Clinical leadership in paramedic services: a narrative synthesis

Abstract

Purpose In North America, delegated practice “medical direction” models are often used as a proxy for clinical quality and safety in paramedic services. Other developed countries favor a combination of professional regulatory boards and clinical governance frameworks that feature paramedics taking lead clinician roles. The purpose of this paper is to bring together the evidence for medical direction and clinical governance in paramedic services through the prism of paramedic self-regulation. Design/methodology/approach This narrative synthesis critically examines the long-established North American Emergency Medical Services medical direction model and makes some comparisons with the UK inspired clinical governance approaches that are used to monitor and manage the quality and safety in several other Anglo-American paramedic services. The databases searched were CINAHL and Medline, with Google Scholar used to capture further publications. Findings Synthesis of the peer-reviewed literature found little high quality evidence supporting the effectiveness of medical direction. The literature on clinical governance within paramedic services described a systems approach with shared responsibility for quality and safety. Contemporary paramedic clinical leadership papers in developed countries focus on paramedic professionalization and the self-regulation of paramedics. Originality/value The lack of strong evidence supporting medical direction of the paramedic profession in developed countries challenges the North American model of paramedics practicing as a companion profession to medicine under delegated practice model. This model is inconsistent with the international vision of paramedicine as an autonomous, self-regulated health profession.

Self-regulation and medical direction

“…Medical direction has a strong hold over paramedicine in North America, where paramedics and managers hold little power to change a system that is embedded in legal structures and accreditation requirements (Bass et al, 2015;Wydro et al, 1997). This contrasts with the situation in other high-income countries operating within the Anglo-American paramedicine system, where professional self-regulatory boards and clinical governance support the growth of an autonomous paramedicine profession (O'Meara et al, 2017;Wankhade and Mackeay-Jone, 2015).…”

“…There is little research comparing these contrasting quality management approaches. Nor did we find in our review of the literature any strong evidence supporting the effectiveness of either approach in paramedic services (O'Meara et al, 2017). For paramedics operating in systems where they are recognised and practice as autonomous health practitioners the medical direction model is perplexing (Council of Ambulance Authorities, 2014), while others aspiring to self-regulation find the concept frustrating (Ontario Paramedic Association, 1991.…”

The Structure and Characteristics of Anglo-American Paramedic Systems in Developed Countries: A Scoping Review Protocol

“…This review is built on the work of O'Meara et al (3,8) in identifying and building on the narrative related to the different models of clinical leadership found within varying models of paramedic systems around the world. With the addition of a wider scope of review, the research question was developed by a multidisciplinary team of researchers including health-based academics and practising paramedics.…”

“…Brief accounts of the differences in the leadership and management structure, education standards, governance, tiers of care and funding are noted in the literature. However, with the exception of O'Meara et al (3), there is paucity in research that critically analyses the difference in this model in any significant depth.…”

Paramedicine and mental health: a qualitative analysis of limitations to education and practice in Ontario

“…CME is provided by individual paramedic services and Base Hospitals. The Base Hospitals are Ontario’s medical direction model in which physicians oversee paramedics’ work and delegate regulated acts to them (O’Meara et al , 2017). CME sessions are either mandatorily required by all paramedics of a certain training level to maintain or update skillsets or optional whereby paramedics receive educational credits for completing training that is not required.…”