Lisa Rose Hobbs Bachelor of Science –Psychology Diploma of ... Rose Hobbs Thesis_Redact… ·...

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)


• 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


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).


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.


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


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


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


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.


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.


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.


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


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


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


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


(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,


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


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).


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


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


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


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).


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


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


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


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).


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 &


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,


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


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


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,


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).


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;


• 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.


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


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


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


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


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


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.


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)


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.


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


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

.


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


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


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).


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


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


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


(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


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


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


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


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.


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.


• 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?


• 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


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.


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


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


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


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.


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.


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


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


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.


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.


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


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


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


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


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.


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).


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


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)


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


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)


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


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.


“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 &


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


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.


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


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


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.


“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….


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).


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


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


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-


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


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


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.


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


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


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).


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


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


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


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


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


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


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


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


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


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


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,


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


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.


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


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/[email protected]/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/[email protected]/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: [email protected]

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 [email protected] 3138 0626

Dr Scott DevenishPrincipal [email protected] 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

Lisa Rose Hobbs Bachelor of Science –Psychology Diploma of ... Rose Hobbs Thesis_Redact… ·...

Documents

Transcript of Lisa Rose Hobbs Bachelor of Science –Psychology Diploma of ... Rose Hobbs Thesis_Redact… ·...