Contribution of paramedics in primary and urgent care: a systematic review

An Integrative Systematic Review of Promoting Patient Safety Within Prehospital Emergency Medical Services by Paramedics: A Role Theory Perspective

Timely and effective prehospital care significantly impacts patient outcomes. Paramedics, as the frontline providers of emergency medical services, are entrusted with a range of critical responsibilities aimed at safeguarding the well-being of patients from the moment they initiate contact in the out-of-hospital environment to the time of handover at healthcare facilities. This study aimed to understand the multifaceted roles of paramedics in promoting patient safety within the context of prehospital emergency medical services. A systematic review with an integrative approach using the Whittemore and Knafl's framework was performed examining qualitative, quantitative, and mixed-methods research, then conducting data assessment, quality appraisal, and narrative research synthesis. Literature search encompassed PubMed (including MEDLINE), Scopus, Cinahl, ProQuest, Web of Science, and EMBASE, with the aim of retrieving studies published in English in the last decade from 2013 to 2023. To conceptualize the roles of paramedics in ensuring patient safety, the review findings were reflected to and analyzed through the role theory. The preliminary exploration of the database yielded 2397 studies, ultimately narrowing down to a final selection of 16 studies for in-depth data analysis and research synthesis. The review findings explored facilitators and obstacles faced by paramedics in maintaining patient safety in terms of role ambiguity, role conflict, role overload, role identity, and role insufficiency in the dynamic nature of prehospital care. It also highlighted the diverse roles of paramedics in ensuring patient safety, which encompassed effective communication and decision making for the appropriate management of life-threatening emergencies. The effectiveness of paramedics in playing their roles in promoting patient safety relies on acknowledging the contributions of paramedics to the culture of patient safety; training and educational initiatives focused on enhancing their decision-making abilities and both their non-technical and technical competencies; developing relevant guidelines and protocols; improving collaboration between paramedics and other healthcare peers; optimizing environmental conditions and equipment; fostering a supportive work environment.

Understanding paramedic work in general practice in the UK: a rapid realist synthesis

BACKGROUND

General practice in the UK is under substantial pressure and practices are increasingly including paramedics as part of their workforce. Little is known about how different models of paramedic working may affect successful implementation of the role, as viewed from patient, clinician and system perspectives. This realist synthesis developed theories about 'models of paramedic working in general practice' in different UK contexts to understand their impact.

METHODS

The rapid realist synthesis comprised data from: (1) empirical and grey literature searches; (2) semi-structured realist interviews with system leaders involved with the implementation of the role; and (3) a stakeholder event with healthcare professionals and the public, to develop initial programme theories that can be tested in future work. Sources were analysed using a realist approach that explored the data for novel or causal insights to generate initial programme theories.

RESULTS

Empirical sources (n = 32), grey sources (n = 95), transcripts from system leader interviews (n = 7) and audio summaries from the stakeholder event (n = 22 participants) were synthesised into a single narrative document. The findings confirmed the presence of a wide variety of models of paramedic working in UK general practice. The perceived success of models was influenced by the extent to which the paramedic service was mature and embedded in practice, and according to four theory areas: (1) Primary care staff understanding and acceptance of the paramedic role; (2) Paramedic induction process, including access to training, supervision and development opportunities; (3) Patient understanding and acceptance of the role; (4) Variations in paramedic employment models.

CONCLUSIONS

Variability in how the paramedic role is operating and embedding into general practice across the UK affects the success of the role. These findings provide a theoretical foundation for future research to investigate various 'models of paramedic working' in different contexts.

Exploring the alignment between paramedicine's professional capabilities and competency frameworks for current and evolving scopes of practice: a literature review

BACKGROUND

To adequately prepare graduates for the dynamic demands of paramedic practice, adopting a contemporary educational approach is essential. This involves collaborating to identify crucial competencies through input from industry stakeholders, experienced practitioners, and discipline-specific experts. Accreditation assumes a central role within this framework, serving as a cornerstone to ensure that paramedicine curricula align with paramedics' diverse and evolving professional roles.

METHODS

A narrative review of the literature and a directed search of grey literature were performed to identify specific developments in paramedicine competencies and scope of practice and mapped to the professional capabilities published by the Paramedicine Board of Australia. In determining a competency map and accreditation's role in a competency framework specific to current and evolving paramedic practice, key documents were analysed using a qualitative approach based on content analysis to identify common traits among documents, countries and other professions.

RESULTS

The review process identified 278 themes that were further allocated to 22 major analytical groupings. These groupings could further be mapped to previously reported cognitive, technical, integrative, context, relationship, affective/moral competencies and habits of mind. At the same time, the highest-rated groupings were key competencies of intellectual skills, safety, accountability, clinical decision-making, professionalism, communications, team-based approach and situational awareness. Two groups were represented in the literature but not in the professional capabilities, namely Health and Social continuum and self-directed practice.

CONCLUSIONS

This review highlights the importance of measuring and validating the professional capabilities of Paramedicine Practitioners. The study explores various metrics and competency frameworks used to assess competency, comparing them against national accreditation schemes' professional capability standards. The findings suggest that accreditation frameworks play a crucial role in improving the quality of paramedicine practice, encompassing intellectual skills, safety, accountability, clinical decision-making, professionalism, communication, teamwork, and situational awareness.

The paramedic-general practitioner relationship: a scoping review

BACKGROUND

Health services internationally are implementing programs that increase working ties between paramedics and general practitioners (GPs) to reduce unnecessary transport to emergency departments (EDs) and improve access to primary health care. As paramedic involvement in primary health care develops, there is increasing focus on the GP-paramedic collaborative relationship. Resulting issues regarding professional boundaries may occur, as paramedics practice in fields that were previously solely in the GP scope. An effective paramedic-GP working relationship will be an essential foundation to the success of future strategies.

METHODS

A search of three electronic databases was completed (Ovid MEDLINE, Embase Classic+ Embase and CINAHL Plus). Eligibility for inclusion required analysis of the relationship between paramedics and GPs. All processes were completed by two independent reviewers.

RESULTS

After removal of duplicates, 4995 titles were screened by title and/or abstract. After full-text review, 15 studies were included. Five themes were identified that contribute significantly to the strengths and weaknesses of the relationship - the importance of communication, understanding scope of practice, leadership roles, responsibility for patient care and interdisciplinary training. Issues identified included significant variation in the structure of different emergency medical services and varying standards of education requirements for paramedics worldwide.

CONCLUSIONS

There were no published Australian studies that had the primary aim of examining the paramedic-GP relationship. The depth of research on this topic is lacking, despite increased interest over the past decade. The relevance of the international literature to the Australian setting is questionable.

A case study of the impact of a dietitian in the multi-disciplinary team within primary care: a service evaluation

BACKGROUND

Expanding the primary care workforce to alleviate general practitioner (GP) workload, improve access and improve quality of care is a current UK strategy. Evidence suggests dietitians can improve patient outcomes and make cost savings. The present study aimed to evaluate a dietitian working as an expert generalist and first contact practitioner (FCP) in a general practice multi-disciplinary team (MDT) to provide appropriate care to patients and reduce GP workload.

METHODS

A dietitian was employed for 6 months at 0.6 full-time equivalents in a group of general practices in Devon, UK. Data were collected on the referral source, patient satisfaction, health outcomes and changes in prescribing data for all patients seen by the dietitian. Focus groups and interviews provided data to understand the experience of introducing a dietitian into the team.

RESULTS

This model of service delivery showed the dietitian acting as an expert generalist, a FCP and able to educate the MDT. A range of professionals within the MDT referred patients with a wide range of diagnoses (both paediatric and adults) and the dietitian acted as a FCP for 29% of patients. Saving were made for the optimisation of medicine management.

CONCLUSIONS

The dietitian can improve patient-centred care for several patient groups; enhance learning for staff around nutrition and dietary issues; and contribute to more efficient working and cost savings around prescription of nutritional products. This was an evaluation of one service and further research is needed to understand the value dietitians can contribute and the factors supporting effective and efficient working in this context.

The general attributes and competence for nurses in a single responder unit: A modified Delphi study

AIM

The aim of this study was to describe the general attributes and competence that nurses in the ambulance's single responder units are considered to need.

BACKGROUND

The development of ambulance care has led to an increased need for new units and working methods. Single responder unit is a single crewed unit that often uses for the patient assessments, to refer patients to the right level of care and to release regular ambulances. There is a lack of description of the needed competence for the nurses within single responder unit.

METHODS

Modified Delphi with three rounds was used. The first round was conducted with focus group interviews and analysed with content analysis. Five competence categories and 19 subcategories were identified. The second and third rounds were conducted through surveys using a 4-point Likert scale and analysed with descriptive statistics.

RESULTS

The ability to communicate with other healthcare providers to achieve one's goal, the ability to create a good encounter alone and to have appropriate professional experience were identified as the most important general attributes and competencies.

CONCLUSIONS

A central competence in prehospital emergency care is the ability to independently assess and treat patients with varying care needs in complex environments. To be able to work in SRU requires good communication and collaborations skills with other healthcare providers but it is also a prerequisite for creating a good patient relationship. Work experience of taking care of varying patients and situations is also needed in SRU.

Understanding the roles and work of paramedics in primary care: a national cross-sectional survey

OBJECTIVES

This research aimed to fill a current knowledge gap, namely the current scope of clinical role of paramedics in primary care, in relation to specific constructs such a level of education and clinical experience.

SETTING

The survey was distributed to paramedics in primary care across the UK through the College of Paramedics.

PARTICIPANTS

A total of 341 surveys were returned (male=215). 90% of responses were from paramedics in England, 1.7% from paramedics in Northern Ireland, 4.6% from paramedics in Scotland and 2.9% from paramedics in Wales. This represents approximately 33% of the primary care paramedic workforce in England and Wales. Estimates for percentages in Northern Ireland and Scotland are unavailable due to the lack of workforce datasets capturing paramedics in primary care.

RESULTS

Considerable variation was found in job titles, level of education and provision of clinical supervision of paramedics in primary care. Differing levels of practice were noted, despite guidance documents that attempt to standardise the role. Statistical analysis of quantitative data highlighted that relationships exist between paramedic clinical exposure in primary care, level of education, and ability of independently prescribe medicines and the extent to which clinical presentations are seen and examinations performed. However, free-text responses indicated that challenges in relation to access to further education and clinical supervision to support clinical development resulted in frustration for paramedics who work in this setting.

CONCLUSIONS

As well as offering an insight into the demographics of the primary care paramedic work force, there is indication of the clinical scope of role undertaken in this setting. Based on our findings, we recommend changes to education and support, governance and legislation to ensure paramedics employed in primary care can work to achieve the full extent of their professional capability.

The development of community paramedicine; a restricted review

Community paramedic roles are expanding internationally, and no review of the literature could be found to guide services in the formation of community paramedicine programmes. For this reason, the aim of this restricted review was to explore and better understand the successes and learnings of community paramedic programmes across five domains being; education requirements, models of delivery, clinical governance and supervision, scope of roles and outcomes. This restricted review was conducted by searching four databases (CENTRAL, ERIC, EMBASE, MEDLINE and Google Scholar) as well as grey literature search from 2001 until 28/12/2021. After screening, 98 articles were included in the narrative synthesis. Most studies were from the USA (n = 37), followed by Canada (n = 29). Most studies reported on outcomes of community paramedicine programmes (n = 50), followed by models of delivery (n = 28). The findings of this review demonstrate a lack of research and understanding in the areas of education and scope of the role for community paramedics. The findings highlight a need to develop common approaches to education and scope of role while maintaining flexibility in addressing community needs. There was an observable lack of standardisation in the implementation of governance and supervision models, which may prevent community paramedicine from realising its full potential. The outcome measures reported show that there is evidence to support the implementation of community paramedicine into healthcare system design. Community paramedicine programmes result in a net reduction in acute healthcare utilisation, appear to be economically viable and result in positive patient outcomes with high patient satisfaction with care. There is a developing pool of evidence to many aspects of community paramedicine programmes. However, at this time, gaps in the literature prevent a definitive recommendation on the impact of community paramedicine programmes on healthcare system functionality.

'Mum, I think we might ring the ambulance, okay?' A qualitative exploration of bereaved family members' experiences of emergency ambulance care at the end of life

BACKGROUND

In the context of a sudden or unexpected event, people with a life-limiting illness and their family caregivers may be dependent on emergency ambulance services.

AIM

To explore bereaved family members' experiences of emergency ambulance care at the end of life.

DESIGN

A qualitative study using reflexive thematic analysis of data collected from semi-structured phone interviews.

SETTING/PARTICIPANTS

A purposive sample of 38 family caregivers identified from a database of deaths in Aotearoa, New Zealand.

RESULTS

Emergency ambulance personnel assist, inform and reassure patients and family caregivers managing distressing symptoms, falls, infections, unexpected events and death itself. Family members and patients are aware of the pressure on emergency services and sometimes hesitate to call an ambulance. Associating ambulances with unwanted transport to hospital is also a source of reluctance.

CONCLUSIONS

The generalist palliative care provided by emergency ambulance personnel is a vital service for patients in the last year of life, and their caregivers. This must be acknowledged in palliative care policy and supported with training, specialist consultation and adequate resources.

Potential for Paramedic roles in Irish General Practice: A qualitative study of stakeholder’s perspectives

Background: Irish health policy emphasises the role of Primary Care and General Practice however, there is a growing shortage of General Practitioners (GPs) in Ireland. Paramedics have traditionally focused on emergency care in the community. More recently Paramedics have taken on roles in General Practice in international jurisdictions, but not yet in Ireland. This study aimed to explore key stakeholder perceptions of ‘the potential for Paramedic roles in Irish General Practice’.

Methods: We conducted an exploratory, qualitative stakeholder consultation study incorporating in-depth semi structured telephone interviews followed by thematic analysis. Interviews were conducted with a total of eighteen participants that included six senior Paramedics (Advanced Paramedics), seven General Practitioners (GPs), three Practice Nurses and two Practice Managers.

Results: Participants in this study expressed polarised views on the potential for Paramedic roles in Irish General Practice. Paramedics were enthusiastic, highlighting opportunity for professional development and favourable working conditions. GPs, Practice Nurses and Managers were more circumspect and had concerns that Paramedic scope and skillset was not currently aligned to General Practice care. GPs, Practice Nurses and Managers emphasised a greater role for expanded General Practice Nursing. There were varied perceptions on what the potential role of a Paramedic in General Practice might entail, but consensus that Government support would be required to facilitate any potential developments.

Conclusions: The findings of this research can inform future development of novel roles in Irish General Practice and suggests that there is appetite from within the Paramedic profession to pursue such roles. A pilot demonstration project, grounded in an action research framework could address data gaps and potential concerns. Any future developments should occur in tandem with and with due consideration for the expansion of General Practice Nursing in Ireland.

Barriers and facilitators to implementation of non-medical independent prescribing in primary care in the UK: a qualitative systematic review

OBJECTIVES

To support workforce deficits and rising demand for medicines, independent prescribing (IP) by nurses, pharmacists and allied health professionals is a key component of workforce transformation in UK healthcare. This systematic review of qualitative research studies used a thematic synthesis approach to explore stakeholders' views on IP in primary care and identify barriers and facilitators influencing implementation.

SETTING

UK primary/community care.

PARTICIPANTS

Inclusion criteria were UK qualitative studies of any design, published in the English language. Six electronic databases were searched between January 2010 and September 2021, supplemented by reference list searching. Papers were screened, selected and quality-appraised using the Quality Assessment Tool for Studies with Diverse Designs. Study data were extracted to a bespoke table and two reviewers used NVivo software to code study findings. An inductive thematic synthesis was undertaken to identify descriptive themes and interpret these into higher order analytical themes. The Diffusion of Innovations and Consolidated Framework for Implementation Research were guiding theoretical anchors.

PRIMARY AND SECONDARY OUTCOME MEASURES

N/A.

RESULTS

Twenty-three articles addressing nurse, pharmacist and physiotherapist IP were included. Synthesis identified barriers and facilitators in four key stages of implementation: (1) 'Preparation', (2) 'Training', (3) 'Transition' and 4) 'Sustainment'. Enhancement, substitution and role-specific implementation models reflected three main ways that the IP role was used in primary care.

CONCLUSIONS

In order to address global deficits, there is increasing need to optimise use of IP capability. Although the number of independent prescribers continues to grow, numerous barriers to implementation persist. A more coordinated and targeted approach is key to overcoming barriers identified in the four stages of implementation and would help ensure that IP is recognised as an effective approach to help alleviate workforce shortfalls in the UK, and around the world.

PROSPERO REGISTRATION NUMBER

CRD42019124400.

Potential for Paramedic roles in Irish General Practice: A qualitative study of stakeholder’s perspectives

Background: Irish health policy emphasises the role of Primary Care and General Practice however, there is a growing shortage of General Practitioners (GPs) in Ireland. Paramedics have traditionally focused on emergency care in the community. More recently Paramedics have taken on roles in General Practice in international jurisdictions, but not yet in Ireland. This study aimed to explore key stakeholder perceptions of ‘the potential for Paramedic roles in Irish General Practice’. Methods: We conducted an exploratory, qualitative stakeholder consultation study incorporating in-depth semi structured telephone interviews followed by thematic analysis. Interviews were conducted with a total of eighteen participants that included six senior Paramedics (Advanced Paramedics), seven General Practitioners (GPs), three Practice Nurses and two Practice Managers. Results: Participants in this study expressed polarised views on the potential for Paramedic roles in Irish General Practice. Paramedics were enthusiastic, highlighting opportunity for professional development and favourable working conditions. GP’s, Practice Nurses and Managers were more circumspect and had concerns that Paramedic scope and skillset was not currently aligned to General Practice care. GP’s, Practice Nurses and Managers emphasised a greater role for expanded General Practice Nursing. There were varied perceptions on what the potential role of a Paramedic in General Practice might entail, but consensus that Government support would be required to facilitate any potential developments. Conclusions: The findings of this research can inform future development of novel roles in Irish General Practice and suggests that there is appetite from within the Paramedic profession to pursue such roles. A pilot demonstration project, grounded in an action research framework could address data gaps and potential concerns. Any future developments should occur in tandem with and with due consideration for the expansion of General Practice Nursing in Ireland.

Out-of-hospital or pre-hospital: Is it time to reconsider the language used to describe and define paramedicine?

The professionalisation of paramedicine in Australasia necessitates discussion about how the profession defines and describes itself in the literature and more broadly. This editorial discusses the descriptors pre-hospital care and out-of-hospital care, and the connotations, relevance and implications of their use to describe paramedic roles and practice.

The Definition of Paramedicine: An International Delphi Study

Introduction

Although paramedicine is an integral element of healthcare systems, there is a lack of universal consensus on its definition. This study aimed to derive a global consensus definition of paramedicine.

Methods

Key attributes pertaining to paramedicine were identified from existing definitions within the literature. Utilising text analysis, common attribute themes were identified and six initial domains were developed. These domains formed the basis for a four-round Delphi study with a panel of 58 global experts within paramedicine to develop an international consensus definition.

Results

Response rates across the study varied from 96.6% (round 1) to 63.8% (round 4). Participant feedback on appropriate attributes to include in the definition reflected the high level of specialized clinical care inherent within paramedicine, and its status as an essential element of healthcare systems. In addition, the results highlighted the extensive range of paramedicine capabilities and roles, and the diverse environments within which paramedics work.

Conclusion

Delphi methodology was utilized to develop a global consensus definition of paramedicine. This definition is as follows: paramedicine is a domain of practice and health profession that specialises across a range of settings including, but not limited to, emergency and primary care. Paramedics work in a variety of clinical settings such as emergency medical services, ambulance services, hospitals and clinics as well as non-clinical roles, such as education, leadership, public health and research. Paramedics possess complex knowledge and skills, a broad scope of practice and are an essential part of the healthcare system. Depending on location, paramedics may practice under medical direction or independently, often in unscheduled, unpredictable or dynamic settings. We believe that the generation and provision of this consensus definition is essential to enable the further development and maturation of the discipline of paramedicine.

Perspectives of pharmacists in general practice from qualitative focus groups with patients during a pilot study

BACKGROUND

Utilising skill mix in general practice is proposed as a solution to the demand-supply issue. Pharmacists can play an important role in this context leading to an increase in training and funding for independent prescriber roles. A role for Pharmacists in General Practice was funded, piloted and evaluated by NHSE from 2015.

AIM

What is the patient perspective of pharmacists in patient facing roles in general practice in the UK?

DESIGN & SETTING

Focus group interviews exploring patient perspectives on the pharmacist role.

METHOD

33 patients, five focus group interviews (January-December 2016). Data was iteratively analysed using the one sheet of paper technique.

RESULTS

While public are aware of the primary care crisis, they are less well informed about potential solutions. Data showed patients primarily sought access to a clinician over expressing a preference for any type of clinician. Low awareness was shown about the role and there was initial confusion about pharmacist's roles. Acceptability levels were high.Pharmacists add value and provide an expert medication focused service which can have a positive impact on medicines use.Patients reported benefit from longer appointments, feeling they weren't rushed, and that all their conditions were being considered holistically. They trusted pharmacists as experts in medication and trust was consolidated over time. Regular coaching from a pharmacist could lead to improved patient self-monitoring and self-care.

CONCLUSION IMPLICATIONS

Pharmacists can add value to the general practice team and this is recognised by patients.

Finnish paramedics' professional quality of life and associations with assignment experiences and defusing use - a cross-sectional study

Background

Paramedics experience traumatic events and social emergencies during assignments while also being subjected to verbal and physical threats. Consequently, they are at risk for burnout and secondary traumatic stress, factors inherent to professional quality of life. Defusing and peer-support potentially decrease such symptoms; however, perceived defusing needs and use are not always balanced. Our aim was to explore Finnish paramedics’ professional quality of life, using the Professional Quality of Life Scale, with associations to EMS assignment experiences as well as formal and informal defusing need and use over a 12-month period.

Methods

A quantitative study of 257 Finnish paramedics using a cross-sectional design. Study outcomes were secondary traumatic stress (STS), compassion satisfaction (CS), and burnout (BO) scores using the modified 9-item Short Professional Quality of Life scale (ProQOL). Likert-type scales were used to collect participants’ recollections of assignment experiences and defusing from a 12-month period. Associations were explored using Spearman’s correlation coefficients.

Results

Short ProQOL score medians were STS 4.00 (IQR 3), BO 6.00 (IQR 3) and CS 13.00 (IQR 3). STS and BO correlated to experiences of social emergencies and traumatic events while BO correlated to experiences of threat situations (r = 0.206, p = .001). Paramedics perceived a need for defusing in general associated with STS (r = 0.178, p < .001) and participated in informal defusing. Participation in defusing of any form did not associate with ProQOL scores.

Conclusions

Finnish paramedics’ more frequent experiences of social emergencies, traumatic events, and paramedic-directed threat situations were associated with higher levels of STS and BO. STS was also associated with paramedics’ increased need for defusing and use of informal peer defusing, although neither STS, BO or CS scores associated to any defusing form. Managing paramedics STS and BO, while fostering CS, could therefore be a future research focus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11851-0.

Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: a scoping review

OBJECTIVES

In response to demographic and health system pressures, the development of non-medical advanced clinical practice (ACP) roles is a key component of National Health Service workforce transformation policy in the UK. This review was undertaken to establish a baseline of evidence on ACP roles and their outcomes, impacts and implementation challenges across the UK.

DESIGN

A scoping review was undertaken following JBI methodological guidance.

METHODS

13 online databases (Medline, CINAHL, ASSIA, Embase, HMIC, AMED, Amber, OT seeker, PsycINFO, PEDro, SportDiscus, Osteopathic Research and PenNutrition) and grey literature sources were searched from 2005 to 2020. Data extraction, charting and summary was guided by the PEPPA-Plus framework. The review was undertaken by a multi-professional team that included an expert lay representative.

RESULTS

191 papers met the inclusion criteria (any type of UK evidence, any sector/setting and any profession meeting the Health Education England definition of ACP). Most papers were small-scale descriptive studies, service evaluations or audits. The papers reported mainly on clinical aspects of the ACP role. Most papers related to nursing, pharmacy, physiotherapy and radiography roles and these were referred to by a plethora of different titles. ACP roles were reported to be achieving beneficial impacts across a range of clinical and health system outcomes. They were highly acceptable to patients and staff. No significant adverse events were reported. There was a lack of cost-effectiveness evidence. Implementation challenges included a lack of role clarity and an ambivalent role identity, lack of mentorship, lack of continuing professional development and an unclear career pathway.

CONCLUSION

This review suggests a need for educational and role standardisation and a supported career pathway for advanced clinical practitioners (ACPs) in the UK. Future research should: (i) adopt more robust study designs, (ii) investigate the full scope of the ACP role and (iii) include a wider range of professions and sectors.

Understanding the role of the paramedic in primary care: a realist review

BACKGROUND

Since 2002, paramedics have been working in primary care within the United Kingdom (UK), a transition also mirrored within Australia, Canada and the USA. Recent recommendations to improve UK NHS workforce capacities have led to a major push to increase the numbers of paramedics recruited into primary care. However, gaps exist in the evidence base regarding how and why these changes would work, for whom, in what context and to what extent. To understand the ways in which paramedics impact (or not) the primary care workforce, we conducted a realist review.

METHODS

A realist approach aims to provide causal explanations through the generation and articulation of contexts, mechanisms and outcomes. Our search of electronic databases was supplemented with Google and citation checking to locate grey literature including news items and workforce reports. Included documents were from the UK, Australia, Canada and the Americas-countries within which the paramedic role within primary care is well established.

RESULTS

Our searches resulted in 205 included documents, from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) within a final programme theory. Our results outline that paramedics are more likely to be effective in contributing to primary care workforces when they are supported to expand their existing role through formal education and clinical supervision. We also found that unless paramedics were fully integrated into primary care services, they did not experience the socialisation needed to build trusting relationships with patients or physicians. Indeed, for patients to accept paramedics in primary care, their role and its implications for their care should be outlined by a trusted source.

CONCLUSIONS

Our realist review highlights the complexity surrounding the introduction of paramedics into primary care roles. As well as offering an insight into understanding the paramedic professional identity, we also discuss the range of expectations this professional group will face in the transition to primary care. These expectations come from patients, general practitioners (family physicians) and paramedics themselves. This review is the first to offer insight into understanding the impact paramedics may have on the international primary care workforce and shaping how they might be optimally deployed.

Future-proofing the primary care workforce: A qualitative study of home visits by emergency care practitioners in the UK

Background

Broadening the skill-mix in general practice is advocated to build resilience into the primary care workforce. However, there is little understanding of how extended-scope practitioners from different disciplines, such as paramedicine and nursing, embed into roles traditionally ascribed to general practitioners (GPs).

Objectives

This study sought to explore patients' and professionals' experiences of a primary care home visiting service delivered by emergency care practitioners (ECPs), in place of GPs; to determine positive impacts/unintended consequences and establish whether interdisciplinary working was achieved.

Methods

Three practices in England piloted an ECP (extended-scope practitioners with a paramedic or nursing background) home visiting service (November 2018–March 2019). Following the pilot, focus groups were conducted with each of the three primary healthcare teams (14 participants, including eight GPs), and one with ECPs (five participants) and nine individual patient interviews. Data were analysed using a modified framework approach.

Results

The impact of ECP home visiting on GP workload and patient care was perceived as positive by patients, GPs and ECPs. Initial preconceptions of GPs and patients about the ECP role and expertise, and reservations about the appropriacy of ECPs for home visiting, were perceived to have been overcome by the expertise and interpersonal skills of ECPs. Fostering a culture of collaboration between ECPs and GPs was instrumental to remodelling professional boundaries at the practice level.

Conclusion

Broadening the skill-mix to incorporate extended-scope practitioners such as ECPs, to deliver primary care home visiting, presents an opportunity to increase resilience in the general practice workforce.

Paramedics working in general practice: a scoping review

Background: The term ‘paramedic’ has traditionally related to a healthcare professional trained to provide pre-hospital emergency care; however, paramedics are increasingly taking on novel additional non-emergency roles. General practice is facing unprecedented demand for its services related to rising expectations, an aging society and increased prevalence of chronic disease. Paramedics may be recruited to work in general practice to meet some of these demands. We undertook a scoping review to map the current literature considering paramedics working in general practice and inform follow-on research. Methods: We employed the six-stage scoping review framework developed by Arksey and O’Malley. Our research question was ‘to identify the scope of practice, nature of training/qualifications, challenges faced, and impacts of paramedics working in general practice’. Results: After searching PUBMED (Medline, n = 487), EMBASE (n = 536) and the Cochrane Library (n = 0) in June 2020, we identified eleven full-text articles that met our inclusion criteria. The literature suggests that paramedics have diverse skills that enable roles within general practice, some of which are context specific. Additional training is considered necessary to facilitate the transition from emergency care to general practice. We found no research that quantitatively assessed the impact of paramedics working in general practice on healthcare expenditure or patient health outcomes. Conclusions: There is a paucity of empiric scientific literature considering paramedic working in general practice. Further research is needed to inform training pathways, the structure of clinical practice and to measure outcomes.