Today’s question follows my post: Is that a job for a nurse or paramedic? (April 4, 2022). My correspondent says
I must admit that I (and many others) were disappointed that the Paramedicine Board did not (and still does not) delineate between the different clinical levels of paramedics, but in looking at your comments generally across your blog it seems that this instead [leaves it] up to the individual paramedic to set and also for the employer of paramedics to accept (or not) depending on the nature of the work that they are employing employees to do.
Naturally therefore, paramedics that feel competent and confident enough to hold themselves out as paramedics would no doubt advertise/sell themselves to be so. What therefore is stopping someone with a paramedic degree saying they are an instant ICP simply because they successfully completed a paramedic degree and received theory and instruction and practice in ICP skills, when in fact they clearly don’t have the years of experience required to consolidate and cement those to competently perform ICP skills and processes to the expected community standards in Australia (especially in solo operator roles)?…
Can an employer that decides to employ paramedics assume the applicant is competent in the skills and processes that they are purporting to hold before they are employed just because they say so in their CV based simply on a degree and registration, noting that the degree may have been years ago and that they may have worked as a private self-declared ICP ever since under an unknowing employer doing only standby roles at sporting venues or the like, which is clearly not the repeated high acuity experience ICP’s require in the community to be competent and experienced?
Is it unreasonable to expect that an applicant proves competence to their new employer in the multiple aspects of prehospital care before working for that employer as a paramedic, or are they required to prove competence to the new employer after employment by way of their internal training, assessment and CPG’s? Or are they not required to at all and their own self-directed CPD is all they need?
Essentially, I am concerned at the vague/general bar that the Paramedicine Board seems to have set in relation to paramedic skill sets, clinical interventions, and CPD. Yes that may instead be up to the employer to decide/watch, but isn’t the HCCC or coroners court or review by the paramedicine board a late mitt to catch claims of “I’m an ICP” when a private employer in particular may not understand or fully appreciate the difference between clinical levels of paramedics, because the employee held themselves out to be a ICP (quite convincingly too I have seen on paper), and when the para-medicine board didn’t see it as important enough to delineate between paramedic levels therefore allowing the perception to an unknowing employer that clinical difference isn’t that important? As we know, the stakes are higher and riskier the more advanced the skills and processes are.
And generally, if the para-medicine board doesn’t state it specifically, in your view what may be expected as a reasonable pattern of training or timeframe for any employer (apart from CPD) to require their paramedics to display skills/process competency/recency for different paramedic levels based on what might be deemed reasonable within law and community/industry expectation, if this is required at all?
That’s a long set of questions. I’m going to try and answer them in a ‘rolled up’ answer rather than distil each question and give a separate answer.
Health Practitioner Regulation National Law
The starting point is the Health Practitioner Regulation National Law. (Although it’s meant to be a national law it is in fact a cooperative scheme where each jurisdiction has had to pass an Act to adopt the national scheme. As is always the case when that happens, there are slight differences between the jurisdictions, so to answer this question (given my correspondent is from NSW) I’ll use the Health Practitioner Regulation National Law (NSW) as my source, but the answer is the same nationwide, that is the differences between the states won’t affect this answer, but I have to quote someone’s Act).
A person must not use the title ‘paramedic’ unless they are indeed a registered paramedic (s 113). For each profession a national board is established, that board is to ‘register suitably qualified and competent persons in the health profession’ and ‘decide the requirements for registration or endorsement of registration in the health profession, including the arrangements for supervised practice in the profession’ (s 35). The boards must develop registration standards (s 38) and may ‘develop and approve codes and guidelines’ (s 39).
The Act provides for registration in recognised specialities and divisions within the professions (ss 51-61; 115; 117-119). To establish a recognised speciality the National Board must obtain the approval of the Ministerial Council (s 13; formerly the Council of Australian Governments (COAG) Health Council, but now known as the Health Minister’s Meeting). There are no specialities within the profession of paramedicine.
The Paramedicine Board
The Paramedicine Board (the Board) has been established to manage the registration of paramedics. The Board has published necessary registration standards and codes, including the Code of Conduct for Paramedics (15 June 2018), soon to be replaced by the Code of Conduct for Paramedics (29 June 2022).
To qualify for registration, a candidate has to complete an approved program of study and meet the registration standards for Continuing professional development, Criminal history, English language skills, Professional indemnity insurance arrangements and Recency of practice.
There is a Supervised Practice Framework (1 February 2022) that relates to each of the registered health professions. It is up to the National Boards to determine when supervised practice is required. It may be required as a registration requirement (eg a person may be given limited or provisional registration pending completion of required hours of supervised practice) or to meet eligibility requirements for registration. The Paramedicine Board does not require supervised practice for graduates who have completed an approved program of study or an accepted qualification within the last two years. In their list of FAQ: Students and graduates the Paramedicine Board poses the following question, and gives the following answer:
Are new graduates required to have a certain amount of supervision in their first year of registered practice?
There is no formal requirement but it’s a good idea as receiving supervision is an important development tool.
If you do not have an approved or accepted qualification or it was completed more than two years old a period of supervised practice is required prior to registration (see https://www.paramedicineboard.gov.au/Registration/Documents-required.aspx).
In finalising my answers I’m going to assume we’re talking about graduates who have completed an approved qualification in the last two years and other registered paramedics.
What is an ICP?
Neither the Paramedicine Board nor the National Law define what, or who, is an ICP. Paramedics Australasia (that merged with the Australia and New Zealand College of Paramedicine to form the Australasian College of Paramedicine) published Paramedicine Role Descriptors (v 211212).The document is still available online but does not appear to be on the ACP website so I would infer that the online version is of historical interest only. In any event, the Role descriptors never had the force of law.
To paraphrase what I wrote in my book Emergency Law (4th ed, Federation Press, 2010 (so before paramedic registration), p. 39):
Humpty Dumpty said “When I use a word … it means just what I choose it to mean – neither more nor less” and in the absence of professional registration, the term “[intensive care] paramedic” means whatever the person using it wants it to mean.
An employer may choose to employ recent registrants – paramedics. The employer may require them to undergo some supervision and some further training to obtain competence in some skills, techniques or procedures that are relevant to that employer’s work environment. The employer (and employees) may agree that a person with those qualifications is for the purposes of that work place an ‘intensive care’ paramedic. A different employer may do something similar but have different required skills and competencies. Paramedics working for each employer may have different skill sets but both are called ‘Intensive Care paramedics’. For the purposes of the law, they are ‘paramedics’. In law, you are either a paramedic (ie registered with the Paramedicine Board) or you are not.
What then is to stop a paramedic calling him or herself an Intensive Care Paramedic? Fundamentally nothing, but an employer or contractor may want to ask ‘what do you mean by that?’ More importantly an employer or contractor would want to identify what skills and training a person has rather than what label they choose to adopt.
The problem is that different employers and contractors will have different levels of sophistication and understanding of paramedicine. A jurisdictional ambulance service will have no difficulty recruiting paramedics, understanding where they sit if they are new graduates, impose their own requirements for limited and supervised practice as a term of the new paramedic’s employment and will have a clear definition of what they mean by ‘ICP’ and which of their employees can use the title.
Other employers will have less skill in that regard. A factory that wants to employ a paramedic as an onsite health practitioner may have much more difficulty understanding claims to competency and title. Different employers will have to have their own ways of recruiting and assessing a potential employee’s skills and suitability.
Fundamentally what is “stopping someone with a paramedic degree saying they are an instant ICP” is that paramedics are now trusted and expected to be professionals. They are trusted to make their own judgements on many matters. The Code of Conduct says
Practitioners have a duty to make the care of patients or clients their first concern and to practise safely and effectively. They must be ethical and trustworthy. Patients or clients trust practitioners because they believe that, in addition to being competent, practitioners will not take advantage of them and will display qualities such as integrity, truthfulness, dependability and compassion. …
Practitioners have a responsibility to recognise and work within the limits of their competence and scope of practice…
Providing good care includes: … recognising the limits to a practitioner’s own skills and competence and referring a patient or client to another practitioner when this is in the best interests of the patients or clients…
Maintaining a high level of professional competence and conduct is essential for good care. Good practice involves:
a) recognising and working within the limits of a practitioner’s competence and scope of practice, which may change over time
b) ensuring that practitioners maintain adequate knowledge and skills to provide safe and effective care
c) when moving into a new area of practice, ensuring that a practitioner has undertaken sufficient training and/or qualifications to achieve competency in that area
The Code of Practice that will come into force in June 2022 has similar requirements.
As a professional a paramedic applying for a job, particularly if it is with an employer that does not have experience in employing paramedics, must consider the skills required for the job and whether they have or can obtain those skills. Failure to do so puts their registration at risk.
The definition of unsatisfactory professional conduct makes reference to conduct ‘below the standard reasonably expected of a practitioner of an equivalent level of training or experience’(s 139B). Where a practitioner claims to have particular skill or expertise he or she can expect to be judged against the reasonable practitioner with that skill or expertise even if, in fact, the paramedic does not have that skill. As the High Court said in Rogers v Whitaker (1992) 175 CLR 479,  (emphasis added) “The standard of reasonable care and skill required is that of the ordinary skilled person exercising and professing to have that special skill …”. If, for example, if a person holds themself out as a paramedic when they are not, they will be expected to demonstrate the skill of a paramedic even though they don’t actually have the relevant ‘level of training or experience’.
A person will be held to the level of skill that they claim to have. In the absence of a definition of ICP, if a paramedic claims to have skill and expertise in say ‘Intra-osseous access’ (something that the Paramedics Australasia Role Descriptor says is a skill for ICPs) then he or she will be expected to demonstrate that skill. If they fail to perform that skill reasonably they may be liable in negligence regardless of any title used.
It’s true that “[the Health Care Complaints Commission] the HCCC or coroners court or review by the paramedicine board [is] a late mitt [sic] to catch claims of “I’m an ICP”…” but that’s a legitimate and general criticism of all law. It is nearly always reactive. The criminal law only punishes after the crime has been committed; negligence law is only relevant after there has been negligence, loss and damage.
There are different ways to regulate behaviour. Paramedics (and other health professionals) could be strictly regulated with rules on each level and title etc. What changed in 2018 was that paramedics had earned their place amongst the other health professionals. They were to be regulated by trust in their own behaviour, their own professional standards. There may be rogues and fools but it is up to the profession to weed them out. Trust means that paramedics can and must make their own decisions about what they are competent to do and take responsibility for that decision if it turns out they are wrong. Trust means that indeed it may be the paramedic who is better placed than the employer (given the growing range of employers) to determine what skills they have, what training they need and what they can or cannot do.
Registration as a paramedic is all or nothing. A person is a paramedic, or they are not. There are no paramedic specialities as there are medical specialities. There is no legal definition of Intensive Care Paramedic, Flight Paramedic, Extended Care Paramedic etc. These are terms that different employers, and in some cases different paramedics can use. Jurisdictional ambulance services probably have very clear definitions of what skills an employee must demonstrate, and what training they must do before they can wear the title and attract the higher pay.
Private employers and contractors (and here I’m not thinking of private ambulance services, but say industries that employ onsite paramedics) have to trust the paramedics and expect the paramedics to practice only within their skills and competence, regardless of the titles they may claim. But the regulation of paramedicine is based on trust – it is the reward that paramedics earned by many years of being ‘the most trusted profession’.
This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.
Great Michael, thank you again, your insights are extremely valuable and beneficial to many.
With much appreciation.
As a retired NSW ICP now working as a Clinical Manager for a Private Provider of Medical Services to the mining industry for the past 3.5 years. This article is reflective of the ongoing battle faced with some new and pre-registration Paramedics who think that an PHTLS/APLS course or worse still an extra year at University to do a Masters, now qualifies them as an ICP. The Paramedics Australia definition you mentioned is usually the “go to” argument they often provide as the standard of ICP and therefore their ability to meet the criteria.
We have purposely built into our companies CGF and our credentialing processes, very strict criteria for recognition of ICP status and this is congruent to what a State Service would accept. We issue a Certificate to Practice to all Paramedics clearly identifying the skills they are authorised to use based on their verified qualification and experience. Sadly this is not accepted by many who feel they have the paper, yet limited actual “on road” experience and as you rightly point out Michael, which makes the real difference between an ICP who is safe to practice versus one who has the qualification.
Whilst we as individual Registered Health professionals do have a responsibility to practice within the scope of our experience, knowledge and ability, the motto I keep coming back to is one taught to me early on in my career …”Confidence does not always equal Competence”… It’s up to the non State Service providers to ensure we all set the bar high as the damage to the profession but worse still the patients we serve, is the result of unregulated ICP practice.