to be a discrepancy
between their expectations of their employers and the reality of their participation in
CPD. This was of interest because both Ted and Luke had initially completed a
diploma and had later gone on to complete a degree in paramedicine. It could be
assumed therefore that both Luke and Ted had actively sought out CPD in the form of
formalising their qualifications through the tertiary sector. Undertaking a step such as
this, aligns with the literature that CPD is central to maintenance, extension and
enrichment of expert knowledge and professional competence (Leahy, Chipchase &
Blackstock, 2017).
Like Jenni and Fred, both Luke and Ted felt that paramedic CPD was limited to
mandatory programs and compliance training. In fact, several participants initially
stated that their extension of paramedic specific qualifications was something that they
did because they wanted to do it. As this was explored further, they each agreed that
this was a form of LLL, but it was not something that they thought of as CPD. They
had chosen to do this for their own personal reasons or interests, and it was not until
later in their interviews as the discussion developed, that all three stated that self-
directed development opportunities could also be considered CPD. This became
somewhat of a common theme in interviews, which through the process of theoretical
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 89
sampling, allowed this emergent theme to be explored. This thread will be discussed
further throughout the chapter.
5.2 TERTIARY QUALIFIED PARAMEDICS
5.2.1 Results
The participant group of paramedics who had completed tertiary qualifications
in paramedicine prior to obtaining employment with an Australasian ambulance
service had different experiences and recollections of engagement in CPD. Some
participants felt that they started their paramedic career unaware that they would be
required to engage in further CPD. They also felt that the tertiary sector had not
adequately prepared them or advised them that CPD would be an expectation of their
future career as a paramedic.
“Realistically, as a paramedic, when I first went through
we were not ever really told that we were required to do
CPD, it was more of a, ‘It's a good thing to keep up with
research,’ type concept. Because of my dual degree and my
training in nursing, I think I had a bit of a greater
understanding of how important CPD was, and so, I was
then more likely to engage in it, I suppose. But I do not
specifically recall any time in my university training where
I was actually told I had to do CPD.” (Tneal)
In contrast, other tertiary qualified paramedics discussed being prepared by their
university to integrate CPD activities and events into their profession.
“Right from the beginning because ours was an integrated
education and work placement program. We were aware
because we worked with the paramedics from our second
year that they would go in they would miss two days of
working with us every year to do their [professional
development] training, so I always knew right from the
word go that I would have to do two days in house
training…. Probably through my university program we
also went about final sessions on professional development
90 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
and where we could see our careers going. From that I was
aware of all the different types of PD6 I could utilise.” (Lily)
Some of the participants spoke of their interest in CPD only increasing as a result
of impending professional registration of paramedics.
“…probably two months ago. When I found out that
registration was going ahead, and it was a requirement to
maintain registration.” (Alisha)
All the participants in this study work for organisations that utilise CPD plans or
Professional Development Plans (PDP). Some of the participants described their PDP
as feeling like nothing more than a token gesture from the employer. They felt that it
did not really matter if they had educational goals, the employer was only going to do
what was best for the employer – and not the paramedic.
“Through my seven and a half years with the first service7,
I sat down once with a manager to talk about my PDP and
it really was a 15 minutes, "How are things going? Where
do you see yourself in the future?" and I wasn't expecting
any kind of change. So it really was just an informal chat.
There wasn't anything formal and in the service I'm in
now, they're just currently going through doing new PDPs
and again, I get the impression that the people around me;
that it hasn't happened for a long time. When it does happen,
it's kind of hard to organise and it's more of a token
gesture.” (Joseph)
Many of the participants in this study had taken, or were taking a self-onus in
furthering their education, in the pre-hospital, health related or other fields of study.
One participant, spoke of doing this in conjunction with their PDP.
“We have a template. But we compose it ourselves…I don’t
know. I guess I’ve become disillusioned. In that, initially, I
did want to advance to management side of things….And I
6 Professional Development7 This participant has worked as a paramedic for two different Australasian ambulance services, the first service for 7.5 years and the second (current) for 3 years.
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 91
put that on my PD. That that was my desire. And I did the
training, but I was never given the opportunity to actually
work in that role. So I put it in my next PDP. Any by 4
years’ time when I had not had the opportunity to do that,
and it wasn’t for the want of trying. I had applied for
positions. So then I decided, I’m not going to do this. I went
hard with my PhD and I thought, I can’t do a PhD
and a management position. I just wouldn’t have the time
to be able to dedicate to both. So I’m better off staying at
the [clinical] level I am and advancing myself
academically.” (Jenni)
5.2.2 Discussion
Given the existing discourse surrounding CPD in the literature, it would be
reasonable to have an expectation that all of the paramedics who had initially qualified
as a paramedic with a degree would demonstrate a greater understanding of CPD,
(Brooks, Grantham, Spencer & Archer, 2018; Johnston & Acker, 2016; O’Brien,
Moore, Dawson & Hartley, 2014). As such they might have developed a better
understanding of CPD being a part of their career choice to become paramedics. While
some participants demonstrated engagement in CPD, it appears that they did not
necessarily feel that the tertiary sector adequately prepared them with skills for LLL
or advised them that this would be an expectation of their future career as a paramedic.
One participant Tneal, recalled being advised by her university that she stay up
to date with research, but she was unable to recall any specific occasion where she was
advised that she would have to continue to engage in CPD as a qualified paramedic.
The statement made by this participant is of particular interest. From the analysed data
this participant appears to be the exception to the general rule, and possibly had an
understanding of CPR which differs to the norm. There are many CPD opportunities
available at Universities. In Australia and New Zealand, there are two major paramedic
associations, PA and ANZCP. Both associations have chapters designed for
undergraduate and student paramedics and have been offering CPD opportunities for
many years. ANZCP has a student committee designed to support students (ANZCP,
2018). A Student Paramedic Association (SPA) has also been set-up by PA, which
hosts CPD events specifically for student paramedics (Paramedics Australasia, 2018).
92 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
Most of the Universities in Australasia that have Paramedicine Programs, have some
type of association available to undergraduates. One example is the QUT Student
Paramedic Undergraduates, which is an association that holds CPD events and actively
encourages students to participate in CPD activities (QUT SPU, 2018). It is likely that
access to information about CPD is available to undergraduate students. Thus, apart
from being encouraged to keep up to date with research, having no recollection of CPD
at any time during an undergraduate program seems an exceptional circumstance, and
most likely the exception and not the rule. Other tertiary qualified participants within
the study stated that they were aware of CPD and entered their career knowing that
they were required to engage with it was part of their choice to be a paramedic.
Participants, such as Lily, discussed being prepared by university for integrating CPD
activities and events into their profession.
The literature suggests that when professional registration is imminent, health
professionals report an increased interest in CPD (Walsh & Craig, 2016; Tran, Tofade,
Thakkar & Rouse, 2014). This concept was discussed by the participants in the study.
For example, one participant, Alisha stated that they had not considered CPD until
more recently. She said that it was only in the beginning of 2018 that she increased her
interest in CPD. The statement from Alisha about CPD and professional registration
aligns with similar findings in other health literature (Macdougall, Epstein & Highet,
2017; Wotherspoon & McCarthy, 2016). When explored deeper, Alisha stated that she
had not considered CPD prior to registering because she did not previously consider
CPD to be a requirement of professional registration. She said that CDP events or
activities would be advertised and that she had been invited to participate, but it was
never a requirement, so she did not participate in anything that was not a mandatory
training requirement of her organisation.
From an employer perspective, CPD occurs in the form of mandatory training,
staff in-service education programs and CPD plans, which all assist the organisation
to demonstrate transparent CPD practices (Grant, 2017; Silva, Stulting & Golnik,
2014). The purpose of a Professional Development Plans (PDP) is to utilise a living
document that specifies CPD activities and objectives, which are to occur over a
defined period of time. PDPs are thus relevant to the individual in order to maximise
their professional development progression (Benes, & Voss, 2017; Maguire &
Blaylock, 2016). Few participants in the study spoke about historically actively
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 93
keeping a PDP, and professional registration has possibly prioritised this concept for
many paramedics. The PDP should be a joint activity, between the individual and the
employer, which: identifies specific areas for further improvement; is action-
orientated and realistic; sits within appropriate time-frames; and is measurable in
achieving a demonstrative outcome (Benes, & Voss, 2017; Maguire & Blaylock,
2016). This feeds into the PDP cycle, which was previously outlined in Chapter Three.
The PDP cycle involves continued assessment, elements of reflective practice
and review of the individual’s learning and development needs throughout their years
of employment. It can also record achievements and outcomes. All of the participants
in this study work for organisations that utilise CPD plans, also referred to as PDPs.
However, their experiences, are somewhat different to the expectations of a fulfilling
and symbiotic relationship between the employee and the employer that is portrayed
in the literature. The statement made by participant Joseph, that his experiences with
PDP’s were more akin to a token gesture than to a living document which can assist
the employee to improve their professional performance with the support of the
employer (Maguire & Blaylock, 2016).
5.3 UNDERSTANDING PARAMEDIC FACILITATORS AND BARRIERS OF CPD
5.3.1 Results
Many participants in this study reflected the literature reported by allied health
professionals relating to facilitators and barriers of CPD. Australasian paramedics in
this study said that they participate in CPD to improve the quality of patient care, and
that they seek out opportunities to engage in supported CPD activities, specifically if
those opportunities/activities are interesting and have minimal personal, time or
financial burdens attached to them.
“I think things have to be interesting for people to want to
participate in them, and if they are interactive, you are
engaging the learner and I think that helps maintain your
knowledge base. It will help keep you engaged in what you
are doing, and I can only see that as a good thing.”
(Luke)
94 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
To this end, many of the participants had personally undertaken CPD activities
in the form of graduate or post-graduate qualifications. Of the participants currently
enrolled in tertiary study, each were undertaking health related courses. Interestingly,
engagement in these academic pursuits, including a master’s degree in Critical Care
Paramedicine, were not initially considered to be CPD. Instead the view was expressed
that CPD was restricted to employer instigated activities, and that a personal choice to
engage in university courses and other forms of study, was something different.
“I would have thought lifelong learning is more intrinsically
motivated where you're not just doing it because it's
mandatory for your organisation and because you want to –
once again intrinsically motivated, you want to get better at
your career. When you think about lifelong you think about
extended periods of time. You wouldn't be thinking like that
if it was just purely for your organisation because you don't
know how long you may be there for.” (Lily)
“I’m doing my PhD. I wouldn’t consider that as compliance
training. Because it’s something that I want to do, it’s not
something that I have to do. It’s something that I want to
do.” (Jenni)
As this concept was explored further, some participants agreed that a connection
exists between engaging in further study as a part of their LLL and CPD.
“I’m engaged with my PhD and that is certainly
professional development that I can show when
professional registration comes about. I can show that I am
learning to do research. It is relevant to ambulance…. So,
even though my PhD research is not directly ambulance, it’s
very much indirectly ambulance.” (Jenni)
Others felt that their choice to engage in further study, was not the same as CPD.
They maintained a view that CPD was more related to paramedic patient care and
paramedic careers.
“I am engaging in stuff [tertiary qualification] outside of
paramedics that is still within the health field. So, I am
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 95
doing health related study but that is to develop into a
different health profession. They do interlink, which is
good, and I do use some of that stuff that I am learning in
my pre-hospital care, but pre-hospital targeted CPD, I
would have liked to have done more of that before I decided
to move into a different area. I think that was a factor in
changing careers as well, was because I wanted to keep
learning stuff and it just did not feel like pre-hospital was
giving me that opportunity to do stuff. I could just see my
career as [a qualified paramedic] and that is what you are
going to be for the rest of your career as a paramedic. You
can go down the management line or you can spend all this
time and money studying to be a CCP with no guarantee
that you will get that position. There is no career
progression or career development that relates back to
learning as CPD.” (Luke)
“Paramedic CPD to me, at the moment, given that I’m
doing a medical degree. Not really relevant, because what
I’m learning now is so much more in depth and
comprehensive that going and learning about hypertension,
it’s like, well that’s the basics. I’ll want to sit there and talk
about the complications and specific disease progression….
they just talk about the very general basics of hypertension.
For me it probably isn’t going to be as interesting as what
my studies are at the moment.” (Alisha)
The variable of time was identified in this study as both a facilitator for and a
barrier to CPD. Some participants found that a shift-work roster and the ability to swap
shifts with colleagues, enabled them to engage in CPD activities such as conferences:
“…often you will be able to either get a shift swap, which
is not too difficult usually, or it might happen to be on your
normal rostered days off. So, I find you tend not to have to
take an entire day off, usually you might just have to
rearrange your roster rather than losing a paid day.” (Lily)
96 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
However, not all of the participants felt that this was the case. Paramedics who
worked in metropolitan areas or for bigger ambulance services had different
experiences when it came to attempting to find time for CPD events and activities.
“I started the degree quite a few years ago and I had exams
on and I ended up having to take sick leave to do my exams
because they wouldn't give me days off.” (Ted)
“One of the biggest factors for me was they [CPD events]
are always on your days off, and on your days off, you want
them to be your days off, because you just spent your last
four to five shifts getting absolutely flogged. No meals,
you’re exhausted, the last thing you want to do on your two,
maybe three, four days off, is go and spend an entire day
back at work or learning something. Like it’s low on the list
of priorities that your days off, you want to be your days
off.” (Alisha)
The financial cost and intangible costs of CPD engagement were points of
discussion, for example the impact on their family, when it came to attending CPD
events or engaging in academic courses. Generally, the participants felt that the
financial cost associated with attending CPD events and activities seemed to outweigh
the educational or networking benefits of attending them, despite the tax deductibility
of CPD activities.
“….some of the really good CDP’s are actually quite
expensive. Especially the big CDP conferences are a couple
of thousand dollars.” (Alisha)
“The costs involved, for me to take that money away from
my family for something that right now isn't a requirement
and then the service that I work for doesn't really support it
and there's no benefit for my workplace, then it's hard for
me to justify those costs and the time.” (Joseph)
Some of the participants expressed views that there was little financial advantage
(e.g. tax benefit or career progression) that they could directly associate with self-
driven CPD. Participants spoke of limited tax-benefits and/or pay increases being
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 97
associated with any self-funded CPD activities or tertiary qualifications that they had
undertaken.
“I paid for my master’s and my graduate certificate, myself.
And I put my family into a very tight situation for probably
about five years and was about another 3 or so years until
we recovered from that. So, over a period of about 8 years,
I put my family into financial strain, in order to be able to
do my studies….it was purely for my own professional
development. There was no pay rise associated with it.”
(Jenni)
It was noted that in some ambulance services there is, in more recent times, some
pay increase linked to completion of some types of CPD programs or activities.
“I just think if you have got extra responsibilities and extra
knowledge you should be rewarded for that, probably
financially, even if it’s a small amount each time. I
supposed as an ACP over the last, since I've been in the job
at least, probably the last 10 years we've had lots of new
skills, lots of expectation put on to us, but nothing has come
as a financial reward for all those extra responsibilities or
duties that you have got…. Until recently pay rises are
starting to come through but up until then it was just
expected because that is good for the patient and good for
your job that you would do it. I did and we all did I guess,
but it would of been nice to just have some sort of -- because
you have got extra responsibilities and if you did something
wrong you have got to go and front somebody to talk about
it. But having that extra responsibility I think there should
be a bit of extra reward for it.” (Ted)
Other barriers to engaging in CPD that were apparent in the analysed findings
included the perception that neither their direct supervisors, nor the service participants
worked for placed any value on paramedics taking self-onus for engaging in CPD
opportunities. There was also a perception that some colleagues were doing the
minimum required to obtain or maintain employment.
98 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
“No incentives. There is no-like the clinical knowledge
would be great but there’s no, good job you’re being
proactive at your learning and engaging, you know. No high
five, none of that….. It was recognised and they’d get-if you
attended x amount of days to maintain your role of clinical
mentor, or if you want to be an OIC and come over you’d
have to, there has to be some accountability. Accountability
for continuing your education. Whereas a lot of people just
do the minimum and that’s it. And never learn another
thing.” (Alisha)
One paramedic also reported that a major barrier was a sense of fear when
engaging in CPD. The participant felt the fear of becoming a novice again could
sometimes decrease their motivational level to engage in new learning.
“…the way that we sometimes train...our trainers giving us
these horror stories….and that’s all well and good but the
reality is that sometimes you scare people off by giving
them the horror stories.…we’re afraid of doing it…You
don’t want to be that officer, that activated PCI and spent
all of this money for nothing…I think that sometimes there
is sort of a too high expectation put on people with baseline
information knowledge of these procedures. And instead of
being able to learn a little bit by mistake, a little bit by trial
and error. There’s this expectation to be perfect every time.”
(Fred)
5.3.2 Discussion
According to the literature, engagement in CPD can be positively or negatively
influenced by: a required improvement of knowledge or skills; professional
recognition linked to completing CPD activities; possibility of career or professional
advancement; mandatory training requirements; professional registration or
regulation; social support of the candidate while they undertake the CPD; the level of
enjoyment or interest in the content that the participant has; the opportunities available
to engage in the CPD; personal and/or financial costs incurred as a result of engaging
in the CPD (Macdougall, Epstein & Highet, 2017; Coventry, Maslin-Prothero &
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 99
Smith, 2015; Filipe, Silva, Stulting & Golnik, 2014; Govranos & Newton, 2014;
McArdle & Coutts, 2010). Many participants reflected the same feelings, thoughts or
views that are documented in the literature by allied health professionals. Specifically,
that participation in CPD can improve the quality of patient care that they provide. It
was apparent from the findings that opportunities to engage in supported CPD
activities that are interesting and have minimal personal, time or financial burdens
attached to them were more highly valued. The following sub-sections will discuss the
responses of this study’s Australasian paramedics, and these findings are discussed in
context with the extant literature where possible.
Make CPD interesting
One of the avenues of interest that emerged, was participants were more likely
to engage in, or want to engage in CPD when they felt that the subject matter was
interesting to them, either professionally or personally. Many participants, regardless
of how they qualified as a paramedic (vocationally or tertiary) had personally
undertaken CPD activities in the form of graduate or post-graduate degrees. The
attitudes expressed by the participants, such as Luke (see above in results) align with
the literature that CPD activities must be enjoyable for practitioners to participate in
them and for CPD activities and programs to be continued (Macdougall, Epstein &
Highet, 2017; Filipe, Silva, Stulting & Golnik, 2014; Govranos & Newton, 2014).
Many of the participants were currently enrolled in further study at a tertiary
level, including both undergraduate and post-graduate degrees. All of the participants
enrolled in tertiary study were undertaking health related courses, some specific to
paramedicine. Interestingly, the participants reported their engagement in these
academic pursuits, including a master’s degree in Critical Care Paramedicine, were not
initially considered to be CPD. The consensus of the participants was that CPD
amounted to employer instigated activities. The collective view was that engaging in
university courses and other forms of study, was something different.
When explored further, participants agreed that engaging in further study was
both a form of LLL and CPD, as seen in the comment from Jenni stating that she is
learning to become a researcher and that she intends to count that as CPD in her
portfolio for professional registration. The literature supports the responses and actions
of the participants who demonstrated that they were attempting to develop capabilities
100 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
and competencies that are personally meaningful to them (Macdougall, Epstein &
Highet, 2017; Filipe, Silva, Stulting & Golnik, 2014).
However, some paramedics still felt that while this could be considered CPD,
because they were engaging in an effort to develop themselves. Therefore, they
expressed this as being different to paramedic CPD. The literature describes CPD in
health, as a commitment to the process of both formal and informal LLL opportunities
that are linked to clinical advancements, practitioner competence and professionalism,
and the delivery of gold standard patient care (Macdougall, Epstein & Highet, 2017;
Martin, 2015; Filipe, Silva, Stulting & Golnik, 2014; Kemp & Baker, 2013). It is very
clear from the literature that the learning activities these paramedics are engaging in,
is CPD. As the interviews progressed, participants agreed that they were engaged in
self-directed CPD, for varied reasons.
Time
Though generally reported in the literature as a barrier to CPD (Bressan, et al,
2016; Mather & Seifert, 2014; Légaré, Ratté, Gravel, & Graham, 2008), during this
study, the variable of time was identified by participants as both a facilitator for and a
barrier to their CPD. Some participants reported that due to the nature of paramedic
shift work, or a rural/remote posting, they were easily able to find the time to engage
in CPD. The experience of Lily when it came to attending conferences, was positive.
She talked of being able to change her shifts around to facilitate her being able to
attend.
Other participants felt that due to their roster, or posting in a metropolitan area,
or other family commitments, time was a precious commodity and therefore a barrier
to their engagement in CPD activities. Specifically, participants felt that their employer
was not willing or able to facilitate time off or study leave for operational staff
members to attend conferences or exams. One participant, Ted, was a vocationally
trained paramedic who had been enrolled in an undergraduate degree in paramedicine.
He spoke of his frustration at not being able to access any study leave to attend his
exams. He said that he had attempted to swap his rostered shift and applied for annual
leave, to no avail. He felt that that in order to continue with his self-directed CPD
(degree), he had to compromise his integrity and professionalism because he had to
take sick leave from work to attend his university exams.
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 101
Time was reported by other professionals to be a barrier in the form of not having
time within the workplace to engage in CPD activities (Bressan, et al, 2016; Filipe,
Silva, Stulting & Golnik, 2014; Ikenwilo & Skåtun, 2014). The results in this study
confirmed the findings from the literature about CPD and time, all be it from a
paramedic perspective. For example, high workloads were alluded to where
paramedics rarely finish their shift on time, or have no meal breaks during their shift.
As a result, some participants in this study reported constantly feeling fatigued, making
it difficult to prioritise their engagement in paramedic CPD.
Cost
The concept of cost has been explored in the literature. Cost, can refer to
financial cost, broader implications associated with cost, and/or other types of cost
relative factors including time or stress (Coventry, Maslin-Prothero & Smith, 2015;
McArdle & Coutts, 2010; Munro, 2008). The previous section dedicated to time,
looked at some participant responses about the cost of time. However, paramedics such
as Alisha and Joseph also talked about the financial cost and the intangible concept of
cost, such as the impact on their family, when it came to attending CPD events or
engaging in academic courses.
In Australia, some of the cost of CPD for nurses is mitigated by leave
entitlements, pay awards and the ability to claim tax deductions for self-education
work-related expenses (Dickerson, Lubejko & Summers, 2015). The ability to claim
tax deductions for self-education if it is work-related has been available to paramedics
as well. However, the participants in this study did not feel that a tax deduction was
always enough, nor was there always a pay award or increase associated with the self-
driven CPD that they had done. Jenni talked about having to pay for her post graduate
qualifications without any financial support from her employer. She said that in doing
so, she felt that she had put her family at a financial disadvantage for a number of
years. Furthermore, after self-funding her qualifications, Jenni felt that there had been
no financial benefit in her case.
The literature also explores the concept of participants receiving financial gain
from having participated in CPD including fast-tracked career progression, mentoring
allowances, or bonuses (Griebenow, et.al. 2015). Most of the participants in this study
stated that they did not consider career progression to be either a facilitator or barrier
to their CPD. Although some participants were disinclined to engage with CPD
102 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
because they did not believe there was opportunity of promotion or recognition
associated with it. Participant Ted spoke about how financial remuneration for having
extra skills and responsibilities hadn’t taken effect until recently in his workplace. His
experience was that over the past decade, he and other paramedics had increased their
knowledge, skills and responsibilities but that there had been no tangible financial gain
for these undertakings.
The participants also talked about a perceived lack of recognition from their
employer for them being pro-active and engaging in CPD opportunities. The
participants said that they felt neither their direct supervisors, nor the service they
worked for seemed to place any value on the individual paramedic seeking or engaging
in self-sourced CPD opportunities. Participants such as Alisha, expressed the view that
management was only interested in paramedics attending mandatory training days, and
there was little incentive within the workplace for paramedics to do anything more.
These barriers, mentioned by participants, such as: no incentives, financial cost,
personal stress and loss of time with family confirmed findings from allied health
literature (Duncombe, 2018; Coventry, Maslin-Prothero & Smith, 2015; Schwarz &
Leibold, 2014; McArdle & Coutts, 2010).
Fear
The concept of fear as an impediment to seeking CPD activities did not reveal
itself in the initial review of the literature. However, one participant in this study
discussed fear being a barrier when it came to their engagement in CPD. Further
critical analysis of the literature revealed the concept of a fear appeal (Putwain, Symes
& Remedios, 2016). This centres around how behaviour and threatening
communication style of the teacher or educator can have a profound effect on the
student learning experience (Roberto, Mongeau & Liu, 2018; Putwain, Symes &
Remedios, 2016). While, fear appeals are commonly utilised in health literature
directed towards the general public, such as warning messages on cigarette packaging
(Ruiter, Kessels, Peters & Kok, 2014), the literature also examines them in the context
of student learning outcomes and high-stakes examinations (Putwain, Symes &
Remedios, 2016; Banks & Smyth, 2015). In this regard, the response from the
participant aligns with the literature.
The participant (Fred) felt that while fear could be a motivator when it came to
participating in CPD, it also had the power to develop the feeling that only perfection
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 103
in paramedic practice is acceptable. While a gold standard of patient care is always
strived for, the fact is that not all clinicians get every single thing right, every single
time. Even though a paramedic holds a qualification and is no longer a novice
practitioner, when it comes to expanding their scope of practice, the new knowledge
and skills can be novice level for the clinician. Fear of becoming a novice again, can
decrease motivational level to engage in new learning. Fred, had experiences of being
made to feel that only perfection was acceptable in his workplace and that clinical
(workplace) educators and paramedics with higher clinical scopes of practice made
him fear CPD because of the consequences associated with clinical errors.
The fear barrier in relation to paramedic CPD is a concept that requires further
investigation. There are many variables that need to be considered in relation to the
comment made by Fred. There could be cultural aspects8 that are influencing the
training methods that his paramedic educators are using. Conversely, the fear may
come from his previous level of education, Fred has advised that he completed a high
school certificate and all other education has been provided by the ambulance service
that he works for.
5.4 OPPORTUNITIES AND MODALITIES FOR PARAMEDICS TO ENGAGE IN CPD ACTIVITIES
The following section discusses opportunities and modalities for paramedics to
engage in CPD activities. The term opportunity not only refers to the paramedic having
the opportunity to participate in CPD, it also enables discussion around the
opportunities that may open to a paramedic once they have completed particular types
of CPD.
5.4.1 Results
The Australasian paramedics in this study did not report a singular preferred
modality when engaging in CPD activities. Participants felt that face-to-face CPD
learning activities were a positive way to keep them actively engaged and wanting to
participate in the classroom. They expressed an appreciation that their employers
generally provide some time during their rostered work hours to participate in CPD.
8 Cultural aspects in relation to the service, region or station where this participant works.
104 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
“I really like face-to-face (CPD). I think there's a lot of
value in being able to do face-to-face. Go off on tangents,
being able to ask questions. It's a lot easier to maintain your
attention when you're talking with someone that you're in
some sort of classroom environment, rather than just
watching a recording. So I think face to face is one of the
better options.” (Joseph)
“I think I'm a hands-on learner. See it, do it and it makes
sense then.” (Ted)
“…it’s a fairly recent sort of advent over the last one or two
years. Is that now over every quarter, there is a day set aside
for training, for all officers. And that is helping a lot more
than just muddling along by yourself.” (Fred)
Another modality discussed by participants was online learning. Most of the
participants in this study work in have access to technology (i.e. smart phones or iPads)
that they can use to access online CPD. Some of the participants said they found this
form of CPD to be easy to utilise and that they believed online technology had
facilitated their engagement in CPD.
“Any CPD that I can do while I'm at work in the times that
we do get down time we get given iPads for our service. So,
if I can do it on my iPad, watch video links, I'm quite a
visual interactive person, so I prefer that than probably
reading a textbook.” (Lily)
However, one participant felt that they had limited digital literacy and there was
little support within the workplace to assist them in completing online CPD activities
that were mandated by the employer.
“Unfortunately, I’m also one of the oldest staff. So,
knowing how to use an iPad is not one of the biggest
abilities that I’ve got. And turning around, giving an iPad
to someone and saying, “Oh, work it out”. Well, that’s just
not good enough…. training in some of the information
technology is very lacking, I find…. some of us are older….
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 105
some of us are not the teeny boppers. There are people now,
who are joining the ambulance service who weren’t even
born when I joined the ambulance service. You know?
That’s the reality. And they lap up the technology stuff. But
it’s never even really been part of my job until recent
years.” (Fred)
Generally, the concept of blended learning9 was appealing to most of the
participants in this study.
“I actually do like that blending things, so if I can do portion
of it. Do an online module.…. say this is twelve hours
bottom line, and four and a half or four hours contact…. I
get 16 hours of official contact using the blended.”
(Herb)
In relation to participants being able to find or have opportunities to engage in
CPD activities, the participants reiterated the types of opportunities discussed in the
literature. The paramedics in this study felt that they were able to find CPD
opportunities that were either self-driven, organisationally driven, or a combination of
external and organisationally driven.
“Through the professional associations and the unions,
maybe more advertisement about different conferences that
are coming up so that there is an availability……if it was in
your face all the time you would go, "Oh, that sounds really
good," and have a look, and I would go make time for that.
With my current studies that I am doing to get into a
different profession, those professional associations send
out an email every week of, "There's this conference up and
coming." (Luke)
“I think something that makes CPD a lot easier for the most
part is if ideas are sort of provided. So, say if station
9 Blended learning can be defined as a composite of on-line and face-to-face learning activities (Nazarenko, 2015).
106 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
managers were to send out, once a month, a journal article
or direct stuff, in a way I think that is a friendly reminder
that, obviously you need to do your CPD but also, "Here are
some things that might be of interest to you." I think a lot
of people, the longer you are out of university, the harder it
is for you to actually go find journal articles and academic
research. I think you start to lose those skills if you do not
use them often enough. So, I think by providing staff with
some options might actually help them to engage a little
better. Aside from that sort of stuff, advertising
conferences, or workshops, or that sort of thing, I think if
it's advertised to staff I think it would be far easier and you
would end up having more people engaging, I think.”
(Tneal)
In relation to organisationally driven CPD, some paramedics felt that some of
the types of CPD activities they have participated in, have been less about the content,
and more about being able to have their training meet an organisational KPI, or being
a networking/social occasion.
“I want to actually learn or refresh something, not just,
“Yeah, I’ve done it.” …. you can attend a conference, get
the points, but not get anything out of it. So, you’re paying
money to go for a networking. Whilst the networking is
important, the content of conference, I find, is equally
important. I think of the conferences, whilst they’re always
good social occasions, I want to get something out of it, as
professionally out of it as well.” (Herb)
The participants from this study said they would prefer to attend conferences
which covered topics such as: clinical interventions, ethics, professionalism,
interprofessional communication skills, reflective practices, how to learn to research
and evidence-based practice. They also discussed the importance of conferences being
cost and time effective.
“…less cost, a variety of time, variety of how it's presented.
So different media and things. So it gives us multiple access
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 107
points and all aiming towards something in the future.”
(Joseph)
“The time, money, those priorities and constraints are
they’re so concrete. They impact on everyone. It’s how the
various – each person deals with it, it’s the only thing with
changes, to me.” (Herb)
Participants expressed a level of frustration regarding employer requirements to
attend non-clinical focused mandatory training.
“I have mandatory training, which is all well and good, and
if it is job based, tends to make more sense. If it tends to be
the administrative or bullying in the workplace people tend
to get a lot more jaded…. Because it’s already been
attended to. You know, these are 12 monthly or 2 yearly
recertification of this stuff, and it’s the same, same. We’ve
done it. Let’s just move on. Most of us know what
constitutes bullying…. But, if it’s clinical….This makes
sense. But when we redo the same protocols yet again,
which hasn’t changed for 5 years – and we are doing it
every two, two or three years, it grates.” (Fred)
Another form of frustration was aimed at colleagues just attending mandatory
training to comply with the organisational requirements, but not necessarily to learn or
engage in the CPD.
“There’s a difference between turning up to a CPD and
getting a tick in the box, and turning up to a CPD applying
yourself, and then applying what you’ve learned on the
road. A lot of people will be column A. Column A turn out
to tick the box, leave that’s it. I’ve done what I need to do,
I am not interested in anymore.” (Alisha)
Engagement in CPD and developing a Professional Development Plan (PDP)
reportedly had varying levels of influence over participants’ ability to apply for other
positions (both clinical and managerial) within their organisation. Literature in other
health disciplines indicates this as a facilitator for engagement in CPD. A number of
108 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
paramedics in this study felt their engagement in CPD had little bearing on their career
progression. Thus the paramedic perspective may differ to findings reported in the
literature about career advancement being a facilitator for CPD.
“I've still got a boss that I don't get on very well with. So,
doing the training means that I'm putting in the time the
effort and the money, but I realistically won't be able to
apply for higher positions.” (Reece)
“I’d been shortlisted for different positions and things like
that. I did learn that I was being undermined by a fellow
employee with regards to my employment opportunities,
and that’s when I decided this is not an organisation that I
want to be a manager of.” (Jenni)
5.4.2 Discussion
The paramedics in this study discussed modalities that they preferred when
engaging in CPD activities. There was no single overwhelming preference to the way
paramedics preferred their CPD content to be delivered. This is supported by the
literature (Staple, Carter, Jensen & Walker, 2018). There were however, three styles
of CPD presentation that the paramedics preferred. These were face-to-face, online
and blended learning.
Face-to-Face
One of the more traditional modalities of CPD delivery is by face to face
methods (Hemmati, Omrani & Hemmati, 2013; Larson & Sung, 2009). This modality
typically occurs in the form of a lecture, conference, tutorial, scenario or simulation
(Chan et.al. 2016; Hemmati, Omrani & Hemmati, 2013; Larson & Sung, 2009). Face
to face training is tangible and fosters connection and communication between the
educator and the participant. It is a model of training that has historically been utilised
in paramedic education and training (Brooks, Grantham, Spencer & Archer, 2018) and
may suit the work environment of the profession. That is paramedics generally work
in pairs, with one paramedic in the crew usually being clinically senior. Thus one-to-
one, face-to-face training actually occurs in the live environment and may include
debriefs after attending cases. The paramedic participants in this study said that face-
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 109
to-face CPD learning activities were a positive route to their active engagement and
participation.
Participant statements reported in the results section, are supported by the
literature which suggests that paramedics enjoy learning that is based in concrete
experiences (Staple, Carter, Jensen & Walker, 2018). Paramedics rely on many tactile
skills to perform their job. Research indicates that undergraduate paramedic students,
are kinaesthetic learners (Erwin, 2017), and it can be a reasonable assumption that
paramedics who are kinaesthetic learners will enjoy or prefer CPD activities that are
face-to-face and/or with hands-on simulation or components.
Online Learning
There have been numerous studies investigating the delivery of CPD activities
through online modalities (Shaw, et.al, 2017; Thepwongsa, Kirby, Schattner &
Piterman, 2014; Hemmati, Omrani & Hemmati, 2013). A systematic review of the
effectiveness of online continuing medical education for general practitioners (GP),
specifically in relation to their satisfaction, clinical practice, knowledge and patient
outcomes, found that GP’s prefer traditional delivery methods such as face-to-face,
over online learning (Thepwongsa, Kirby, Schattner & Piterman, 2014). Findings from
some paramedic participants in this study confirmed the results from the GP studies
about face-to-face training modalities and CPD.
One paramedic participant (Fred) agreed, he had spoken about his preference for
face-to-face training earlier and now clarified why he preferred that to on-line or
blended learning activities. This participant appeared genuinely distressed about being
required to integrate technology into his CPD and paramedic practice. It is possible
that this participant represents an anomaly purely due to his personality traits.
However, when his response, years of service, chronological age and the literature are
combined, there is also a possibility that he is a part of a decreasing portion of the
paramedic population that is faced with this problem. However, it should be noted that
participant Jenni has more than 20 years ambulance service, is of a similar age group,
and does not appear to have trouble utilising technology.
Research into generational differences in learning to use technology suggests
that age is not a determining factor when it comes to learning to use digital
technologies (Lai & Hong, 2015). The literature on how older adults interact with
110 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
technology has identified 10 factors that influence perceptions and adoption of
technology (Lee & Coughlin, 2015). These factors are: value, confidence, usability,
experience, affordability, independence, accessibility, emotion, social support and
technical support (Lee & Coughlin, 2015). It is not known if the difference in approach
Jenni and Fred take towards technology due to the factors described by Lee &
Coughlin (2015), or the participants having different personality types. Is Fred a
Luddite, and Jenni tech-savvy? The study did not encompass participants’ relationship
with technology when engaging in CPD. Therefore, further research is warranted to
investigate specific paramedic demographics, such as years of service, and their ability
to assimilate technology such as iPads into their CPD.
The literature also states that time can be used effectively if the CPD activity
utilises learning materials, such as online or web-based packages that can easily be
accessed by the participant (Shaw, et.al, 2017). Most of the participants in this study
have been issued technology such as iPads by their employer for use in the workplace.
Some of the participants, such as Lily, said that they found this form of CPD to be easy
to utilise and that they believed online technology had facilitated their engagement in
CPD.
Currently, paramedics in Australia and New Zealand who are members of PA
and ANZCP, have the ability to engage in online CPD activities and opportunities; as
well as utilise software to capture the activities they are undertaking (A. Batucan,
personal communication, January 11, 2019; J. Bruning, personal communication,
January 14, 2019). There are many regular CPD events scheduled throughout the year
which paramedics of all clinical levels are able to access. The current uptake of
paramedics subscribing and attending these events and CPD activities is between 20%
and 30% (A. Batucan, personal communication, January 11, 2019; J. Bruning, personal
communication, January 14, 2019).
Blended Learning
Blended learning is an approach where the CPD activity is delivered via multiple
modes, generally, two components: online and face-to-face (Kiviniemi, 2014; Larson
& Sung, 2009). While there is limited literature on the effectiveness of blended
learning in CPD for health professionals (McCutcheon, Lohan, Traynor & Martin,
2014), research was found indicating that undergraduate students enrolled in health
disciplines have responded positively when engaged in it, and improved their academic
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 111
performance (Kiviniemi, 2014). The concept of blended learning was appealing to
most participants.
It is reasonable to conclude that blended learning as a modality will appeal to
paramedics for two reasons. First, paramedics appreciate face-to-face learning and
second, paramedics work in a dynamic 24/7 environment. Working a 24/7 roster means
that paramedics are able to access online elements of blended learning at any time of
the night or day. Herb spoke about doing a portion of the module online and then later
attending a workshop to complete the CPD course. The nature of a paramedic roster
means for most paramedics, that there is an ability to complete online material in down
time, or during a night shift, or while ramped10 at hospital, which can be an effective
way to time manage their learning activities.
Finding Opportunities
The ways that professionals seek and utilise opportunities to engage in CPD has
been canvased in the literature (Coventry, Maslin-Prothero & Smith, 2015; Casey &
Clark, 2009). Generally, the literature discusses the role of employers in providing
CPD opportunities through a variety of avenues including: PDP’s, performance
appraisals, paid study leave, training needs analysis, mentoring, and managerial
support (Coventry, Maslin-Prothero & Smith, 2015; Munro, 2008). Participants in this
study discussed many of the types of opportunities discussed in the literature.
However, participants Luke and Tneal also made mention of finding opportunities that
were not necessarily organisationally driven, or that were a combination of external
and organisationally driven. Both of these participants are enrolled in health related
(non-paramedic) degrees and are finding CPD opportunities through the new networks
they are establishing as a result of their studies.
Achievement of a Learning Outcome, Not a “Tick and Flick”, Tax Write Off, or Social Occasion
Much of the allied health literature in the CPD space refers to any form or type
of CPD leading to some type of positive outcome (Knox, et.al, 2016; Martin, 2015;
Miraglia & Asselin, 2015; Reeves, Perrier, Goldman, Freeth & Zwarenstein, 2013).
Research indicates that some employees view CPD activities with a level of suspicion
10 The term ramped is utilised for when a patient is still on the ambulance stretcher, under the care of the paramedic, in the emergency department, waiting to be allocated a bed.
112 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
and report a belief that their professional development is directed purely by their
employers’ requirement to meet organisational key performance indicators (KPIs), or
health and safety reporting requirements (Mather & Seifert, 2014). The participants in
this study held similar views to those reported in allied health literature. Some
participants felt that some of the types of CPD activities that they have participated in,
have been less about the content, and more about being able to have their training meet
an organisational KPI. Other participants such as Herb felt that CPD is sometimes just
utilised more as a social occasion or networking event, instead of an opportunity to
learn and development themselves as a clinician.
Several participants reported wanting to get more out of attending a paramedic
conference than social networking, and to attend conferences that help them to develop
professionally. This reflection could provide useful insight for paramedic professional
associations organising paramedic conferences. It is suggested that conference
organisers should also ensure that conferences are filled with content that will appeal
to the majority of paramedics. The participants from this study stated that they would
like to attend conferences that included content such as: clinical interventions, ethics,
professionalism, interprofessional communication skills, reflective practices, how to
research and evidence-based practice. Other participants such as Joseph and Herb,
agreed and expressed the importance of conferences being cost and time effective,
which almost as important as the content being presented.
As previously mentioned, mandatory CPD can be perceived as a point gathering,
tick and flick exercise that indicates compliance with workplace policies or arbitrary
sign-offs, and does not necessarily improve professional practice (Haywood, Pain,
Ryan & Adams, 2012). Participants in this study expressed frustration at workplace
requirements to participate in repetitive non-clinical mandatory training, such as
“workplace bullying” or “code of conduct” training year in and year out.
In the results section Alisha, spoke of mandatory training equating to merely
“ticking boxes” for some of her colleagues. Her comment touches on the concept that
attendance at a CPD activity may not necessarily improve [paramedic] professional
practice, which aligns with the literature (Haywood, Pain, Ryan & Adams, 2012).
Several participants discussed having some level of suspicion of their paramedic
colleagues not engaging in CPD activities to develop themselves as clinicians but
engaging in it merely to comply with professional obligations. Each of these
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 113
participants spoke of professional pride and wanting to provide the best care that they
were capable of to their patients. Many participants had engaged in self-directed
professional and educational development programs to increase their clinical rank or
professional status within their organisation. Several expressed or indicated an
expectation of their colleagues to be striving to do the same, but that this expectation
might not align with the reality of all paramedic practice.
Career Progression
As discussed in section 3.4.9, a Professional Development Plan (PDP) is by its
nature linked to professional development, which is in-turn often linked to opportunity
for career progression. Many of the participants stated that they felt as though their
PDP’s had some influence on their ability to apply for other positions within their
organisation. While the literature in other health disciplines, indicates that this is a
facilitator for engagement in CPD, some paramedics felt abandoned or shunned by
management when it came to both CPD and career progression. Participants such as
Reece and Jenni discussed feeling that it didn’t really matter how much they engage
in CPD or attain successful outcomes on their PDP. They felt there are other
interpersonal issues with their supervisor or colleagues influencing their ability to
progress their career. To some degree this should be expected as engaging in CPD does
not equate to a promotion in and of itself. One explanation for these perceptions could
be due to a phenomenon similar to the glass ceiling effect (Sahoo & Lenka, 2016).
Paramedicine is a small industry in relation to many other health professions. As a
relatively small employer in the health environment, ambulance services offer a
limited number of managerial roles and opportunities for progression into higher
clinical or operational roles are limited.
5.5 PERCEIVED DIFFERENCE BETWEEN LLL AND MANDATORY TRAINING
5.5.1 Results
Every participant in this study had completed one or more of the following
paramedic qualifications: a tertiary qualification in paramedicine; an associate diploma
or diploma of paramedicine. After completing the initial qualification, they had each
then either completed upskilling or a probationary phase within their organisation to
enable them to practice at a minimum (now nationally accredited) level of Advanced
114 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
Care Paramedic11. Some participants were practicing as Critical Care Paramedics12
and Extended Care Paramedics13. While the participants had taken different academic
pathways to obtain the same minimum clinical level, they appeared to have a shared
view of a distinct difference between Lifelong Learning (LLL) and Mandatory
Training. Mandatory Training was overwhelmingly viewed by participants as being
paramedic CPD.
“I think it the compliance training [has] been renamed into
CPD right now and that lifelong learning is the sort of thing
which we should be aiming towards.” (Joseph)
However, many participants did not view other academic or professional
development endeavours to be CPD. There appears to be a distinction between CPD
(Mandatory Training) and LLL (any other academic upskill/course/activity), even if
directly related to the role of paramedic.
“…life-long learning is, you’ve got the basic knowledge
and you’re applying common sense, you’re applying
experience, life experience to what you’ve been trained in,
and appropriately apply those techniques.” (Fred)
“Lifelong learning is about improving yourself as a
practitioner and a clinician. Because new things are coming
out, also there are new studies that are changing the way we
do things, and that is good…..But the basic compliance
stuff that is just ticks and boxes for the organisation to say
that they are doing the right thing providing people of a
certain level. But most of it is learning and training and
revision that does not help me as a paramedic.” (Reece)
11 Pre-hospital emergency health care specialist (CAA, 2009; Paramedics Australasia, 2012a).12 Pre-hospital emergency health care specialist with advanced knowledge, skills and protocols to provide expert pre-hospital interventions in accordance with organisational protocols (Von Vopelius-Feldt & Benger, 2013).13 An experienced paramedic working in a specialised role which allows them to respond to both traditional paramedic cases, and to perform additional treatment options (Long, 2017).
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 115
5.5.2 Discussion
The literature clearly describes LLL as any type of formal or informal learning
opportunity that assists the continued acquisition, development and improvement of
knowledge, skills or abilities which can be utilised in both the learners’ personal or
Martin, 2015; Tofade, Duggan, Rouse, & Anderson, 2015; Kemp & Baker, 2013;
Currie, Lockett, Finn, Martin & Waring, 2012). Mandatory or compliance training can
be defined as both formal and informal learning activities designed to improve
knowledge, skills and abilities that are connected to work-based requirements and
fulfil the needs of the employer more than give a choice of content to the learner
(Mythen & Gidman, 2011). The commonality between LLL activities and mandatory
training, being that the learning opportunity or activity has been designed to improve
some element of the professional life of the learner. However, there appears to be the
need to better embed cognisance of the importance of LLL in the curricula.
The study’s results confirm similar findings in the literature. Mandatory training
is not necessarily being designed to facilitate any intrinsic desire to learn, rather, it is
often designed to assist the employer in meeting organisational KPI’s and targets
(Mythen & Gidman, 2011). While there are obvious differences, it is the contention of
this research that both LLL and mandatory training constitute CPD. For this thesis,
CPD as described in the health literature includes both formal and informal life-long
learning (LLL) opportunities linked to clinical advancements, practitioner competence
and professionalism, and the delivery of gold standard patient care (Macdougall,
Epstein & Highet, 2017; Martin, 2015; Filipe, Silva, Stulting & Golnik, 2014; Kemp
& Baker, 2013).
Throughout the interview process, participants continued to discuss differences
between CPD for the purpose of mandatory training or clinical advancement, and CPD
for personal development or career advancement. Mandatory training (also referred to
as compliance training by some participants) was described as CPD. Joseph spoke of
his experience of compliance training being rebadged as CPD, when in effect what he
felt was that LLL should be the goal of paramedic CPD, but that it was not paramedic
CPD. As this was explored in more depth, other participant responses took a similar
focus, regardless of their initial qualification, or whether they had previously, or were
116 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
currently, engaged in further academic or professional study, LLL was viewed as
different to CPD.
One explanation of this perceived difference between the concept of LLL and
CPD may be the paramedic experience of the traditional didactic educational model.
Much like rote learning, paramedics were instructed on how things were to be done –
the way the organisation dictated and not necessarily in a way that would develop the
clinician (Long, Devenish & Hobbs, 2018). Prior to the evolution of a tertiary pathway
to paramedicine, training was done ‘the company way’, on ‘company time’ and paid
for by ‘the company’. Paramedics were ambulance officers, who often came from trade
backgrounds.
In 1994, the structure of paramedic education began to change from
organisational to professional as the tertiary sector began to offer a pathway into
paramedicine (O’Brien, Moore, Dawson & Hartley, 2014; Hou, Rego & Service, 2013;
Lord, 2003). The literature remains regrettably silent regarding higher education for
paramedics equating to a higher understanding or appreciation of LLL. Perhaps
misperception about paramedic CPD is a result of the fusion between the vocationally
trained paramedics who had been trained what to think, and the tertiary trained
paramedics who had been trained how to think. Now paramedics trained under both
systems have become clinicians in their own right, and both strive for a gold standard
of patient care. Reflective practice is a part of CPD (Leahy, Chipchase & Blackstock,
2017; Eppich, et.al. 2016) and is taught in undergraduate degrees. However, it was not
necessarily something vocationally trained paramedics were trained to consider prior
to the implementation of paramedic registration requirements. Therefore, variances in
paramedic understanding of reflective practice is potentially one reason for the
participants in this study viewing LLL as different to CPD; something to work towards,
but not necessarily a current part of CPD, and not a part of any mandatory training
regime.
Analysis of the data revealed a distinct divide in perceptions about how one
engages in CPD. Overwhelmingly, at the beginning of the interview process
paramedics viewed mandatory training as being what constituted their CPD. While
many of the participants had previously engaged, or were currently engaged in further
developing their knowledge and skills through the undertaking of courses of study,
they did not consider this to be a part of their CPD. This was the case regardless of
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 117
whether the paramedic was engaged in courses that were directly or indirectly related
to paramedicine. Theoretical sampling enabled this emergent theme to be explored.
However, the parameters of the study were too limited to enable a full investigation of
differences (if any) between vocationally trained and university-educated paramedics
understanding of LLL and how and where it fits into shaping the way that one thinks.
5.6 PERCEIVED IMPLICATIONS PARAMEDIC REGISTRATION
5.6.1 Results
All of the participants involved in this study stated that they were aware that
professional registration would mean a specific engagement with CPD activities and
an enhanced commitment to LLL. Paramedics in this study believed that they had
become more vigilant about recording CPD in the lead-up to professional registration.
“There's already been talk of some online programs where
we can upload what we've done. At the moment I'm just
using AusMed.com. Every time I get a certificate just
making sure to keep it rather than I guess in the past people
just threw that stuff away. Some people keep it, some
people wouldn't, but knowing now it's important.”
(Lily)
During the interview process, the potential changes in how paramedics may
interact with CPD post registration were explored. Some participants felt the way they
interact with CPD would not change significantly. While others felt there would be
little change other than to ensure that they improved how they seek out and/or record
CPD opportunities.
“I already attend conferences when I can, and I engage in
further learning, and I’m constantly making sure my skills
are up to date, that type of thing. I think that there will
probably be a little bit more urgency for me to do it, because
it is a requirement of our registration and without my
registration, I can’t keep my job.” (Alisha)
“It may not achieve anything personally, but it takes your
hours away. So, you can look for more opportunities. You
become better at logging that activities, because you have
118 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
to log in. I carry an app on the phone, and if I do something,
I log in my hours…. You become a lot better at just logging
it and writing it down.” (Herb)
Like other health professionals, some of the participants expressed the view that
the CPD standards imposed by professional registration were merely providing a way
for the employer to force the cost and the onus, of CPD back onto them.
“I think there’s going to be a drive to make it more your
responsibility to do the paperwork, do the outside training
and what have you…. If there’s this expectation that you
are going to be spending thousands and thousands of dollars
on training yourself, well, no!” (Fred)
“Hopefully work wise there will still be the days that we get
because that is very specific to what we do…. We'll have to
go outside of that and maybe attend a session or a
conference or something to enhance our knowledge,
continue that knowledge.” (Ted)
5.6.2 Discussion
The data for this study was collected prior to the implementation of professional
registration of Australasian paramedics. Participation in CPD is an expectation placed
on all registered health professions. All of the participants in this study stated that they
were aware that there would be a requirement to participant in CPD post professional
registration, irrespective of whether they were practicing in Australia or New Zealand.
Paramedics in the UK and Canada have been registered health professionals for some
time and have been engaging in CPD as per their professional requirement (HCPC,
2017b; Paramedic Association of Canada, 2017b).
Participant Ted spoke of looking outside paramedicine for further CPD
opportunities. This highlights the opportunity for paramedicine to continue to build
upon and offer broader CPD opportunities, and for the paramedic profession to
accredit CPD offerings from other professions. Interprofessional education (IPE) leads
to improved quality of patient care and interprofessional collaboration (Rogers et al,
2017; WHO, 2010). Some Australasian ambulance services, such as Ambulance New
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 119
South Wales, already actively promote IPE opportunities and encourage paramedics
to attend CPD activities within the wider health community.
Previously, there has been a professional expectation that health professionals
would maximise their involvement with CPD when professional registration is
impending (Wotherspoon & McCarthy, 2016; Cleary, Horsfall, O’Hara-Aarons,
Jackson & Hunt, 2011). None of the paramedic participants in this study said that they
had engaged in more CPD than usual because of impending registration. However,
participants in this study had become more vigilant when it came to recording any
CPD involvement that they were doing.
Paramedics who were capturing their CPD evidence prior to registration are
demonstrating that they can adapt to professional standards like other health
professionals. Other professionally registered health practitioners who are required to
capture and provide evidence of their CPD have literature available to assist them to
do this (Middleton & Llewellyn, 2016). Guidance for paramedics who are not yet
recording their evidence is evolving and may prove beneficial.
Similar to other health professionals, some participants felt that professional
registration standards were providing a way for paramedic employers to force the onus
and the cost of CPD back onto the individual (Grehan, Butler, Last & Rainford, 2018).
There was difficultly accepting that to be professional, registered and accountable,
they should be engaging in more than just mandatory training. Even discussion
regarding the expectation of professional bodies that paramedics would engage in self-
directed CPD events and opportunities, there was some pushback from the participants
about this concept. Some participants were reluctant to take self-onus of their CPD.
Participants, like Fred and Ted, expressed concern that this may have a personal cost
associated with it. Personal costs were defined by these participants as either financial
cost or the cost of time.
Further research into the different experience of VET and tertiary educated
paramedics, would enable the different expectations from participants to be better
understood. Alisha and Herb are tertiary educated paramedics. Fred and Ted are
vocationally trained paramedics. This study has opened another avenue of theoretical
interest for future research into possible differences between vocationally trained and
tertiary educated paramedics. Further investigation of the relationship between
120 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
paramedic education and LLL may provide important insights on paramedic attitudes
and perceptions and inform the development of new educational offerings or learning
platforms.
5.7 EXPECTATIONS
5.7.1 Results
When discussing paramedic engagement in CPD, participants in this study
expressed strong views regarding their high expectations of their colleagues, and of
themselves.
“The service needs this [CPD] but I don't think there's space
for the people that are, you know, "I don't really want to."
It's probably not the right job for them anymore. They're
probably the person that will complain because they don't
want to do x, y, z. Used up all their sick leave. So that's
probably not the kind of person that we need to be putting
a lot of focus on anyway. I think the goal is to be
professional, have knowledge and the people that are keen
for that are the people that you want to be paramedics
anyway and they're the ones you want looking after your
family. But the overall vibe here seems to be very positive
because I think people haven't had any CPD. They haven't
had any PDP interviews and they want more knowledge.
It’s definitely good.” (Joseph)
One theme that emerged during the analysis of the expectations that paramedics
have of their peers, was a shift in paramedic professional socialisation culture. The
concept of hierarchical stigmatisation in paramedicine has received little attention in
the literature. However many paramedics have experienced some form of
marginalisation in the workplace due to their lack of clinical or managerial rank. This
study has highlighted evidence of a new form of hierarchical stigmatisation developed
in relation to education. This stigmatisation relates not just to the type of education
(VET or tertiary) a paramedic has undertaken; but also, the level (undergraduate,
postgraduate) and in some cases the prestige beholding to the university where the
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 121
qualification has been awarded; and a general feeling that if a paramedic didn’t engage
in CPD, they were not a good paramedic.
“I feel that being a paramedic is a privilege. We are invited
into a person’s life, at a time that is quite possibly one of
the lowest points of their life. And they’re looking to us to
alleviate their pain and their suffering. And, by getting a
degree from the best university, keeping up to date with best
practice, and the skills that our employer allows us to
undertake when we go on any job, providing that we have
the qualifications to undertake the skills. I think that this a
responsible (SIC) of every paramedic to do that. Seriously.
Or you’re no good.” (Jenni)
“I think CPD is an excellent thing that should be utilized
significantly more than what it is. And I think that those
who aren’t willing to participate probably shouldn’t
continue to hold their position. Because paramedics is not a
static job at all. It’s not like accounting or teaching or being
a mechanic. It’s not static, it changes. If you’re not willing
to keep up on research, and you are not willing to keep up
on developments, and all those types of things, then you
probably don’t have a lot of respect for your job. You
probably shouldn’t be doing it, because you are probably
not a good paramedic.” (Alisha)
Many participants in this study enthusiastically engage in CPD activities.
Paramedics are committed to Lifelong Learning (LLL) and expressed high
expectations of themselves to continue to participate in both mandatory and self-
directed CPD. However, most of the paramedics interviewed were unsure their
employers would or could support their LLL endeavours outside of mandatory training
within the workplace.
“I was talking to nurses and they get so many hours a year
to attend conferences and I believe they get an allowance of
a certain amount of money that they can spend as well as
part of their professional development. I don't believe that
122 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
will happen with us. I think it’s going to be up to us to either
take off an accrued leave day or something to be able to
attend these things. Then it’s going to depend on the
workload and how busy it is and how many people are
already away. It’s very limited. It can be very hit and miss
whether you are able to get a day off. I think it will be a
challenge, let’s put it that way.” (Ted)
5.7.2 Discussion
There is evidence that for a number of years, paramedics have expanded their
skill-set and the qualification standards through employer led reform. However
engagement with CPD and LLL as required professional activity is mixed (ABS,
2012a, ABS, 2017). The nursing literature demonstrates that nurses are expected to
expand their clinical skill-set; engage in higher education and actively participate in
LLL in order to achieve professionalisation (Tanaka, Taketomi, Yonemitsu &
Kawamoto, 2016; Thomas & Richardson, 2016). Literature from the medical
profession also strongly proposes that CPD is driven by multiple factors including
societal expectations and expectations of colleagues and oneself (Filipe, Golnik &
Mack, 2018).
Expectation is what a person may believe is the most likely outcome, and/or what
their attitude about it is (Csikszentmihalyi, 2014). It is reasonable to assume the
expectations a person may have regarding any issue are influenced by personality traits
or belief systems that they may hold. A systematic review by Mirhaghi, Mirhaghi,
Oshio & Sarabian, (2016) concluded that paramedics showed high levels of empathy,
resilience, sensation seeking behaviour and conscientiousness. The review also
determined that paramedics demonstrated low levels of neuroticism, extroversion and
agreeableness (Mirhaghi, Mirhaghi, Oshio & Sarabian, 2016). During the interview
process, the participants portrayed some of these traits, specifically conscientiousness,
when discussing expectations of paramedic CPD.
Expectations of Colleagues and of Self
The literature proposes an interprofessional and collegial expectation that
professionals who work in healthcare will participate in CPD activities (Chong,
Sellick, Francis, & Abdullah, 2011). The participants shared their view on the
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 123
expectations of their colleagues, and of what they believed their colleagues expected
on them, in terms of paramedic engagement in CPD.
Personal traits that may drive paramedics to engage in CPD and better
themselves as an act of professionalism were identified in the analysed findings. These
can arguably be linked back to a paramedic personality trait of conscientiousness
(Mirhaghi, Mirhaghi, Oshio & Sarabian, 2016), and describe an innate and diligent
desire to ensure that they, as paramedics are performing at the top of their clinical
game. In this statement, a participant (Joseph), refers to the type of paramedic that
“you want looking after your family”. Within paramedic culture, it has long been a
badge of honour to have another paramedic tell you that they would want you to look
after their family. Indeed, there is likely no higher honour than to know that your
colleagues would trust you with the lives of the people dearest to them. Linking this
level of personal trust, to professionalism, clinical knowledge and gold standard
patient care, demonstrates the expectations that paramedics place on their colleagues
to proactively engage in CPD.
A major component of the CPD cycle requires the individual to self-assess and
reflect (Tofade, et.al, 2010). Expectations of self can affect how a person self-assess
and reflects on their interaction with CPD (Filipe, Golnik & Mack, 2018). The
literature clearly demonstrates that one of the drivers to engage in CPD is the
individual practitioners desire to develop and maintain a skill set that is beneficial to
the patient (Gent, 2016; Coventry, Maslin-Prothero & Smith, 2015; Martin, 2015). It
is reasonable to extrapolate from this, that the practitioner must also be placing
expectations upon themselves to ensure that they are engaged in the CPD cycle and
maintain a clinically appropriate skill-set. As previously described, many of the
participants in this study had demonstrated active engagement in CPD activities. Most
participants spoke of their commitment to LLL and of their expectations of themselves
to continue to participate in CPD activities that were both mandatory and self-directed.
The paramedic personality traits of high levels of conscientiousness (Mirhaghi,
Mirhaghi, Oshio & Sarabian, 2016) may explain why paramedics place high
expectations on each other to be at the top of their clinical game and why they have
difficulty articulating what their expectations are about how they themselves will
engage with CPD post-registration. Many of the participants talked about what they
expected their relationship with CPD would look like post-registration. However in
124 Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD
most cases, their engagement was directly linked to what their previous experiences
have been.
Of particular importance was the uncertainty of employer support for LLL
endeavours outside of mandatory training. This reflects an ongoing confusion about
what is expected as a professional practitioner when it comes to self-driven education
opportunities, which are self-funded and completed in non-work hours. It remains to
be seen how paramedic employers will assist paramedics to engage in self-directed
CPD events and activities. Some ambulance services have programs and policies that
support paramedics engaging in different forms of CPD (Ambulance Victoria, 2019;
QAS, 2019). Currently paramedics are able to access and apply for research and
professional development grants provided by paramedic associations such as ANZCP
and PA (ANZCP, 2019; PA, 2019). However there appears to be limited uptake by
paramedics. At this time, many paramedics interviewed were uncertain of how their
employers would or could support their LLL endeavours outside of mandatory
training. This may indicate that there is an opportunity for ambulance services to look
at how allied health employers support their staff and enable them to participate in
self-directed CPD opportunities.
Hierarchical Stigmatisation
Another theme that emerged during the analysis of the expectations that
paramedics have of their peers, was a shift in paramedic professional socialisation
culture. Studies have found that tertiary educated paramedics endured stigmatisation
and marginalisation as they assimilated into an ambulance service (Devenish, 2014).
This presumably, occurred due to the cultural differences between university and
ambulance services. That is, ambulance services are paramilitary organisations with
distinct hierarchy, both managerial and clinical (Devenish, 2014, Reynolds, 2008).
Hierarchical stigmatisation in paramedicine has received little attention in the
literature, yet anecdotally the concept of ‘scissors, paper, rank’ exists in many
ambulance services; and many paramedics can recount a time when they have been
subjected to some form of marginalisation due to their lack of clinical or managerial
rank. It appears that along with the professionalisation of paramedicine, a new form of
stigmatisation has developed: the hierarchical stigmatisation of education. It appears
the new trend is to have letters behind ones’ name, rather than rank on your shoulders.
According to the analysed findings, the respect accredited to one taking personal
Chapter 5: Results and Discussion of the Australasian Paramedic Relationship with CPD 125
responsibility for continuing education and actively engaging in CPD activities
appears to be the way of the future as one avenue of retaining the respect of your peers.
5.8 SUMMARY
This chapter described participants’ perspectives on paramedic engagement in
CPD. The experiences of tertiary educated and vocationally trained paramedics, in
relation the facilitators of and barriers against their engagement in CPD activities, has
been examined and discussed. Perceived differences between LLL and mandatory
training have been conceptualised, and perceived implications of paramedic
registration are identified. Finally, the expectations that paramedics have of themselves
and their colleagues in relation to participation in CPD activities and opportunities
have been explored. The next chapter summarises the research findings and results,
then discusses the significance and limitations of the study.
126 Chapter 6: Conclusions
Chapter 6: Conclusions
Chapter Six discusses the implications of the research findings from this study
and presents a framework based on these findings for paramedic CPD. The
significance of this research is described and opportunities to develop new approaches
to paramedic CPD are explored. The limitations of this study are described. Finally,
conclusions arising from the results of this study are presented.
6.1 SUMMARY OF THE RESEARCH FINDINGS
This research study investigated paramedic CPD. The research questions posed
in order to explore this topic were divided into main questions and sub-questions. The
main research questions were as follows:
• How do Australasian paramedics engage with CPD?
• What factors influence CPD in the Paramedicine discipline?
• What do Australasian paramedics perceive to be facilitators of their
engagement in CPD?
• What do Australasian paramedics perceive to be barriers that prevent their
engagement in CPD?
The sub-questions were:
• What do Australasian paramedics understand the concept of CPD to entail?
• What affects paramedic attitudes towards participating in CPD?
• What expectations do Australasian paramedic have of themselves and their
colleagues?
• What is the relationship between paramedic CPD, professionalism and clinical
competence?
• What influence do external bodies such as AHPRA, CAA, PA and ANZCP
have on paramedic CPD?
• What do paramedics perceive to be the barriers that prevent them and
facilitators that encourage them to engaging in CPD activities?
Chapter 6: Conclusions 127
• Does previous level of education correlate level of personal engagement in
LLL and CPD?
• What are Australasian paramedic perceptions about paramedic registration;
CPD and being professional?
The study answered these main and sub-questions, revealing several major
outcomes, these being:
1. Paramedics need to understand that taking personal onus for their engagement
in CPD and LLL, will assist in allowing them have positive experiences when
engaging in these types of activities. The literature clearly states that positive
CPD experiences lead to continued engagement in CPD activities, which is
highly correlated with practitioner competence and improved patient
outcomes.
2. Paramedic employers need to develop a stronger conceptual understanding
how CPD relates to not only the development of, but also the
professionalisation of their workforce; and provide appropriate opportunities.
The findings of this study indicate paramedics feel that the employer is only
concerned with ‘ticking the boxes’ to ensure legislative compliance, as
opposed to developing clinical competence and high quality CPD.
3. Professional bodies need to upgrade their CPD offerings and facilitate access
to other opportunities outside the paramedic profession. The analysed
findings of this study indicate current paramedic CPD modes of offering are
limited and possibly favour those in the metropolitan setting, and are not
conducive to shift-work.
Furthermore, this study detailed how Australasian paramedics were credentialed
either through a vocational educational training or a tertiary qualification pathway. The
findings highlighted that paramedic education pathways (VET or tertiary) did not have
a significant impact on engagement in CPD. Regardless of how the participants
qualified, their educational level or amount of self-directed CPD they had engaged in,
participants in this study initially equated the concept of paramedic CPD to mean
mandatory training. Almost all paramedics who participated in this study actively
engage in some form of LLL. For the purposes of this study, LLL has been defined as
both formal and informal learning opportunities that assist the continued acquisition,
128 Chapter 6: Conclusions
development and improvement of knowledge, skills or abilities that can be utilised in
both the learners’ personal or professional life (Jaiswal, 2017; Sockalingam et.al, 2017;
Kemp & Baker, 2013; Currie, Lockett, Finn, Martin & Waring, 2012; Wyatt, 2003).
The concept of LLL can be considered a 'philosophy of practice' and the skills
associated with it can be learned.
Contemporary theories of learning view CPD as the integration of external
processes (i.e. social, cultural, environmental) and internal processes (i.e.
psychological, motivational) for acquisition of knowledge which will benefit the
individual professionally or personally (Illeris, 2018). The results of this study indicate
a possible juxtaposition between LLL in an ideal world and what it currently
constitutes in reality for paramedics. Notably, during the interview process it was noted
that some participants required further explanation of LLL to enhance their
understanding. Thus demonstrating that perhaps this is a skill set that could be more
robustly developed within the paramedic paradigm. It was evident by the end of the
interview process and after reflecting on their personal relationships with LLL,
participants in this study had an improved understanding of what constitutes CPD. This
ability to conceptualise CPD as it is described by health literature, demonstrates that
Australasian paramedics possibly are able to think critically beyond the clinical
reasoning skills previous paramedic CPD studies have afforded them.
Many of the facilitators and barriers of CPD discussed in extant health profession
literature apply to paramedics in this study. One unique finding of the study not
discussed in allied literature was fear of not being a perfect paramedic, and looking
inept to peers and other healthcare professionals. However, overwhelmingly this study
showed paramedics are looking for CPD that includes a clear learning outcome, is
interesting and professionally relevant, and both time and cost effective. Correlating
with the rural medical and nursing literature, paramedics are also diverse learners who
want CPD to be delivered in a blended learning environment (online and face-to-face).
The findings of this study highlight that paramedics are similar to other health
professionals in that they can be suspicious of organisational motives behind
mandatory CPD.
Unlike literature pertaining to other healthcare practitioners, there appears to be
limited evidence in this study to support career progression being positively linked to
Chapter 6: Conclusions 129
paramedic engagement in CPD. Moreover, the paramedic experience, in this study
relating to career progression was reported as being more negative in nature. This may
be the case at present, however it could possibly change with the increasing
expectation of the level of qualification required of individuals in management
positions within ambulance services. Tacit knowledge is described in the literature as
an advantageous way to transfer knowledge between employees (Ranucci & Souder,
2015). The unique working environment of paramedicine appears, on face-value to be
facilitator of tacit knowledge transfer from one paramedic to another. Despite tacit
knowledge being recognised in the nursing literature as resulting in a positive influence
on processional and reflective practice (Hayes, Fox, Scott-Thomas & Graham, 2018;
Brenner, 1984), the results from this study appear to indicate that tacit knowledge is
undervalued could possibly be better incorporated into the current paramedic CPD
framework.
Paramedics reported, in this study, a different personal experience with CPD
involvement in the lead up to professional registration, compared to that of other health
professions. Despite none of the paramedics in this study engaging in more CPD in the
lead up to registration, they had become more attentive when documenting CPD
evidence. Paramedics from a vocationally trained background were possibly more
sceptical of CPD requirements for professional registration due to the perception that
paramedic employers were simply ‘offloading’ the onus of responsibility on acquiring
registration to the individual. Registration is the obligation of the individual not the
employer. Furthermore, in relation the professional registration, this study may
indicate that paramedics did not appear to identify conceptual links between AHPRA
and paramedic professional bodies in relation to CPD opportunities and requirements.
Regardless of whether they came from a vocationally trained or tertiary
background, it appears paramedics reflect the allied literature through their
commitment to engage in CPD stemming from a desire to provide the best patient care
possible. In this regard, the analysed findings indicate paramedics expressed high
expectations of both themselves and their peers. These expectations opened some
theoretical avenues of interest. The shift in paramedic professional socialisation
culture which uses education to form a new architype of hierarchical stigmatism within
the paramedic culture is therefore of particular significance.
130 Chapter 6: Conclusions
The results of this study confirmed that while paramedics share common traits
with other health professionals, it is not necessarily readily transferable. The nuances
of the paramedic paradigm mean that other CPD frameworks are not necessarily a
perfect fit for paramedicine. Frameworks such as those developed by Kennedy (2005)
which organises CPD models, along a spectrum demonstrating the capacity for
transformative practice and professional autonomy within each of the models, are
possibly not entirely transferable to current paramedic practice. Conversely, the
framework developed by Filipe, Golnik & Mack (2018), which incorporates LLL,
political, social, economic and professional influences, CME, PDP, mandatory
requirements, and CBCPD has levels of complexity designed for medicine. This model
is highly developed and meticulous, which works well for the health professionals that
is was designed for. However, some of the levels of detail encompassed in this model
may not be relevant to paramedicine at this juncture. Nonetheless, the work of Filipe
and colleagues provides a positive direction and insight for the development of a
paramedic specific framework. The justification being that paramedics’ work in a
dynamic environment that is subjected to unique enculturation factors and paramilitary
hierarchical structures.
Paramedics have attained their initial qualifications in varied ways (pre-VET,
VET and university educated), and they have increased their qualifications in varied
ways (clinical, managerial and academia). Longer serving paramedics have
experienced CPD in the form of mandatory programs developed by the ambulance
service, which facilitated change in scope of practice, organisational policy, or
procedure. This form of CPD was always done during work hours, facilitated and
financed by the employer. In more recent years, paramedics have either commenced
their working career with an undergraduate degree in paramedicine or extended their
academic qualifications (i.e. bridged from diploma to degree in paramedicine or
completed post graduate qualifications). Any or all of these elements appear to be
incorporated into paramedic attitudes and perceptions; and can possibly influence the
way that they experience and engage in adult learning, which requires the development
of a CPD framework specific to paramedicine.
After analysing and evaluating the research findings, the following paramedic
specific CPD framework is proposed. Paramedic CPD encompasses activities that are
mandatory or self-directed and utilise CPD models that are transmissive, malleable or
Chapter 6: Conclusions 131
transformative. These activities occur in conjunction with some form of personal
reflection regarding future learning requirements, goal setting, planning, engagement,
achievement, and further personal reflection. Paramedic CPD assists the development
or maintenance of knowledge, skills, competence or professional expertise. It can be
influenced by professional, economic, political and social realities; and demonstrates
commitment to the delivery of gold-standard patient care, and/or advancement of the
paramedic profession, and/or a commitment to LLL. Figure 7, on the following page,
represents the proposed framework for paramedic CPD.
132
Cha
pter
6:C
oncl
usio
ns
Figu
re 7
.Pro
pose
d pa
ram
edic
CPD
fram
ewor
k
The
prop
osed
fram
ewor
k fo
r par
amed
ic C
PD is
ada
pted
from
Fili
pe, G
olni
k &
Mac
k (2
018)
and
Ken
nedy
(200
5).
Bibliography 133
The proposed framework for paramedic CPD incorporates the findings of this
research study with the work of Kennedy (2005) by integrating CPD models which are
transmissive, malleable and transformative. The outcomes of engaging in the CPD
model lead the paramedic towards increasing their capacity for professional autonomy.
It should be noted that professional autonomy is different to paramedic scope of
practice. The framework does not endorse paramedics working outside of their
employers clinical practice guidelines. The proposed framework also integrates the
work of Filipe, Golnik, & Mack, (2018), by extending on the factors that influence
change and incorporate the five measurable LLL key competencies for clinical
practice. Finally, the framework articulates the relationship between initiating a PDP,
implementing and engaging in mandatory CPD, then incorporating learning into
professional practice. The overall cycle demonstrates commitment to LLL and leads
to a commitment towards a gold standard of patient care.
6.2 KEY CONCLUSIONS AND IMPLICATIONS FOR THE FUTURE
As no published studies on Australasian paramedic attitudes and perceptions
about CPD exist, this research has contributed new knowledge and filled a gap in the
profession’s understanding of the attitudes and perceptions of paramedics to the level
of CPD and LLL required by professional registration. The study has also opened some
avenues for further research. This section explores these potential avenues. It also
outlines the key conclusions of this study.
The conclusions that can be drawn from this research indicate paramedics should
increase their understanding of CPD and LLL in order to ensure that they have positive
experiences when engaging in CPD. Furthermore, Paramedicine in Australasia is
changing as a result of the implementation of professional registration, and currently,
there is no specific framework for accrediting paramedic CPD activities. Of particular
note, there is no current structure to ascribe CPD points/values/worth, despite
opportunity for paramedic professional bodies to engage with AHPRA to develop a
framework for accrediting paramedic CPD now exists.
The study has resulted in the development of a new conceptual understanding of
LLL in relation to paramedics that informs current paramedic education practices. It
highlights that different delivery methods of CPD should be investigated by CPD
providers. As such it is now time to look forward and develop CPD programs that go
134 Bibliography
beyond topics such as CPR or intubation, and add learning activities that are relevant
to the expanding roles, responsibilities and development of professional paramedics.
As registration continues to change the shape of the paramedic profession, ambulance
services may not be the sole preferred employer of paramedics. Thus CPD activities
need to cater to the needs of paramedics working in inter-disciplinary environments
and/or independent or privately run paramedical services.
The concept of ‘self-onus’ in relation to CPD refers not only to the individual
paramedic taking responsibility for their learning. The paramedic profession also
needs to take some responsibility for approving the value of CPD pathways and
opportunities. It is recommended that professional bodies (i.e. Paramedics Australasia,
and the Australian and New Zealand College of Paramedicine) take on some of the
responsibility of deciding the value of CPD opportunities. The Australasian paramedic
profession must examine the progression of other like health professions and registered
paramedics from around the world, in order to determine how to move forward now
that they are registered professionals.
6.3 LIMITATIONS OF THIS STUDY
There may possibly be several limitations of this study. The study’s recruitment
strategy required participants to self-nominate. Thus, despite being advertised through
Australasian paramedic associations and being inclusive of a large proportion of the
Australasian paramedic population, it was a small study that possibly only included
paramedics with strong views, either positive or negative, about CPD. This type of
cohort is an expectation of qualitative research and the limitations of the type of
participants was mitigated by the researcher following participant recruitment
processes and a well-recognised methodology (constructivist grounded theory),
thereby not adversely affecting the richness of the data. As this was a small study, the
finding reflect the experiences, attitudes and perceptions of the participants (N=10)
and not the wider Australasian paramedic community. Therefore the views portrayed
in this study are of the participants and not the paramedic profession as a whole.
The researcher’s lived experience could be regarded as a limitation of the study.
In keeping with the constructivist grounded theory process as described by Charmaz
(2014), the researcher acknowledged their reflexivity in relation to this study. The
researcher’s previous experience as a paramedic arguably strengthens the analysis of
Bibliography 135
the data, as it provides a conduit of understanding of paramedic culture and
paramilitary modus operandi.
Constructivist Grounded Theory was chosen as the most appropriate research
methodology, as it has been utilised effectively in health and education disciplines
(Mills, Bonner & Francis, 2006). Epistemological assumptions were continually
assessed and reassessed as part of the research process as they can influence how the
researcher codes data, write memos, and conducts theoretical sampling and sorting
(Charmaz, 2017). The researcher utilised experience and engagement in paramedic
CPD to in analyse and interpret the qualitative data through the lens of her own reality
which ensures a high degree of trustworthiness, reliability and transferability
(Klakegg, 2015; Lincoln & Guba, 1985). Furthermore, an inter-coder agreement
including supervisory checks was also implemented.
The use of semi-structured interviewing as a method for data collection could
also be viewed as a possible limitation of the study. However, using semi-structured
interviews is in keeping with like studies. It is possible that some participants may
have embellished their experiences in this study in an attempt to demonstrate superior
understanding of, or engagement in paramedic CPD. Therefore, Charmaz (2014) and
Minichiello, Aroni and Neville-Hays (2008) were referred to when developing an
interview guide, and interview techniques in an attempt to minimise this limitation.
6.4 INFLUENCERS OF CHANGE
A number of influencers of change have been identified as a result of this study,
which may inform research, policy, CPD opportunities or curriculum development.
6.4.1 Paramedic Understanding of CPD
There appears to be a ‘strange tension’ within the paramedic discipline regarding
their understanding of CPD and LLL. Despite paramedics engaging in external CPD,
it appears that they do not always recognise their external academic pursuits as
contributing to their CPD. Paramedics need to increase their understanding of what
constitutes CPD and LLL, so that they can begin to talk more self-onus of their learning
opportunities.
136 Bibliography
6.4.2 Employer Understanding of CPD Facilitation of External Opportunities
Paramedic employers need to understand CPD and assist in the provision of
appropriate internal and external CPD opportunities. Ambulance services are not
solely responsible for paramedic CPD, however employer facilitation of external CPD
opportunities can enhance paramedic skills and knowledge, which can ultimately lead
to improved patient experience and outcomes. Employer facilitation of external
opportunities may occur in a variety of ways, including, but not limited to:
• Internal policies/scheme/programs that support paramedics enrolling in tertiary
qualifications. Some Australasian ambulance services currently provide
either/or financial assistance, or time off in lieu to assist paramedics who are
studying a tertiary qualification.
• Paramedic employers can provide information to staff via email and staff notice
boards, about upcoming (non-mandatory) CPD events that are externally
facilitated, such as paramedic conferences or IPL opportunities.
• Ambulance services could enable paramedics to utilise roster changes or leave
balances to enable them to attend external CPD opportunities.
6.4.3 Professional Bodies
Professional bodies need to upgrade their CPD offerings and facilitate access to
other opportunities outside the paramedic profession. The professional bodies
contacted during the course of this study currently offer some paramedic CPD
opportunities through a variety of modalities. Yet, these offerings appear to have a
smaller uptake by paramedics than would be expected. By increasing their
understanding of how paramedics prefer to engage in CPD and the types of activities
(both paramedic and non-paramedic specific) they favour, professional bodies could
tailor CPD opportunities.
6.4.4 IPL Opportunities
Some paramedics are already engaging in interprofessional learning (IPL)
opportunities. Further research into IPL opportunities and implications need to be
undertaken in order to maximise CPD that is inclusive of interprofessional education
and collaborative practice. The World Health Organization (WHO) estimate that over
4 million additional health care workers are required worldwide, and actively
encourage IPL as a means to build multi-disciplinary health service teams to assist in
Bibliography 137
providing improved health care (WHO 2013; WHO, 2010). IPL enables opportunities
for health practitioners to share or build upon their clinical experience, competence,
expectations and understanding of other health professionals. Research demonstrates
that undergraduate students who engage in IPL, graduate with higher interprofessional
abilities and communication skills (WHO, 2013). Registered paramedics may also
hold registration in other health professions, such as nursing. Thus, enabling paramedic
CPD activities to include IPL opportunities can benefit the paramedic profession and
improve health care quality.
6.4.5 CPD Modalities
Paramedics actively engage in all modalities of CPD opportunities, with no real
preferred style of presentation. Providers of paramedic CPD should ensure that content
is delivered via one or more of these avenues, to maximise paramedic engagement.
However, it is possible that preference of modality could be affected by the age of the
paramedic and the area they work in (metropolitan/rural/remote), and/or the service
that they work for. Thus, warranting further research which could provide more insight
into how to ensure maximum uptake of a particular CPD activity.
6.5 CONCLUSION
Through the utilisation of constructivist grounded theory methods based on the
work of Charmaz (2014), and models of CPD, workplace training, and adult education
theory, this thesis has explored Australasian paramedic attitudes and perceptions about
continuing professional development. The findings of this thesis report that
paramedics actively engage in some form of LLL. Their understanding of what
constitutes CPD is of particular interest, as there appears to be a disparity between the
pursuit of educational or clinical qualifications and the commitment to processes of
formal and informal LLL opportunities that are linked to practitioner competence and
professionalism, and the delivery of gold standard patient care.
Paramedics have preferences in relation to the delivery of CPD, preferring a
blended learning environment. Similarly to other health professionals, paramedics
appear to be suspicious of organisational motives behind employer led CPD. However,
unlike the nursing, medicine and allied health literature, Australasian paramedics
appear to have not significantly increased their involvement in CPD in conjunction
138 Bibliography
with the implementation (Australia) or imminence (New Zealand) of professional
registration, other than becoming more vigilant when recording CPD activities.
Of particular significance, an unexpected finding in this study was the
emergence of a new cultural theme of intellectual/academic hierarchical
stigmatisation. Paramedic culture has a history of rank hierarchical stigmatisation,
which has been examined in the literature. However, this study revealed that education,
and more specifically continued education and attainment of qualifications throughout
one’s career, is a new form of hierarchical stigmatization. While the incidence of
paramedics engaging in CPD and LLL does not appear to have changed significantly,
some older paramedics may experience fear about engaging in CPD/LLL. Education
is now possibly used as another hierarchical phenomenon within the paramilitary
paramedic culture, where rank and clinical scope of practice matter. The hierarchical
phenomenon may widen the gap between paramedics who are tertiary qualified and
long serving (pre)VET paramedics that historically encountered limitations to
accessing educational opportunities and qualifications. This finding highlights a shift
in the paramedic culture.
The results of this study may inform research, policy or curriculum development
within the paramedic discipline. Of significance, the knowledge gained through
understanding the attitudes and perceptions of the participants, could provide insight
to businesses providing CPD, regulatory authorities, paramedic professional
organisations, and Australasian ambulance services when developing or designing
CPD activities/opportunities for Australasian paramedics.
The study has highlighted some areas for further exploration to increase our
understanding of paramedic engagement in CPD. One area of further exploration is
the strategic development of best practice paramedic CPD by looking to other health
professions for guidance in making effective and timely changes in how CPD is
managed within a profession. In doing so, it negates the need for paramedicine to
‘reinvent the wheel’, and enables the profession to concentrate resources into proven
and timely measures. The concept of intellectual hierarchal stigmatisation also requires
further investigation, as it may lead to uber/over specialisation, which is not conducive
to the paramedic profession. Therefore, further research into this new paramedic
phenomenon, and comparisons with experiences in the medical profession, may lead
to further insights that have not been explored within this study.
Bibliography 139
Bibliography
ACT Ambulance Service. (2017). Careers - Emergency Operations. Retrieved 4 May 2017, from http://esa.act.gov.au/actas/
Adams, J., Sirel, J., Marsden, K., & Cobbe, S. (1997). Heartstart Scotland: The use of paramedic skills in out of hospital resuscitation. Heart, 78(4), 399-402. doi: 10.1136/hrt.78.4.399
Ahl, C., Hjälte, L., Johansson, C., Wîreklint-Sundström, B., Jonsson, A., & Suserud, B. (2005). Culture and care in the swedish ambulance services. Emergency Nurse, 13(8), 30-37. doi: 10.7748/en2005.12.13.8.30.c1203
Alexander, M., Weiss, S., Braude, D., Ernst, A., & Fullerton-Gleason, L. (2009). The relationship between paramedics' level of education and degree of commitment. The American Journal Of Emergency Medicine, 27(7), 830-837. doi: 10.1016/j.ajem.2008.06.039
Alsop, A. (2000). Continuing Professional Development: A Guide for Therapists (1st ed.). Malden, Mass; Oxford: Blackwell Science.
Ambulance Tasmania. (2017). Employment. Retrieved 4 May 2017, from http://www.ambulance.tas.gov.au/employment
Ambulance Victoria. (2017). Careers. Retrieved 4 May 2017, from http://www.ambulance.vic.gov.au/careers
Ambulance Victoria. (2019). Research. Retrieved 23 January 2019, from https://www.ambulance.vic.gov.au/about-us/research/
Aparicio, A. (2015). Continuing Professional Development for doctors, certification, licensure and quality improvement. A model to follow?. Educación Médica, 16(1), 50-56. doi: 10.1016/j.edumed.2015.04.008
Australian Government. (2017). Ambulance Services. Retrieved 2 January 2019, from https://www.pc.gov.au/research/ongoing/report-on-government-services/2017/health/ambulance-services/rogs-2017-volumee-chapter11.pdf
Australian Health Practitioner Regulation Agency (AHPRA) (2017a). Registration standard. Retrieved 15 January 2017, from http://www.ahpra.gov.au/Registration/Registers-of-Practitioners.aspx
Australian Health Practitioner Regulation Agency (AHPRA) (2017b). Paramedic Registration. Retrieved 25 October 2017, from http://www.paramedicineboard.gov.au/Registration/FAQ-for-paramedics.aspx
Australian Health Practitioner Regulation Agency (AHPRA) (2017c). Professional Standards – Nursing and Midwifery. Retrieved 9 November 2017, from http://www.ahpra.gov.au/competancy-standards
Australian Health Practitioner Regulation Agency (AHPRA) (2018a). Paramedicine Board of Australia: Professional Standards. Retrieved 14 September 2018, from http://www.paramedicineboard.gov.au/Professional-standards.aspx
140 Bibliography
Australian Health Practitioner Regulation Agency (AHPRA) (2018b). Paramedicine Board of Australia: About. Retrieved 14 September 2018, from http://www.paramedicineboard.gov.au/about.aspx
Australian Health Practitioner Regulation Agency (AHPRA) (2018c). Registers of Practitioners. Retrieved 20 September 2018, from http://www.ahpra.gov.au/Registration/Registers-of-Practitioners/professions-and-divisions.aspx
Australian Health Practitioner Regulation Agency (AHPRA) (2018d). Paramedicine Board of Australia: Paramedic Registration. Retrieved 11 Octobers 2018, from http://www.paramedicinebaord.gov.au/Registration.aspx
Australian Health Practitioner Regulation Agency (AHPRA) (2018e). Paramedicine Board of Australia: Continuing Professional Development Registration Standard. Retrieved 11 October 2018, from http://www.paramedicineboard.gov.au/Professional-standards/Registration-standards/CPD.aspx
Australian & New Zealand College of Paramedicine (ANZCP) (2017). Membership Options. Retrieved 7 July 2017, from http://www.anzcp.org.au/membership
Australian & New Zealand College of Paramedicine (ANZCP) (2018). Member Committees. Retrieved 16 October 2018, from http://www.anzcp.org.au/member-committees/
Australian & New Zealand College of Paramedicine (ANZCP) (2018). Research Grants. Retrieved 9 January 2019, from https://www.anzcp.org.au/research/grant
Australian Bureau of Statistics. (2012a). 6202.0- Labour Force, Australia. Retrieved 13 July 2017 from http://www.abs.gov.au/
Australian Bureau of Statistics. (2016). 6202.0- Labour Force, Australia. Retrieved 23 November 2017 from http://www.abs.gov.au/
Australian Bureau of Statistics. (2017). 3101.0 – Australian Demographic Statistics. Retrieved 13 July 2017 from http://www.abs.gov.au/ausstats/abs@.nsf/mf/3101.0
Australian Bureau of Statistics. (2018). 6227.0.30.001 – Microdata; Education and Work. Retrieved 29 October 2018, fromhttp://www.abs.gov.au/ausstats/abs@.nsf/mf/6227.0.30.001
Australian Government (n.d). Australian Institute of Health and Welfare. Retrieved 7 September 2018 from http://www.aihm.gov.au/reports/workforce/medical-practioners-workfoce-2015/contents/how-many-medical-practioners-are-there
Australian Health Ministers’ Advisory Council. (2012). Consultation Paper: Options for regulation of Paramedics. Retrieved 30 March 2016, from http://www.paramedics.org/content/consulation-paper-paramedic-registration.pdf
Aveling, E., Martin, G., Herbert, G., & Armstrong, N. (2017). Optimising the community-based approach to healthcare improvement: Comparative case
Bibliography 141
studies of the clinical community model in practice. Social Science & Medicine, 173, 96-103. doi: 10.1016/j.socscimed.2016.11.026
Banks, J., & Smyth, E. (2015). ‘Your whole life depends on it’: Academic stress and high-stakes testing in Ireland. Journal Of Youth Studies, 18(5), 598-616. doi: 10.1080/13676261.2014.992317
Batt, A., Morton, J., Kloepping, K., Buick, J., & Todd, J. (2015). The evolution of the paramedic. Canadian Paramedicine, 38, 22-25. Retrieved from http://www.reseachgate.net/publications/28172003
Benner, P. (1984). From novice to expert. Menlo Park.
Bigham, B., Kennedy, S., Drennan, I., & Morrison, L. (2013). Expanding paramedic scope of practice in the community: A systematic review of the literature. Prehospital Emergency Care, 17(3), 361-372. doi: 10.3109/10903127.2013.792890
Bilecki, K. (2012). Paramedicine: recognition beyond algorithms. The Meducator, 1(16). Retrieved from http://www.journals.mcmaster.ca/meducator/article/download/750/717
Bolino, M., & Grant, A. (2016). The bright side of being prosocial at work, and the dark side, too: A review and agenda for research on other-oriented motives, behavior, and impact in organizations. The Academy Of Management Annals, 10(1), 599-670. doi: 10.1080/19416520.2016.1153260
Bressan, V., Tolotti, A., Barisone, M., Bagnasco, A., Sasso, L., Aleo, G., & Timmins, F. (2016). Perceived barriers to the professional development of modern nursing in Italy – A discussion paper. Nurse Education In Practice, 17,52-57. doi: 10.1016/j.nepr.2016.02.007
Brink, P., Bäck-Pettersson, S., & Sernert, N. (2012). Group supervision as a means of developing professional competence within pre-hospital care. International Emergency Nursing, 20(2), 76-82. doi: 10.1016/j.ienj.2011.04.001
Brown, C. (2002). Cost effectiveness of continuing professional development in health care: A critical review of the evidence. British Medical Journal, 324(7338), 652-655. doi: 10.1136/bmj.324.7338.652
Brooks, I., Grantham, H., Spencer, C., & Archer, F. (2018). A review of the literature: The transition of entry-level paramedic education in Australia from vocational to higher education (1961-2017). Australasian Journal Of Paramedicine, 15(2). http://dx.doi.org/10.33151/ajp.15.2.584
Burford, B., Morrow, G., Rothwell, C., Carter, M., & Illing, J. (2014). Professionalism education should reflect reality: Findings from three health professions. Medical Education, 48(4), 361-374. doi: 10.1111/medu.12368
Burstow, B., & Winch, C. (2013). Providing for the professional development of teachers in England: A contemporary account of a government-led intervention. Professional Development In Education, 40(2), 190-206. doi: 10.1080/19415257.2013.810662
142 Bibliography
Bury, G., Janes, D., Bourke, M., & O’Donnell, C. (2007). The advanced paramedic internship: An important clinical learning opportunity. Resuscitation, 73(3), 425-429. doi: 10.1016/j.resuscitation.2006.09.017
Canadian Medical Association. (2011). Guidelines for Paramedic Programs. Retrieved 5 November 2017, from http://www.cma.ca/assets/assets-library/document/en/about-us/guidelines-nocp-2011-req-e.pdf
Campeau, A. (2015). Why Paramedics require "theories-of-practice". Australasian Journal Of Paramedicine, 6(2). http://dx.doi.org/10.33151/ajp.6.2.451
Casey, D., & Clark, L. (2009). Professional development for registered nurses. Nursing Standard, 24(15), 35-38. doi: 10.7748/ns2009.12.24.15.35.c7438
Chan, A., Chair, S., Sit, J., Wong, E., Lee, D., & Fung, O. (2016). Case-based web learning versus face-to-face learning. Journal Of Nursing Research, 24(1), 31-40. doi: 10.1097/jnr.0000000000000104
Charman, S. (2013). Sharing a laugh. International Journal Of Sociology And Social Policy, 33(3/4), 152-166. doi: 10.1108/01443331311308212
Charmaz, K. (2000). Grounded theory: objectivist and constructivist methods. In N. Denzin & Y. Lincoln (Eds.). Handbook of interview research (2nd ed., pp. 509-535). Thousand Oaks, CA: Sage.
Charmaz, K. (2012). The power and potential of grounded theory. Medical Sociology Online, 6(3), 2-15. Retrieved from http://pdfs.semanticscholar.org/93d2/8c60474e1cedd4464c5b24ae0af2efbc090.pdf
Charmaz, K. (2014). Constructing grounded theory (2nd ed.). London: Sage.
Charmaz, K. (2017). Special invited paper. International Journal Of Qualitative Methods, 16(1), 160940691771935. doi: 10.1177/1609406917719350
Chernikova, I., & Chernikova, D. (2016). Evolutional epistemology and evolutional constructivism as cognitive practices of the modern science. SHS Web Of Conferences, 28, 01020. doi: 10.1051/shsconf/20162801020
Chong, M., Sellick, K., Francis, K., & Abdullah, K. (2011). What influences malaysian nurses to participate in continuing professional education activities?. Asian Nursing Research, 5(1), 38-47. doi: 10.1016/s1976-1317(11)60012-1
Cleary, M., Horsfall, J., O’Hara-Aarons, M., Jackson, D., & Hunt, G. (2011). The views of mental health nurses on continuing professional development. Journal Of Clinical Nursing, 20(23-24), 3561-3566. doi: 10.1111/j.1365-2702.2011.03745.x
Clompus, S. R., & Albarran, J. W. (2016). Exploring the nature of resilience in paramedic practice: A psycho-social study. International emergency nursing, 28(1-7). http://dx.doi.org/10.1016/j.ienj.2015.11.006
COAG Health Council. (2016). Incorporating the Australian Health Workforce Ministerial Council Communique. Retrieved 26 January 2016, from
Bibliography 143
http://www.health.gov.au/internet/main/publishing.nsf/content/4EF9C42740F7FC4ECA258045001C0397/$File/dept006.pdf
Collective professional knowledge. (2000). Medical Education, 34(7), 505-506. doi: 10.1046/j.1365-2923.2000.00712.x
Cooper, S., & Grant, J. (2009). New and emerging roles in out of hospital emergency care: A review of the international literature. International Emergency Nursing, 17(2), 90-98. doi: 10.1016/j.ienj.2008.11.004
Cooper, S., O'Carroll, J., Jenkin, A., & Badger, B. (2007). Collaborative practices in unscheduled emergency care: Role and impact of the emergency care practitioner qualitative and summative findings. Emergency Medicine Journal, 24(9), 625-629. doi: 10.1136/emj.2006.043943
Corbin, J., & Strauss, A. (2015). Basics of Qualitative Research: Techniques & Procedures for Developing Grounded Theory (4th ed.). Thousand Oaks: Sage Publications Inc.
Council of Ambulance Authorities. (2009). Discussion Paper for the Review of the Report on Government Services. Retrieved 28 February 2017, from http://caa.net.au/images/stories/CAA sumbission review RoGS july 2009.pdf
Council of Ambulance Authorities (2013). Paramedic Professional Competency Standards, version 2.2. Retrieved 31 October, 2017 from: https://www.caa.net.au/images/documents/resources for universities/Paramedic
Professional Competency Standards V2.2 February 2013 PEPAS.pdf
Coventry, T., Maslin-Prothero, S., & Smith, G. (2015). Organizational impact of nurse supply and workload on nurses continuing professional development opportunities: An integrative review. Journal Of Advanced Nursing, 71(12), 2715-2727. doi: 10.1111/jan.12724
Cruess, R., Cruess, S., & Steinert, Y. (2016). Teaching Medical Professionalism.Cambridge: Cambridge University Press.
Csikszentmihalyi, M. (2014). Toward a psychology of optimal experience. In Flow and the foundations of positive psychology (pp. 209-226). Springer, Dordrecht.
Currie, G., Lockett, A., Finn, R., Martin, G., & Waring, J. (2012). Institutional work to maintain professional power: Recreating the model of medical professionalism. Organization Studies, 33(7), 937-962. doi: 10.1177/0170840612445116
Davis, D., & McMahon, G. (2018). Translating evidence into practice: Lessons for CPD. Medical Teacher, 1-4. doi: 10.1080/0142159x.2018.1481285
Day, C., & Sachs, J. (2004). International handbook on the continuing professional development of teachers. Maidenhead: Open University Press.
DeLuca, C., Bolden, B., & Chan, J. (2017). Systemic professional learning through collaborative inquiry: Examining teachers' perspectives. Teaching And Teacher Education, 67, 67-78. doi: 10.1016/j.tate.2017.05.014
144 Bibliography
Dent, J., Harden, R., & Hunt, D. (2017). A practical guide for medical teachers.Elsevier Health Sciences.
Devenish, A. S. (2014). Experiences in becoming a paramedic: A qualitative study examining the professional socialisation of university qualified paramedics. (Doctorial dissertation, Queensland University of Technology).
Dew, K. (2017). The Regulation of practice: practitioners and their interactions with organisations. Routledge.
Dickerson, P., Lubejko, B., & Summers, A. (2015). Continuing professional development in Australia: Barriers and support. The Journal Of Continuing Education In Nursing, 46(8), 337-339. doi: 10.3928/00220124-20150721-11
Donaghy, J. (2008). Higher education for paramedics—why?. Journal Of Paramedic Practice, 1(1), 31-35. doi: 10.12968/jpar.2008.1.1.42030
Draucker, C., Martsolf, D., Ross, R., & Rusk, T. (2007). Theoretical sampling and category development in grounded theory. Qualitative Health Research, 17(8), 1137-1148. doi: 10.1177/1049732307308450
Duncombe, D. (2018). A multi-institutional study of the perceived barriers and facilitators to implementing evidence-based practice. Journal Of Clinical Nursing, 27(5-6), 1216-1226. doi: 10.1111/jocn.14168
Dworkin, S. (2012). Sample size policy for qualitative studies using in-depth interviews. Archives Of Sexual Behavior, 41(6), 1319-1320. doi: 10.1007/s10508-012-0016-6
Eburn, M., & Townsend, R. (2014). Professional Discipline for Registered Health Professionals: Lessons for Australian Paramedics. Retrieved 11 January 2019, from http://hdl.handle.net/1885/51222
Edgar, A. (2014). Professionalism in Healthcare. Handbook of the Philosophy of Medicine, 1-21. doi: 10.1007/978-94-017-8706-2-30-1
Eisenhardt, K. (1989). Building theories from case study research. Academy Of Management Review, 14(4), 532-550. doi: 10.5465/amr.1989.4308385
Emms, C., & Armitage, E. (2010). Paramedic training and higher education: a natural progression?. Journal Of Paramedic Practice, 2(11), 529-533. doi: 10.12968/jpar.2010.2.11.80046
Eppich, W., Rethans, J., Teunissen, P., & Dornan, T. (2016). Learning to work together through talk: Continuing professional development in medicine. Professional And Practice-Based Learning, 47-73. doi: 10.1007/978-3-319-29019-5_3
Erwin, C. (2017). Is There A Relationship Between Significant Learning and Critical Thinking Among Students Enrolled in Paramedic Courses? (Doctorial dissertation, University of South Alabama).
Farnsworth, V., Kleanthous, I., & Wenger-Trayner, E. (2016). Communities of practice as a social theory of learning: a conversation with etienne wenger.
Bibliography 145
British Journal Of Educational Studies, 64(2), 139-160. doi: 10.1080/00071005.2015.1133799
Filipe, H., Golnik, K., Silva, E., & Stulting, A. (2014). Continuing professional development: Best practices. Middle East African Journal Of Ophthalmology, 21(2), 134. doi: 10.4103/0974-9233.129760
Filipe, H., Mack, H., Mayorga, E., & Golnik, K. (2016). ICO guide to effective CPD/CME 1st Ed. International Council of Ophthalmology. Retrieved 6 November 2018, from www.icoph.org/ICO-CPD-CME.html
Filipe, H., Golnik, K., & Mack, H. (2018). CPD? What happened to CME? CME and beyond. Medical Teacher, 40(9), 914-916. doi: 10.1080/0142159x.2018.1471200
Finlay, L., & Gough, B. (2003). Reflexivity: A practical guide for researchers in health and social sciences. Malden, MA: Blackwell Science.
First, S., Tomlins, L., & Swinburn, A. (2012). From trade to profession-the professionalisation of the paramedic workforce. Journal Of Paramedic Practice, 4(7), 378-381. doi: 10.12968/jpar.2012.4.7.378
Friedman, A., & Phillips, M. (2001). Leaping the CPD hurdle: A study of the barriers and drivers to participation in continuing professional development. Retrieved from http://www.leeds.ac.uk/educol/documents/00001892.htm
Furness, S. E., Lehmann, J., & Gardner, F. (2016). Autoethnographic analysis of the self through an occupational story of a paramedic. Journal of Paramedic Practice, 8(12), 589-595. https://doi.org/10.12968/jpar.2016.8.12.589
Gallagher, L. (2007). Continuing education in nursing: A concept analysis. Nurse Education Today, 27(5), 466-473. doi: 10.1016/j.nedt.2006.08.007
Gent, P. (2016). Continuing professional development for paramedics: A systematic literature review. Australasian Journal Of Paramedicine, 13(4). http://dx.doi.org/10.33151/ajp.13.4.239
Glaser, B. (2002). Constructivist grounded theory?. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 3(3). doi: 10.17169/fqs-3.3.825
Glen, S. (2017). Problem-based learning in nursing: A new model for a new context.Basingstoke: Macmillan.
Govranos, M., & Newton, J. (2014). Exploring ward nurses' perceptions of continuing education in clinical settings. Nurse Education Today, 34(4), 655-660. doi: 10.1016/j.nedt.2013.07.003
Government of Canada. (2017). Canada health care system. Retrieved 4 November 2017, from https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act-frequently-asked-questions.html#a3
Grant, J. (2017). The good CPD guide: A practical guide to managed continuing professional development in medicine. CRC Press.
146 Bibliography
Gregory, P. (2012). Training for emergency care practitioners: Bsc degree. Australasian Journal Of Paramedicine, 4(1). Retrieved from http://ro.ecu.edu.au/jephc/vol4/iss1/5
Grehan, J., Butler, M. L., Last, J., & Rainford, L. (2018). The introduction of mandatory CPD for newly state registered diagnostic radiographers: An Irish perspective. Radiography, 24(2), 115-121.https://doi.org/10.1016/j.radi.2017.09.007
Griebenow, R., Campbell, C., Qaseem, A., Hayes, S., Gordon, J., & Michalis, L. et al. (2015). Proposal for a graded approach to disclosure of interests in accredited CME/CPD. Journal Of European CME, 4(1), 29894. doi: 10.3402/jecme.v4.29894
Hallberg, L. (2006). The "core category" of grounded theory: Making constant comparisons. International Journal Of Qualitative Studies On Health And Well-Being, 1(3). doi: 10.3402/qhw.v1i3.4927
Hayes, C., Fox, A., Scott-Thomas, J., & Graham, Y. (2018). The relevance of tacit knowledge to healthcare assistant practice. British Journal Of Healthcare Assistants, 12(2), 84-90. doi: 10.12968/bjha.2018.12.2.84
Haywood, H., Pain, H., Ryan, S., & Adams, J. (2012). Engagement with continuing professional development: Development of a service model. Journal Of Allied Health, 41(2), 83-89.
Health and Care Professions Council (HPCP). (2017a) Paramedics. Retrieved 4 November 2017, from http://www.hcpcuk.org/aboutregistration/professions/index.asp?id=10#profDetails
Health and Care Professions Council (HPCP). (2017b) Registration standards. Retrieved 4 November 2017, from http://www.hcpc-uk.org/aboutregistration/standards/
Health Practitioner National Law Act. (2009) ss 140-141. Retrieved 11 January 2019, from http://classic.austlii.edu.au/au/legis/qld/consol act/hprnla2009428/
Hemmati, N., Omrani, S., & Hemmati, N. (2013). A comparison of internet-based learning and traditional classroom lecture to learn CPR for continuing medical education. Turkish Online Journal Of Distance Education, 14(1). doi: 10.17718/tojde.42961
Henwood, S., Yielder, J., & Flinton, D. (2004). Radiographers attitudes to mandatory CPD: A comparative study in the United Kingdom and New Zealand. Radiography, 10(4), 251-258. doi: 10.1016/j.radi.2004.05.008
Hill, H., Beisiegel, M., & Jacob, R. (2013). Professional development research. Educational Researcher, 42(9), 476-487. doi: 10.3102/0013189x13512674
Hoffmann, T., Bennett, S., & Mar, C. (2017). Evidence-based practice across the health professions. Amsterdam: Elsevier.
Bibliography 147
Hou, X., Rego, J., & Service, M. (2012). Review article: Paramedic education opportunities and challenges in Australia. Emergency Medicine Australasia, 25(2), 114-119. doi: 10.1111/1742-6723.12034
Howell, C., & Sayed, Y. (2018). Improving learning through the CPD of teachers: mapping the issues in sub-Saharan Africa. Continuing Professional Teacher Development in Sub-Saharan Africa: Improving Teaching and Learning, 15.
Hyett, N., Kenny, A., & Dickson-Swift, V. (2014). Methodology or method? A critical review of qualitative case study reports. International Journal Of Qualitative Studies On Health And Well-Being, 9(1), 23606. doi: 10.3402/qhw.v9.23606
Ikenwilo, D., & Skåtun, D. (2014). Perceived need and barriers to continuing professional development among doctors. Health Policy, 117(2), 195-202. doi: 10.1016/j.healthpol.2014.04.006
Illeris, K. (Ed.). (2018). Contemporary theories of learning: learning theorists in their own words. Routledge.
Irvine, A., Drew, P., & Sainsbury, R. (2012). ‘Am I not answering your questions properly?’ clarification, adequacy and responsiveness in semi-structured telephone and face-to-face interviews. Qualitative Research, 13(1), 87-106. doi: 10.1177/1468794112439086
Jaiswal, V. (2017). Continuing professional development: Inevitable for academic excellence. Educational Quest- An International Journal Of Education And Applied Social Sciences, 8(3), 595. doi: 10.5958/2230-7311.2017.00111.8
Johnston, T., & Acker, J. (2016). Using a sociological approach to answering questions about paramedic professionalism and identity. Australasian Journal Of Paramedicine, 13(1). http://dx.doi.org/10.33151/ajp.13.1.301
Johnston, T., MacQuarrie, A., & Rae, J. (2014). Bridging the gap: Reflections on teaching interprofessional communication to undergraduate paramedic and nursing students. Australasian Journal Of Paramedicine, 11(4). http://dx.doi.org/10.33151/ajp.11.4.2
Joint Royal Colleges Ambulance Liaison Committee, Association of Ambulance Chief Executives (2017) JRCALC Clinical Practice Supplementary Guidelines 2017. Bridgwater: Class Professional Publishing.
Jones, T., Shaban, R., & Creedy, D. (2015). Practice standards for emergency nursing: An international review. Australasian Emergency Nursing Journal, 18(4), 190-203. doi: 10.1016/j.aenj.2015.08.002
Joyce, C., Wainer, J., Pitermann, L., Wyatt, A., & Archer, F. (2009). Trends in the paramedic workforce: A profession in transition. Australian Health Review, 33(4), 533. doi: 10.1071/ah090533
Kemp, S., & Baker, M. (2013). Continuing professional development – reflections from nursing and education. Nurse Education In Practice, 13(6), 541-545. doi: 10.1016/j.nepr.2013.04.009
148 Bibliography
Kennedy, A. (2005). Models of continuing professional development: A framework for analysis. Journal Of In-Service Education, 31(2), 235-250. doi: 10.1080/13674580500200277
Kennedy, A. (2014). Understanding continuing professional development: The need for theory to impact on policy and practice. Professional Development In Education, 40(5), 688-697. doi: 10.1080/19415257.2014.955122
Kennedy, C., Cannon, E., Warner, D., & Cook, D. (2014). Advanced airway management simulation training in medical education. Critical Care Medicine, 42(1), 169-178. doi: 10.1097/ccm.0b013e31829a721f
Khan, S. (2014). Qualitative research method: Grounded theory. International Journal Of Business And Management, 9(11). doi: 10.5539/ijbm.v9n11p224
Kilner, T. (2004). Educating the ambulance technician, paramedic, and clinical supervisor: Using factor analysis to inform the curriculum. Emergency Medicine Journal, 21(3), 379-385. doi: 10.1136/emj.2003.009605
King, F., Ní Bhroin, O., & Prunty, A. (2017). Professional learning and the individual education plan process: Implications for teacher educators. Professional Development In Education, 1-15. doi: 10.1080/19415257.2017.1398180
Kitto, S., & Grant, R. (2014). Revisiting evidence-based checklists: interprofessionalism, safety culture and collective competence. Journal Of Interprofessional Care, 28(5), 390-392. doi: 10.3109/13561820.2014.916089
Kiviniemi, M. (2014). Effects of a blended learning approach on student outcomes in a graduate-level public health course. BMC Medical Education, 14(1). doi: 10.1186/1472-6920-14-47
Klakegg, O. J. (2015). Ontology and epistemology: Gower Farnham, Surrey.
Klee, S., & Renner, K. H. (2013). In search of the “Rescue Personality”. A questionnaire study with emergency medical services personnel. Personality and Individual Differences, 54(5), 669-672.https://doi.org/10.1016/j.paid.2012.11.006
Knox, S., Cullen, W., & Dunne, C. (2014). Continuous professional competence (CPC) for Irish paramedics and advanced paramedics: A national study. BMC Medical Education, 14(1). doi: 10.1186/1472-6920-14-41
Knox, S., Dunne, S., Hughes, M., Cheeseman, S., & Dunne, C. (2016). Regulation and registration as drivers of continuous professional competence for Irish pre-hospital practitioners: A discussion paper. Irish Journal Of Medical Science, 185(2), 327-333. doi: 10.1007/s11845-016-1412-z
Knowles, E., Ahmed, N., Bishop-Edwards, L., & O’Cathain, A. (2017). OP07 might ambulance service organisational culture affect ambulance non conveyance rates?. Emergency Medicine Journal, 34(10), e2.2-e2. doi: 10.1136/emermed-2017-207114.7
Bibliography 149
Lai, K. W., & Hong, K. S. (2015). Technology use and learning characteristics of students in higher education: Do generational differences exist?. British Journal of Educational Technology, 46(4), 725-738. doi:10.1111/bjet.12161
Lancer, N., Clutterbuck, D., & Megginson, D. (2016). Techniques for Coaching and Mentoring. Routledge.
Larson, D., & Sung, C. (2009). Comparing student performance: Online versus blended versus face-to-face. Journal Of Asynchronous Learning Network, 13(1), 31-42.
Launer, J. (2016). Humour in health care. Postgraduate Medical Journal, 92(1093), 691-692. doi: 10.1136/postgradmedj-2016-134567
Leahy, E., Chipchase, L., & Blackstock, F. (2017). Which learning activities enhance physiotherapy practice? A systematic review protocol of quantitative and qualitative studies. Systematic Reviews, 6(1). doi: 10.1186/s13643-017-0475-x
Lee, C., & Coughlin, J. F. (2015). Perspective: Older adults' adoption of technology: an integrated approach to identifying determinants and barriers. Journal of Product Innovation Management, 32(5), 747-759. doi: 10.1111/jpim.12176
Légaré, F., Ratté, S., Gravel, K., & Graham, I. (2008). Barriers and facilitators to implementing shared decision-making in clinical practice: Update of a systematic review of health professionals’ perceptions. Patient Education And Counseling, 73(3), 526-535. doi: 10.1016/j.pec.2008.07.018
Liamputtong, P. (2017). Research methods in health: Foundations for Evidence Based Practice (3rd ed.). New York, NY: Oxford University Press.
Lim, D., Hou, X., & Tippett, V. (2016). Teaching epidemiology to undergraduate paramedics. Australasian Epidemologist, 23(1), 24.
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic Inquiry. London England: Sage Publications.
Long, D., Devenish, A., & Hobbs, L. (2018). Rote learning: the ugly duckling of student paramedic education? Irish Journal of Paramedicine. 3(2). https://doi.org/10.32378/ijp.v3i2.97
Long, D. (2017). Out of the silo: A qualitative study of paramedic transition to a Specialist role in community paramedicine. (Doctorial dissertation. Queensland University of Technology, Queensland, Australia).
Long, D., Clark, M., Lim, D., & Devenish, S. (2016). What’s in a name? The confusion in nomenclature of low-acuity specialist roles in paramedicine. Australasian Journal Of Paramedicine, 13(3). http://dx.doi.org/10.33151/ajp.13.3.518
Lord, B. (2014). The development of a degree qualification for paramedics at Charles Sturt University. Australasian Journal Of Paramedicine, 1(1). Retrieved from https://ajp.paramedics.org/index.php/ajp/article/view/40
150 Bibliography
Lowe, R. (2016). Special educational needs in English language teaching: Towards a framework for continuing professional development. English Language Teacher Education And Development, 19, 23-31.
Macdougall, C., Epstein, M., & Highet, L. (2017). Continuing professional development: putting the learner back at the centre. Archives Of Disease In Childhood - Education & Practice Edition, 102(5), 249-253. doi: 10.1136/archdischild-2016-310864
Maguire, W., & Blaylock, P. (2017). Preparing a personal development plan for all members of the dental team. BDJ, 223(6), 402-404. doi: 10.1038/sj.bdj.2017.730
Mahajan, R. (2017). Importance of informal learning over formal learning in 21st century. International Journal, 5(2), 152-154.
Maher, B., Faruqui, A., Horgan, M., Bergin, C., Tuathaigh, C., & Bennett, D. (2017). Continuing professional development and Irish hospital doctors: A survey of current use and future needs. Clinical Medicine, 17(4), 307-315. doi: 10.7861/clinmedicine.17-4-307
Maher, C., Hadfield, M., Hutchings, M., & de Eyto, A. (2018). Ensuring rigor in qualitative data analysis: A design research approach to coding combining vvivo with traditional material methods. International Journal of Qualitative Methods, 17(1), 1-13. doi:10.1177/1609406918786362.
Mahoney, K. (2003). The politics of professionalisation: Some implications for the occupation of ambulance paramedics in Australia. Australasian Journal Of Paramedicine, 1(3). http://dx.doi.org/10.33151/ajp.1.3.198
Manley, K., Martin, A., Jackson, C., & Wright, T. (2018). A realist synthesis of effective continuing professional development (CPD): A case study of healthcare practitioners' CPD. Nurse Education Today, 69, 134-141. doi: 10.1016/j.nedt.2018.07.010
Manning, K. (1997). Authenticity in constructivist inquiry: Methodological considerations without prescription. Qualitative Inquiry, 3(1), 93-115. doi: 10.1177/107780049700300105
Manuti, A., Pastore, S., Scardigno, A., Giancaspro, M., & Morciano, D. (2015). Formal and informal learning in the workplace: A research review. International Journal Of Training And Development, 19(1), 1-17. doi: 10.1111/ijtd.12044
Maguire, B.J., O'Meara, P., & Newton, A. (2016). "Toward an international paramedic research agenda." Irish Journal of Paramedicine 1(2). http://dx.doi.org/10.32378/ijp.v1i2.38
Marr, A. (2003). The Australian college of ambulance professionals-who and what is ACAP?. Australasian Journal of Paramedicine, 1(1). http://dx.doi.org/10.33151/ajp.1.1.38
Martin, J. (2015). The challenge of introducing continuous professional development for paramedics. Australasian Journal Of Paramedicine, 42(2). http://dx.doi.org/10.33151/ajp.4.2.368
Bibliography 151
Mason, M. (2010). Sample size and saturation in PhD studies using qualitative interviews. Forum Qualitative Sozialforschung, 11(3). http://dx.doi.org/10.17169/fqs-11.3.1428
Mather, K., & Seifert, R. (2013). The close supervision of further education lecturers: ‘You have been weighed, measured and found wanting’. Work, Employment And Society, 28(1), 95-111. doi: 10.1177/0950017013490332
Matteson, M. L., Anderson, L., & Boyden, C. (2016). "Soft skills": A phrase in search of meaning. Libraries and the Academy, 16(1), 71-88.doi:10.1353/pla.2016.0009
Mazzotti, V., Rowe, D., Simonsen, M., Boaz, B., & VanAvery, C. (2017). Steps for implementing a state-level professional development plan for secondary transition. Career Development And Transition For Exceptional Individuals, 41(1), 56-62. doi:10.1177/2165143417741478
McArdle, K., & Coutts, N. (2010). Taking teachers' continuous professional development (CPD) beyond reflection: Adding shared sense-making and collaborative engagement for professional renewal. Studies In Continuing Education, 32(3), 201-215. doi:10.1080/0158037x.2010.517994
McCann, L., Granter, E., Hassard, J., & Hyde, P. (2015). Where next for the paramedic profession? An ethnography of work culture and occupational identity. Emergency Medicine Journal, 32(5), e6.3-e7. doi: 10.1136/emermed-2015-204880.17
McCutcheon, K., Lohan, M., Traynor, M., & Martin, D. (2014). A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. Journal Of Advanced Nursing, 71(2), 255-270. doi: 10.1111/jan.12509
Michau, R., Roberts, S., Williams, B., & Boyle, M. (2009). An investigation of theory-practice gap in undergraduate paramedic education. BMC Medical Education, 9(1). doi: 10.1186/1472-6920-9-23
Middleton, L., & Llewellyn, D. (2016). How to record and evidence continuing professional development for revalidation. Nursing Standard, 30(44), 42-46. doi: 10.7748/ns.2016.e10512
Mills, J., Bonner, A., & Francis, K. (2006). The development of constructivist grounded theory. International Journal Of Qualitative Methods, 5(1), 25-35. doi: 10.1177/160940690600500103
Minichiello, V., Aroni, R., & Hays, T. (2008). In-techniques, analysis (3rd ed.). Frenchs Forest, N.S.W: Pearson Education Australia.
Miraglia, R., & Asselin, M. (2015). Reflection as an educational strategy in nursing professional development. Journal For Nurses In Professional Development, 31(2), 62-72. doi: 10.1097/nnd.0000000000000151
Mirhaghi, A., Mirhaghi, M., Oshio, A., & Sarabian, S. (2016). Systematic review of the personality profile of paramedics: Bringing evidence into emergency
152 Bibliography
medical personnel recruitment policy. Eurasian Journal Of Emergency Medicine, 15(3), 144-149. doi: 10.5152/eajem.2016.80299
Morse, J. (1995). The significance of saturation. Qualitative Health Research, 5(2), 147-149. doi: 10.1177/104973239500500201
Mostafa, R., & Klepper, S. (2018). Industrial development through tacit knowledge seeding: Evidence from the Bangladesh garment industry. Management Science, 64(2), 613-632. doi: 10.1287/mnsc.2016.2619
Munro, K. (2008). Continuing professional development and the charity paradigm: Interrelated individual, collective and organisational issues about continuing professional development. Nurse Education Today, 28(8), 953-961. doi: 10.1016/j.nedt.2008.05.015
Mythen, L., & Janice, G. (2011). Mandatory training: evaluating its effectiveness. British Journal Of Healthcare Management, 17(11), 522-526. doi: 10.12968/bjhc.2011.17.11.522
Nazarenko, A. L. (2015). Blended learning vs traditional learning: What works? (A case study research). Procedia-Social and Behavioral Sciences, 200, 77-82.
New South Wales Ambulance. (2017a). Employment. Retrieved 4 May 2017, from http://www.ambulance.nsw.gov.au/Employment.html
New South Wales Ambulance. (2017b). About us - History. Retrieved 23 April 2017, from http://www.ambulance.nsw.gov.au/about-us/History.html
New South Wales Government. (2017a). Media and Publications. Retrieved 28 October 2017, from http://www.ambulance.nsw.gov.au/Media-And-Publications/Latest-News/Paramedics-voted-most-trusted-profession.html
New South Wales Government. (2017b). Health – legislation – agreements. Retrieved 6 August 2017, from http://www.health.nsw.gov.au/legislation/Pages/agreements.aspx
New Zealand Government. (2017). Careers – paramedic. Retrieved 2 June 2017, from https://www.careers.govt.nz/jobs-database/health-and-community/health/paramedic/
Nicholls, G. (2014). Professional Development in Higher Education: New Dimensions and Directions. Routledge.
Nixon, V. (2013). Professional practice in paramedic, emergency and urgent care.Chichester, West Sussex: Wiley-Blackwell.
Noble, H., & Mitchell, G. (2016). What is grounded theory?. Evidence Based Nursing, 19(2), 34-35. doi: 10.1136/eb-2016-102306
O'Brien, K., Moore, A., Dawson, D., & Hartley, P. (2014). An Australian story: Paramedic education and practice in transition. Australasian Journal Of Paramedicine, 11(3). Retrieved from https://ajp.paramedics.org/index.php/ajp/article/view/14
Bibliography 153
Oliver, K., Innvar, S., Lorenc, T., Woodman, J., & Thomas, J. (2014). A systematic review of barriers to and facilitators of the use of evidence by policymakers. BMC Health Services Research, 14(1). doi: 10.1186/1472-6963-14-2
O'Meara, P., & Duthie, S. (2018). Paramedicine in Australia and New Zealand: A comparative overview. Australian Journal of Rural Health, 26(5), 363-368. https://doi.org/10.1111/ajr.12464
O’Reilly, M., & Parker, N. (2012). ‘Unsatisfactory saturation’: A critical exploration of the notion of saturated sample sizes in qualitative research. Qualitative Research, 13(2), 190-197. doi: 10.1177/1468794112446106
Panahi, S., Watson, J., & Partridge, H. (2016). Conceptualising social media support for tacit knowledge sharing: Physicians’ perspectives and experiences. Journal Of Knowledge Management, 20(2), 344-363. doi: 10.1108/jkm-06-2015-0229
Paramedic Association of Canada. (2017a). National occupational competency profile. Retrieved 5 November 2017, from http://paramedic.ca/site/nocp?nav=02
Paramedic Association of Canada. (2017b). Professional responsibilities. Retrieved 5 November 2017, from http://paramedic.ca/site/nocp_area1?nav=02
Paramedics Australasia. (2012a). Paramedic. Retrieved 3 March 2015, from https://www.paramedics.org/paramedics/what-is-s-paramedic/
Paramedics Australasia. (2012b). Paramedic role descriptions. Retrieved 15 January 2019, from https://paramedics.org/wp-content/uploads/2016/09/PRD 211212 WEBONLY.pdf
Paramedics Australasia. (2014). Australia’s most trusted profession call for registration. Retrieved 28 October 2017, from https://www.paramedics.org/australias-most-trusted-profession-calls-for-registration/
Paramedics Australasia. (2016). Registration. Retrieved 9 November 2017, from https://www.paramedics.org/?s=professional+registration
Paramedics Australasia. (2017a). Membership information. Retrieved 17 June 2017, from https://www.paramedics.org/membership/
Paramedics Australasia. (2017b). Competency standards. Retrieved 11 November 2016, from https://paramedics.org/wp-content/uploads/2016/09/PA Australasian-Competency-Standards-for-paramedics July-20111.pdf
Paramedics Australasia. (2017c). Paramedic registration. Retrieved 9 October 2016, from https://www.paramedics.org/registration/
Paramedics Australasia. (2017d). Competency standards. Retrieved 5 November 2017, from https://www.paramedics.org/registration/
Paramedics Australasia. (2018). Student paramedic organisation. Retrieved 16 October 2018, from https://www.studentparamedic.org.au/
154 Bibliography
Paramedics Australasia. (2019). Scholarships and grants. Retrieved 16 October 2018, from https://www.paramedics.org/scholarships-grants/
Parker, R. (2008). The management and operations of the ambulance service of NSW (Report No 27). New South Wales Parliamentary Library: Legislative Council. Retrieved 11 August 2017, from: http://www.ambulance.nsw.gov.au/Media/docs/081020councilreport-83758ed3-d308-46ff-8a4d-0882822581fa-0.pdf
Plsek, P., & Wilson, T. (2001). Complexity science: Complexity, leadership, and management in healthcare organisations. BMJ, 323(7315), 746-749. doi: 10.1136/bmj.323.7315.746
Pringle, S. (2017). The challenges of upskilling health care assistants in community nursing. British Journal Of Community Nursing, 22(6), 284-288. doi: 10.12968/bjcn.2017.22.6.284
Putwain, D., Symes, W., & Remedios, R. (2016). The impact of fear appeals on subjective-task value and academic self-efficacy: The role of appraisal. Learning And Individual Differences, 51, 307-313. doi: 10.1016/j.lindif.2016.08.042
Queensland Ambulance Service. (2017). Recruitment. Retrieved 4 May 2017, from https://www.ambulance.qld.gov.au/rec-paramedic.html
Queensland Ambulance Service. (2019). KJM. Retrieved 23 January 2019, from https://www.ambulance.qld.gov.au/KJM.html
Queensland Government. (2017). Queensland-NSW cross-border collaboration. Retrieved 6 August 2017, from https://www.premiers.qld.gov.au/about-us/what-we-do/border.aspx
Queensland University of Technology Student Paramedic Union. (2018). Retrieved 16 October 2018, from https://www.facebook.com/qutspu
Ramalho, R., Adams, P., Huggard, P., & Hoare, K. (2015). Literature review and constructivist grounded theory methodology. Forum Qualitative Sozialforschung, 16. http://nbn-resolving.de/urn:nbn:de:0114-fqs1503199
Ranucci, R., & Souder, D. (2015). Facilitating tacit knowledge transfer: Routine compatibility, trustworthiness, and integration in m & as. Journal Of Knowledge Management, 19(2), 257-276. doi: 10.1108/jkm-06-2014-0260
Reynolds, L. (2008). Beyond the front line an interpretative ethnography of an ambulance service (Ph.D). University of South Australia.
Richardson, R., & Kramer, E. (2006). Abduction as the type of inference that characterizes the development of a grounded theory. Qualitative Research, 6(4), 497-513. doi: 10.1177/1468794106068019
Ritchie, J., Lewis, J., McNaughton Nicholls, C., & Ormston, R. (2014). Qualitative research practice (2nd ed.). Los Angeles, California: Sage.
Bibliography 155
Roberto, A., Mongeau, P., & Liu, Y. (2018). A (re)defining moment for fear appeals: A comment on Kok et al. (2018). Health Psychology Review, 12(2), 144-146. doi: 10.1080/17437199.2018.1445546
Rogers, G. D., Thistlethwaite, J. E., Anderson, E. S., Abrandt Dahlgren, M., Grymonpre, R. E., Moran, M., & Samarasekera, D. D. (2017). International consensus statement on the assessment of interprofessional learning outcomes. Medical Teacher, 39(4), 347-359. doi: 10.1080/0142159X.2017.1270441
Ross, L., & Kabidi, S. (2017). Embedding volunteer activity into paramedic education. Journal Of Allied Health, 46(3), 192-196.
Ross, K., & Anderson, T. (2013). Deciding what kind of course to take: Factors that influence modality selection in accounting continuing professional development. Knowledge Management & E-Learning, 5(2), 137. Retrieved from https://gateway.library.qut.edu.au/login?url=https://search.proquest.com/docview/1955098463?accountid=13380
Rowe, A., & Regehr, C. (2010). Whatever gets you through today: An examination of cynical humor among emergency service professionals. Journal Of Loss And Trauma, 15(5), 448-464. doi: 10.1080/15325024.2010.507661
Ruiter, R., Kessels, L., Peters, G., & Kok, G. (2014). Sixty years of fear appeal research: Current state of the evidence. International Journal Of Psychology, 49(2), 63-70. doi: 10.1002/ijop.12042
Rumball, C., Macdonald, D., Barber, P., Wong, H., & Smecher, C. (2004). Endotracheal intubation and esophageal tracheal combitube insertion by regular ambulance attendants: A comparative trial. Prehospital Emergency Care, 8(1), 15-22. doi: 10.1080/312703002764
Sahoo, D. K., & Lenka, U. (2016). Breaking the glass ceiling: Opportunity for theorganization. Industrial and Commercial Training, 48(6), 311-319.https://doi.org/10.1108/ICT-02-2015-0017
Saldaña, J. (2016). The coding manual for qualitative researchers (3rd ed.). Thousand Oaks, California: London: Sage.
Sargeant, J., Wong, B., & Campbell, C. (2017). CPD of the future: A partnership between quality improvement and competency-based education. Medical Education, 52(1), 125-135. doi: 10.1111/medu.13407
Schwarz, L., & Leibold, N. (2014). Perceived facilitators and barriers to baccalaureate degree completion among registered nurses with an associate’s degree. The Journal Of Continuing Education In Nursing, 45(4), 171-180. doi: 10.3928/00220124-20140219-03
Scotland, J. (2012). Exploring the philosophical underpinnings of research: Relating ontology and epistemology to the methodology and methods of the scientific, interpretive, and critical research paradigms. English Language Teaching, 5(9). doi: 10.5539/elt.v5n9p9
Scott, T., Mannion, R., Davies, H., & Marshall, M. (2018). Healthcare Performance and Organisational Culture. Boca Raton: Chapman and Hall/CRC.
156 Bibliography
Senate Legal and Constitutional Affairs Committee Canberra. (2016). Establishment of a national registration system for Australian paramedics to improve and ensure patient and community safety. Legal and Constitutional Affairs Reference Committee. Retrieved from https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0ahUKEwjL2NiesrrVAhWFnJQKHVfvAYkQjBAIMDAB&url=http%3A%2F%2Fwww.aph.gov.au%2FParliamentary Business%2FCommittees%2FSenate%2FLegal and Constitutional Affairs%2FParamedics%2FReport&usg=AFQjCNGvAfqSLRqxkXV48ZhHDxBzZiNfrw
Shaban, R. Z., Considine, J., Fry, M., & Curtis, K. (2017). Case study and case-based research in emergency nursing and care: Theoretical foundations and practical application in paramedic pre-hospital clinical judgment and decision-making ofpatients with mental illness. Australasian Emergency Nursing Journal, 20(1), 17-24. http://dx.doi.org/10.33151/ajp.4.2.369
Shaw, T., Yates, P., Moore, B., Ash, K., Nolte, L., & Krishnasamy, M. et al. (2017). Development and evaluation of an online educational resource about cancer survivorship for cancer nurses: A mixed-methods sequential study. European Journal Of Cancer Care, 26(4), e12576. doi: 10.1111/ecc.12576
Shaw, T., Barnet, S., Mcgregor, D., & Avery, J. (2014). Using the knowledge, process, practice (KPP) model for driving the design and development of online postgraduate medical education. Medical Teacher, 37(1), 53-58. doi: 10.3109/0142159x.2014.923563
Silva, H., Bühler, F., Maillet, B., Maisonneuve, H., Miller, L., Negri, A., & Stonier, P. (2012). Continuing medical education and professional development in the European Union. Pharmaceutical Medicine, 26(4), 223-233. doi: 10.1007/bf03262479
Silverman, D. (2011). Interpreting qualitative data: A guide to the principles of qualitative research. London: Sage.
Silverman, D. (2016). Qualitative research. Sage Publications Limited.
Sockalingam, S., Soklaridis, S., Yufe, S., Rawkins, S., Harris, I., & Tekian, A. et al. (2017). Incorporating lifelong learning from residency to practice. Journal Of Continuing Education In The Health Professions, 37(2), 90-97. doi: 10.1097/ceh.0000000000000156
South Australian Ambulance Service. (2017). Careers. Retrieved 4 May 2017, from http://www.saambulance.com.au/Careers.aspx
Squire, B., Tamayo-Sarver, J., Rashi, P., Koenig, W., & Niemann, J. (2013). Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation. Prehospital Emergency Care, 18(1), 1-8.doi: 10.3109/10903127.2013.836263
Stagnitti, K., Schoo, A., Reid, C., & Dunbar, J. (2005). Access and attitude of rural allied health professionals to CPD and training. International Journal Of Therapy And Rehabilitation, 12(8), 355-362. doi: 10.12968/ijtr.2005.12.8.19538
Bibliography 157
Staple, L., Carter, A., Jensen, J., & Waker, M. (2018). Paramedic learning style preferences and continuing medical education activities: A cross-sectional survey study. Journal Of Allied Health, 47(1), 51-57.
Stevens, B., & Wade, D. (2017). Improving continuing professional development opportunities for radiographers: A single centre evaluation. Radiography, 23(2), 112-116. doi: 10.1016/j.radi.2016.12.001
St Johns New Zealand. (2017). Join St John – Ambulance officers. Retrieved 4 May 2017, from http://www.stjohn.org.nz/About-St-John/Join-St-John/Ambulance-Officers/
St Johns Ambulance Northern Territory. (2017). Careers - Paramedic. Retrieved 4 May 2017, from https://www.stjohnnt.org.au/careers/paramedic.php
St Johns Ambulance Western Australia. (2012). Most trusted paramedics. Retrieved 28 October 2017, from http://newsroom.stjohnambulance.com.au/most-trusted-paramedics/
St Johns Ambulance Western Australia. (2017). Employment. Retrieved 4 May 2017, from http://changelives.stjohnambulance.com.au/changelives/employment/employed/student-ambulance-officer
Strauss, A., & Corbin, J. (1990). Basics of qualitative research. Thousand Oaks, Calif.: Sage Publications, Inc.
Suddaby, R. (2006). From the editors: What grounded theory is not. Academy Of Management Journal, 49(4), 633-642. doi: 10.5465/amj.2006.22083020
Sutherland Olsen, D. (2016). Adult learning in innovative organisations. European Journal Of Education, 51(2), 210-226. doi: 10.1111/ejed.12170
Tanaka, M., Taketomi, K., Yonemitsu, Y., & Kawamoto, R. (2014). Professional behaviours and factors contributing to nursing professionalism among nurse managers. Journal Of Nursing Management, 24(1), 12-20. doi: 10.1111/jonm.12264
Taylor, R. B. (2015). The Profession and Professionalism. In On the Shoulders of Medicine's Giants (pp. 2-25). Springer, New York, NY.
Tavares, W., & Boet, S. (2015). On the assessment of paramedic competence: A narrative review with practice implications. Prehospital And Disaster Medicine, 31(01), 64-73. doi: 10.1017/s1049023x15005166
Tessier, S. (2012). From field notes, to transcripts, to tape recordings: Evolution or combination?. International Journal Of Qualitative Methods, 11(4), 446-460. doi: 10.1177/160940691201100410
The Council of Ambulance Authorities (n.d). Annual Report 2015-16. Retrieved 26 June 2017, from http://www.caa.net.au/publications/caa-annual-reports
Theqwongsa, I., Kirby, C., Schattner, P., & Piterman, L. (2014). Online continuing medical education (CME) for GPs: does it work?: A systematic review. Australian Family Physician, 43(10), 717.
158 Bibliography
Thomas, G., & Richardson, E. (2016). Memories of nursing: A timeline of the profession part two. British Journal Of Nursing, 25(19), 1072-1074. doi: 10.12968/bjon.2016.25.19.1072
Tofade, T., Foushee, L., Chou, S., Eckel, S., & Caiola, S. (2010). Evaluation of a condensed training program to introduce the process of continuing professional development. Journal Of Pharmacy Practice, 23(6), 560-569. doi: 10.1177/0897190010375852
Tofade, T., Duggan, C., Rouse, M., & Anderson, C. (2015). The responsibility of advancing continuing professional development and continuing education globally. American Journal Of Pharmaceutical Education, 79(2), 16. doi: 10.5688/ajpe79216
Tran, D., Tofade, T., Thakkar, N., & Rouse, M. (2014). US and international health professions’ requirements for continuing professional development. American Journal Of Pharmaceutical Education, 78(6), 129. doi: 10.5688/ajpe786129
Trede, F. (2009). Becoming a professional in the 21st century. Australasian Journal Of Paramedicine, 7(4). http://dx.doi.org/10.33151/ajp.7.4.180
Tunnage, B., Swain, A., & Waters, D. (2015). Regulating our emergency care paramedics. The New Zealand Medical Journal, 128(1421), 55-58. Retrieved from http://gateway.library.qut.edu.au/login?url=https://search-proquest-com.ezp01.library.qut.edu.au/docview/1712457079?accountid=13380
Turner, S. (2018). The Social Theory of Practices: Tradition, Tacit Knowledge and Prepositions. John Wiley and Sons.
Von Vopelius-Feldt, J., & Benger, J. (2013). Who does what in prehospital critical care? An analysis of competencies of paramedics, critical care paramedics and prehospital physicians. Emergency Medicine Journal, 31(12), 1009-1013. doi: 10.1136/emermed-2013-202895
Von Wyl, T., Zuercher, M., Amsler, F., Walter, B., & Ummenhofer, W. (2009). Technical and non-technical skills can be reliably assessed during paramedic simulation training. Acta Anaesthesiologica Scandinavica, 53(1), 121-127. doi: 10.1111/j.1399-6576.2008.01797.x
Wagner, S., Martin, C., & McFee, J. (2009). Investigating the "Rescue personality”. Traumatology, 15(3), 5-12. https://doi.org/10.1177%2F1534765609338499
Walsh, R., & Craig, A. (2016). Radiation therapists’ and diagnostic radiographers’ participation in continuing professional development and knowledge of regulatory body registration. Journal Of Radiotherapy In Practice, 15(02), 150-160. doi: 10.1017/s1460396916000054
Wang, E., Quinones, J., Fitch, M., Dooley-Hash, S., Griswold-Theodorson, S., & Medzon, R. et al. (2008). Developing technical expertise in emergency medicine- The role of simulation in procedural skill acquisition. Academic Emergency Medicine, 15(11), 1046-1057. doi: 10.1111/j.1553-2712.2008.00218.x
Bibliography 159
Wankhade, P. (2012). Different cultures of management and their relationships with organizational performance: Evidence from the UK ambulance service. Public Money & Management, 32(5), 381-388. doi: 10.1080/09540962.2012.676312
Wankhade, P., & Brinkman, J. (2014). The negative consequences of culture change management. International Journal Of Public Sector Management, 27(1), 2-25.doi: 10.1108/ijpsm-05-2012-0058
Wankhade, P., Heath, G., & Radcliffe, J. (2017). Cultural change and perpetuation in organisations: Evidence from an English emergency ambulance service. Public Management Review, 20(6), 923-948. doi: 10.1080/14719037.2017.1382278
Wanstall, M. (2010). Compulsory CPD - Keeping your knowledge and skills current. Keeping Good Companies, 62(6), 383.
Tonkin, A., & Whitaker, J. (Eds.). (2016). Play in healthcare for adults: Using play to promote health and wellbeing across the adult lifespan. Routledge.
Wellington Free Ambulance Service. (2019). History. Retrieved 11 January 2019, from https://www.wfa.org.nz/about-us/our-history/
[WHO] World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice (No. WHO/HRH/HPN/10.3). Geneva: World Health Organization. Retrieved 27 March 2019, from https://www.who.int/hrh/resources/framework action/en/
[WHO] World Health Organization. (2013). Transforming and scaling up health professionals’ education and training: World Health Organization guidelines 2013. World Health Organization.
Williams, B., Onsman, A., & Brown, T. (2009). From stretcher-bearer to paramedic: The Australian paramedics’ move towards professionalisation. Australasian Journal Of Paramedicine, 7(4). http://dx.doi.org/10.33151/ajp.7.4.191
Williams, B., Onsman, A., & Brown, T. (2012). Is the Australian paramedic discipline a profession? A national perspective. International Paramedic Practice, 2(3), 77-84. doi: 10.12968/ippr.2012.2.3.77
Williams, B., Onsman, A., & Brown, T. (2010). Is the Australian paramedic discipline a full profession? Australasian Journal of Paramedicine, 8(1). http://dx.doi.org/10.33151/ajp.8.1.113
Williams, B., Brown, T., McKenna, L., Beovich, B., & Etherington, J. (2017). Attachment and empathy in Australian undergraduate paramedic, nursing and occupational therapy students: A cross-sectional study. Collegian, 24(6), 603-609. doi: 10.1016/j.colegn.2016.11.004
Wong, C. K. (2014). Minimizing false activation of cath lab for STEMI—a realistic goal?. International journal of cardiology, 172(1), e91-e93.doi: 10.1016/j.ijcard.2013.12.132
Wyatt, A. (2003). Paramedic practice-knowledge invested in action. Australasian Journal Of Paramedicine, 1(3). http://dx.doi.org/10.33151/ajp.1.3.211
160 Bibliography
Yang, C., Yen, Z., McGowan, J., Chen, H., Chiang, W., & Mancini, M. et al. (2012). A systematic review of retention of adult advanced life support knowledge and skills in healthcare providers. Resuscitation, 83(9), 1055-1060. doi: 10.1016/j.resuscitation.2012.02.027
Young, R., & Collin, A. (2004). Introduction: Constructivism and social constructionism in the career field. Journal Of Vocational Behavior, 64(3), 373-388. doi: 10.1016/j.jvb.2003.12.005
Appendices 161
Appendices
Appendix A
Research Questions (utilised in semi-structured interviews)
Concept of exploration QuestionsGeneral questions Without stating where you work or who you
work for, can you tell me a little bit about yourself – as a paramedic?
How long have you been a Paramedic?
How did you do your training to become a paramedic? (i.e. through VET or university)
What is your current clinical level?
Do you have any future plans to change your clinical role? (i.e. progress into a new clinical role such as ACP to CCP).
Engagement in CPD Can you when you knew that you had to engage in CPD as part of your career choice to be a paramedic?
Can you tell me how you engage in CPD as part of your career choice to be a paramedic?
Have you ever had a CPD plan?If response is yes: Can you tell me what a typical CPD plan would be like for you?If response is no: Can you tell me why you think that it is that you have not had a CPD plan in the past, and how or if this might change when paramedics are professionally registered?
Can you tell me about some factors that might help or hinder your engagement in CPD? (Prompting question: For instance: time; financial gain or cost; career opportunities).
Attitudes about CPD Can you tell me what you, as a current paramedic, think about CPD?
162 Appendices
Can you tell me about some of the things that influences your level of engagement in CPD activities?
What are some reasons that would make you want to engage in a CPD activity?
What are some of the reasons that would make you not want to engage in a CPD activity?
As a paramedic, what would be your preferred way to engage in CPD? (I.e. conference,workshop, online course, etc.)
Perceptions about CPD When you became a paramedic or think back over your paramedic career, what were your perceptions about CPD, and have they changed?
What is your understanding of the difference is between the idea of Lifelong Learning and Compliance Training, in relation to paramedic CPD?
In what ways do you think that as an Australasian paramedic your interaction with CPD will change post professional registration?
How do you think any previous level of education effects paramedic CPD? (Prompting question: For instance, will someone who has completed a paramedical degree have the same view of CPD as someone who was trained through a vocational system….and why, or why not?)
What do you think are the expectations of your peers (other paramedics) in relation to how we as paramedics should be interacting with CPD?
Paramedic Careers What does CPD mean to you in the context of your current clinical role?
What does CPD mean to you in the context of career progression?
Appendices 163
Appendix B
Research Ethics, Integrity and Safety Modules 1 and 2
164 Appendices
Appendix C
QUT University Human Research Ethics Committee Approval
Appendices 165
166 Appendices
Appendix D
Approach Emil to Participants
Subject Title:Australasian Paramedics needed for a research study of paramedic Attitudes and Perceptions about Continuing Professional Development (CPD)
Dear colleaguesMy name is Lisa Hobbs from the School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT) Brisbane, Australia and I’m doing a research study into some of the influences surrounding CPD in the Australasian paramedic population. Specifically, as professional registration approaches, I’m looking at paramedic attitudes and perceptions about CPD.
I’m looking for qualified paramedics of any age complete a 45-60 minute interview. Please view the attached Participant Information Sheet and Consent Form for further details on the study. Should you wish to participate or have any questions, please contact me via email: lr.hobbs@qut.edu.au
Please note that this study has been approved by the QUT Human Research Ethics Committee (approval number 1800000232).
Many thanks for your consideration of this request.
Lisa HobbsMaster of Philosophy studentlr.hobbs@qut.edu.au07 3138 0626
Dr Scott DevenishPrincipal Supervisorscott.devenish@qut.edu.au07 3138 3581School of Clinical Sciences, Faculty of HealthQueensland University of Technology
168 Appendices
Appendices 169
Appendices 171
Appendix G
Participant Information
172 Appendices
Appendices 173
Appendix H
Consent Form
174 Appendices
Appendix I
Glossary of Terms and Assumptions made available to participants before and
during the interview
QUT Verified Signature
176 Appendices
Appendix K
Progression to Date
Milestones
Stage 2- completed on time (no revisions required)
Coursework
Year 1: IFN001 – AIRS program completed, Semester 1, 2015. (Grade=7)
Publications
Hobbs, L., Devenish, S., Clark, M. & Tippett, V. Clinical Skills Degradation
in Paramedicine Specific to Trauma Management: A Critical Review of the
Literature. Australian Journal of Paramedicine. 2015, 12(5)(Conference
Proceeding)
Extra Courses and Activities Completed
Research Methods Group Qualitative Workshop: Introduction to qualitative
and mixed methods research
Comprehensive Systematic Review Training Programme (Joanna Briggs
Institute) – protocol to be submitted on completion of confirmation.
EndNote Workshop.
HDR Research Writing Program.
Successful Confirmation Workshop.
Accepted as a mentee in the QUT Women in STEMM program 2017.
The Imposter Syndrome Workshop (STEMM organised).
Time Management Workshop (STEMM organised)
HDR Student Workshop – Working well with your Supervisors
Qualitative Research Masterclass with Prof Charmaz - Grounded Theory, held
at the Queensland University of Technology, Gardens Point Campus on 29 -
30 September 2017.
Qualitative Research Masterclass with Prof Charmaz - Grounded Theory, held
at the Queensland University of Technology, Gardens Point Campus on 25 -
27 September 2017.
Publishing within and from your thesis’ seminar.
Appendices 177
Registered with Australian Bureau Of Statistics; access to Census TableBuilder
Basic.
Established ORCID ID https://orcid.org/0000-0001-5706-6674
Naturalistic or Manufactured Data with Professor Emeritus David Silverman.
Managing your Research Data workshop.
Peer Reviewed Conference Presentations
Paramedics Australasia International Conference, Melbourne 24-26 November
2017. Hobbs, L., Devenish, S., & Tippett, V. Mandatory Continuing
Professional Development (CPD) requirements for professional health
registration: Paramedic Implications.
Paramedics Australasia International Conference, Adelaide Convention Centre
1-3 October 2015. Hobbs, L., Devenish, S., Clark, M. & Tippett, V. Clinical
Skills Degradation in Paramedicine Specific to Trauma Management: A
Critical Review of the Literature.
Non-Peer Reviewed Presentations
QUT Student Paramedic Union Conference, QUT Kelvin Grove 25 June 2016.
Oral Presentation “Continuing Professional Development in Paramedicine”.
3 Minute Thesis Presentations, Queensland University Technology, Gardens
Point Campus 3rd December 2015.Paramedic Professional Development:
What does it look like in evolving professions?
178 Appendices
Appendix L
Resources and Funding
Resources and funding over the tenure of the research (part-time) are outlined in
the table below:
Activity Estimated
Expense
Funding Source
Travel (Data
Collection)
$5000 ANZCP grant/s
HDR Student Allocation
External grants available
through community groups
such as CWA, LAC, etc.
Conference
Attendance
International and
Domestic
$6000 School conference travel
allocation
ANZCP grant/s
Transcription
($1/min)
30 transcripts x 60
minutes
Up to
$1800
HDR Student Allocation
Some transcription to be done
by the researcher.
Courses
NVIVO
Methods
Academic
writing
$2000 Grant in Aid
Appendices 179
Appendix M
Researcher Timeline
182 Appendices
Appendix N
Paramedic CPD Post Professional Registration