Advanced clinical practice roles started appearing in the UK in the 1980s and now include various healthcare professions (Leary and Maclaine, 2019; Xi et al, 2021). ‘Advanced clinical practitioners’ can be defined as individuals who have a high level of expertise, autonomy and complex decision-making skills within a profession (Health Education England, 2017; Hill and Mitchell, 2021). The aim of this paper is to review the factors influencing UK paramedic advanced practice, while also exploring the attributes required and the impact of the role on healthcare. Although this paper will only be referring to UK-based paramedics and the UK healthcare system, its analysis can provide a potential model and template for how the development of the paramedic role may influence other healthcare infrastructure worldwide. Evans et al (2020) state that the global health workforce crisis, coupled with ageing populations, financial struggles and communicable diseases, have prompted the need to consider the optimal skill mix within a workforce. This is further acknowledged and supported by the NHS Long Term Plan (NHS England, 2019), which also identified a clear need for change. In March 2023, there were 35125 paramedics registered with the Health and Care Professions Council in the UK; these professionals are now able to be included in the advanced care practitioner cohort (Health and Care Professions Council, 2023).
Four pillars of advanced practice
Health Education England defines advanced clinical practice through four pillars: clinical; leadership and management; education; and research (Health Education England, 2017). Its multi-professional advanced care practitioner framework sets out a vision on how to develop the advanced practice workforce in a consistent way to ensure both safety and effective care across many settings (Health Education England, 2017). All registered paramedics are now eligible to become advanced care practitioners and are encouraged to complete a MSc degree in advanced-level practice. Such a degree involves the completion of 180 credits at level 7, from a selection of modules that include non-medical prescribing, clinical decision-making, research and education models. Clinicians can pick modules that will specifically enhance their area of practice; this aspect helps with application. However, it is suggested that paramedics should have at least 5 years of clinical experience before commencing an advanced practice programme, so they have the experience that they can build on. This is not an entry requirement for many MSc courses (Health Education England, 2017; Hill and Mitchell, 2021) and many UK universities see this as a recommendation rather than a requirement. Many UK paramedics have less experience than suggested before commencing on a MSc programme; it could be suggested this is due to the growing demand, increased job exhaustion and burnout experienced by the profession, with an eagerness to escape from the frontline profession. The Ambulance Service Charity (2022) reports that burnout in paramedics was recognised by the World Health Organization as an occupational phenomenon in 2019 (Miller, 2021).
Diamond-Fox (2021) and Reynolds and Mortimore (2021) both discuss the clinical elements when working at an advanced level. They stress the importance of patient consultation and clinical assessment, which are the key elements that aid with decision-making in advanced practice. Ideally, when training, advanced practitioners should have access to adequate clinical supervision to aid their progression and to support their early skill development. However, it is noted that the effectiveness of clinical supervision certainly depends on the mentor facilitating it. Due to ongoing workforce pressures, mentors frequently do not have adequate time available; this can particularly be a problem for healthcare professionals undertaking the MSc route rather than an apprenticeship route, as there is not a compulsory requirement for a mentor (Murphy and Mortimore, 2020; Hindi et al, 2021; Lee et al, 2023).
Advanced practice is certainly more than having the advanced clinical skills. Practitioners must also show they can critically assess and address their own learning needs, engage in self-directed learning and contribute to a culture of organisation learning (Health Education England, 2017).
Self-directed learning can be achieved through a variety of ways such as clinical reflection, attending training courses and updates, peer supervision and auditing. Ross (2012) and Brown (2017) both highlight that self-awareness and the ability to reflect on practice drive the culture of continuous development. They suggest that it helps with patient satisfaction and clinical improvements. Self-awareness is needed for the advanced practitioner to highlight any areas that require updating to ensure they can remain accountable for their decision-making (Hill and Diamond-Fox, 2023).
In addition to the clinical and educational elements of advanced practice, an advanced practitioner must be able to show leadership and management, which also coincides with research. Leadership includes being a role model, showing values of their workplace and demonstrating a person-centred approach to development (Osborne, 2018; Hill and Diamond-Fox, 2023). Advanced practitioners will frequently encourage learning within their setting, which creates a positive learning culture; they will also operate as a source of support for newly qualified clinicians (Dover et al, 2019; Lawler et al, 2020). With healthcare being ever changing, an advanced practitioner must be able to critically analyse research literature to ensure their own practice and that of others is up to date. This helps ensure that they are using evidence-based practice and can justify their decision-making.
History of paramedicine's clinical development
Paramedic practice within the UK has evolved rapidly over a short space of time. Paramedics have developed from being primarily a transportation service to hospital, to having the skills and ability to diagnose and discharge patients at home. These developments have made them increasingly recognised by other employers (Griffin, 2015). Paramedics became registered with the Health and Care Professions Council in 2001. Their professional body recently gained independent and supplementary prescribing rights in 2018 (College of Paramedics, 2018). Many paramedics are now employed as advanced practitioners in a variety of settings, including out of hours, walk-in centres, GP surgeries, emergency departments and acute care wards (Sharman, 2015; Collins, 2019; Eaton et al, 2020).
Similar to advanced nurse practitioners, paramedics can use a variety of titles that signify advanced practice roles; these include advanced practitioner, emergency care practitioner, paramedic practitioner and advanced paramedic (Eaton et al, 2020; Xi et al, 2021).
Currently, the title ‘advanced practitioner’ is not regulated, which means that there is not a list of professionals who have satisfied a regulator that they are appropriately qualified. Therefore, anyone can refer to themselves as an advanced practitioner. As such, job advertisements for the role vary significantly (Department of Health and Social Care, 2021; Hill and Diamond-Fox, 2023). Carney (2016), King et al (2017) and Hooks and Walker (2020) all suggest regulation will help reduce uncertainty in both the advanced practice concept and role. This will give members of the public more confidence about clinical safety and the standards of care they will receive.
Paramedics and non-medical prescribing
Although paramedic advanced practitioners are now expanding into a variety of medical environments within the UK healthcare system, the lack of prescribing capabilities has historically hindered this development, with nurses often being the most recognised advanced practitioner, especially in primary care (Booker and Voss, 2019). Griffin (2015), Sharman (2015) and Diamond-Fox (2021) all acknowledge the importance of non-medical prescribing aiding a journey in providing the best possible care for a patient. It allows for increased continuity of care and helps to ensure patient care is met in a timely manner, with no disruption or delay. The NHS ‘A plan for investment: a plan for reform’ (2000) suggested that non-medical prescribing will create benefits to service uses; these included improved patient care through giving them choice and access, and better use of health professional skills, which would also help contribute to patient safety (Department of Health and Social Care, 2000). Although legislation for paramedics to become non-medical prescribers came into force in April 2018, they still do not have access to the full formulae and are unable to prescribe controlled drugs such as codeine and pregabalin (Dixon, 2020). This creates a barrier to functionality in the workplace, especially when paramedics are working in general practice. For example, if the advanced paramedic practitioner is conducting palliative care home visits and visits a patient who requires further pain management, they will frequently be on controlled drugs, which the practitioner would not be able to change or increase—creating duplicate work. However, it is important to know that non-medical prescribing is not a requirement of advanced practice (Health Education England, 2017).
Effectiveness of paramedics as advanced practitioners
Collins (2019) and Courtenay and Berry (2007) both look at the effectiveness of and opinions regarding nursing and parademic-based advanced practitioners. Both conclude that they can provide equivalent clinical outcomes to GPs, and offer a high level of knowledge on prescribed medications and their specific area of practice. A review by Collins (2019) is specifically relevant to paramedic advanced practitioners, as it looks at the effectiveness of advanced nurse practitioners in out-of-hours and primary care within England. The conclusion by Collins (2019) is that advanced nurse practitioners are just as effective as GPs in undertaking urgent home visits and their documentation is more consistent.
Although written about nurse practitioners, this could also be reflected on paramedics who become advanced practitioners. It could also be argued that due to previous exposure, paramedics are more effective in out-of-hours and home-visit scenarios. These findings were echoed in Mi et al's (2018) randomised control trial, which demonstrated how community paramedics were able to reduce the number of older adults who re-attend the emergency department within 30 days of discharge, essentially supporting the effectiveness of paramedics within the community environment. This is a benefit to primary care employers, as advanced practitioners can ease the workload of GPs and allow them more time for the more complex clinical presentations. However, it could still be argued that more research is required in regard to the effectiveness and benefits of paramedics within the primary care setting, due to their recent addition into this role.
Williams (2017) and Evans et al (2020) also discuss benefits of advanced practitioners. It is clear advanced practitioner roles evolved out of medical staff shortages, the changing healthcare population and the introduction of the European working time directive—which stressed the need for further trained professions to extend and expand clinical roles. The literature review conducted by Williams (2017) highlighted a positive attitude towards advanced practitioners, with a consensus that they improve patient care and patient journey. The literature review was focused on emergency department care across the UK, but it could be suggested that other healthcare environments, such as primary care, also have similar pressures. Griffin (2015) supports this drive and need for expansion of workforces, and argues that five distinct areas can benefit from advanced paramedics:
Challenges and barriers for advanced paramedics
Advanced paramedic practitioners within the UK can often come across many challenges and barriers when trying to fulfil their role. Patients are often not aware of an advanced practitioner's scope or practice and can be reluctant to engage with them during consultation. Evans et al (2020) undertook a qualitative study evaluating the advanced care practitioner role and looking at patient and stakeholder understanding of their practice. It concluded that the full realisation of the advanced care practitioner role potential is impeded by variability in capabilities. They also went on to say that advanced practitioners working in primary care settings are frequently perceived as clinicians who ‘fill gaps’. The lack of awareness from patients is a common occurrence and may be due to advanced practice not being regulated through separate registers (Hill and Diamond-Fox, 2023). The lack of consistency in the advanced practitioner's scope can cause a degree of confusion for members of the public, especially if they experience different advanced practitioners within the same healthcare setting who still have different scope of practices and capabilities. Furthermore, specifically paramedics have historically been seen as ambulance drivers with extremely limited skills and members of the public have a poor understanding of the fast-paced development of the profession in recent years (Mursell, 2009; Evans et al, 2021). This limited understanding then creates further difficulties for the advanced practitioner, especially in general practice, as patients will frequently start the consultation unhappy that they have not been able to see a GP. This causes an initial communication barrier that the advanced practitioner must break down by showing their competence within their scope.
Scope of practice is hugely variable among advanced practitioners and the individual practitioner must acknowledge the attributes that are needed to ensure patient safety. Capability can be defined as the attributes that individuals bring to the workplace. This includes being competent and able to manage situations that may be complex and ever-changing (Health Education England, 2021). It can take many years to acquire the knowledge, skills and experience to work at an advanced level (Hill and Diamond-Fox, 2023). These attributes can be developed through educational training and professional development, mentorship, reflection, evidence-based practice and experience. All healthcare practitioners working at any level are aware that they are responsible and accountable for the decisions they make. This is closely linked to the Health and Care Professions Council (HCPC) code of conduct (HCPC, 2016).
It can be argued under the educational pillar of the advanced practice framework that an advanced practitioner must be aware of their own educational needs to ensure they are working within their own scope of practice (Health Education England, 2017). Cooper and Lidster (2021) conducted a cross-sectional qualitative study using semi-structured interviews to analyse clinical practitioners' perceptions of the word ‘competence’. Most participants referred to competence as the ability to undertake a task at a standard in which others would do it. Although there is no set definition, this perception can be supported by Axley (2008), Mitchell and Boak (2009) and Melnyk et al (2014), which all discuss evidence-based practice and the appropriate knowledge to successfully undertake a skill. The limitations of these studies are their small sample sizes and lack of varied healthcare professionals, as the participants were all registered nurses. Further research is needed that looks specifically at paramedics and other healthcare professionals to ensure they also have a good understanding and awareness.
Conclusion
In conclusion, paramedics can become capable advanced practitioners working in multiple healthcare settings in the UK, such as emergency departments, GP surgeries, walk-in centres and out-of-hours services. While this transition is supported through MSc programmes and the Health Education England four pillars of practice, it also requires in-house support and supervision (Hill and Diamond-Fox, 2023). Advanced practitioners are a vital resource for many healthcare settings, as they create further access for patients, provide a high level of care and ease pressure on already stretched healthcare services (Williams, 2021; Cooper and Lidster, 2021).
As paramedics are relatively new to both prescribing and working in other settings, there is very limited research that looks at the effectiveness of paramedics working in a prescribing role and across different environements. It is recommended from this review that more research be conducted specifically to evaluate paramedics' effectiveness as advanced practitioners. Further research into education opportunities would also be of benefit regarding the regulation of the advanced practice title and how this would benefit members of the public in their understanding of the role.