Today’s question revisits the issue of conflict between an employer’s expectations and a paramedic’s scope of practice. My correspondent is:
… graduating as a Paramedic in Victoria at the end of the year and as such will be registering with AHPRA, I also work as a First Responder/First Aider with a company providing services to events. At a particular event, where I operate as a single officer there are items provided as part of my equipment that are well beyond the scope of a First Aider such as intubation equipment, chest decompression needles and physical aids such as pelvic binders and slishman traction splints.
I currently do not utilise them (nor have I had the need to) as I am not currently qualified or accredited, but that will change once I graduate.
I have been told by some currently registered paramedics that to work at that site may jeopardise our registration by not making full use of our registered skills when the equipment is present if it is required for patient care. It is an event with a high likelihood of significant trauma (Recreational Dirtbike/Motorcross with large jumps) where the use of such equipment may well become needed.
I recognise that this is a multifaceted question, involving ethics, duty of care, employment roles, legal ramifications etc., but was advised to ask on here as my lecturer was unable to assist.
I have answered this question, or questions like it, many times – see Don’t let the patient die (June 11, 2019), Revisiting conflict between a paramedic’s skills and an employer’s duty statement (April 26, 2021) and all the posts you can find here https://australianemergencylaw.com/?s=%22let+the+patient+die%22. I have also plenty of posts where people talk about being a health professional and working in a lower expected skill set (eg a doctor as surf-lifesaver, paramedics as firefighters).
There is however one point in this question I want to address. I want to reiterate that the Health Practitioner Regulation National Law does not define the scope of practice of a paramedic. Becoming ‘registered’ does not automatically open the door to a skill set or permission to do things that one did not otherwise have. There are no laws that say who can use ‘intubation equipment, chest decompression needles and physical aids such as pelvic binders and slishman traction splints’. They can be used by anyone who knows how and when, and when not, to use them.
A paramedic is required to practice within their scope of practice. The Code of Conduct for paramedics, published by the Paramedicine Board says:
Good practice includes that you:
- ensure you maintain adequate knowledge and skills to provide safe and effective care
- ensure that, when moving into a new area of practice, you have sufficient training and/or qualifications to achieve competency in that new area
- …
- consider the balance of potential benefit and harm in all clinical management decisions…
Your ‘scope of practice’ is that which you are capable of doing. A new graduate paramedic does not suddenly acquire new skills and competency on the day of registration or suddenly have access to and permission to perform procedures they did not have the day before. What they are required to do is reflect on their own skills and experience and consider what it is they are competent to do. Part of that self-reflection must also consider the limitations if any imposed by an employer. No-one really expects newly graduated paramedics to be competent to practice on their own hence jurisdictional ambulance services have long on-boarding processes to get the graduates up to an appropriate skills level. A newly graduated paramedic may have been trained in some techniques, but a reflective paramedic may still consider whether those things are truly in their scope such as they would apply them when operating as a single officer. What it means for this paramedic is not for me to say but for them to know and consider.
Fundamentally a paramedic has to provide care in the best interests of his or her patient taking into account that paramedic’s skills and knowledge, the equipment available, the directions of the employer. If you’re a paramedic, you don’t cease to be a paramedic because you work in a job with another title. You are practising paramedicine when you use your skills and knowledge as a health practitioner which you do regardless of the job title. You can expect to be judged against the standard of what an equally qualified and experienced paramedic would do in the same circumstances – ie not what they would do if they were part of a two-person crew responding in a jurisdictional ambulance but if they were facing the same circumstances including directions from an employer.
I cannot go past my earlier advice of Don’t let the patient die (June 11, 2019).
This blog is made possible with generous financial support from (in alphabetical order) the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), the Australian Paramedics Association (Qld), 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.
This blog is a general discussion of legal principles only. It is not legal advice. Do not rely on the information here to make decisions regarding your legal position or to make decisions that affect your legal rights or responsibilities. For advice on your particular circumstances always consult an admitted legal practitioner in your state or territory.
Australian Emergency Law 
Thanks for the work
An informative reply as always, thank you Dr Eburn for your continued worked in this space.
This question also raises important questions for us a profession and those educating our future paramedics. What is the independent scope we should be reasonably expecting of new graduates and is there even one scope of a freshly graduated paramedic (as is often expected)? Self reflection as always remains the most important aspect of this, but with a growing number of graduates working outside JAS (and often with no formal ‘graduate year’), industry also has an important role to play in assisting newly graduated paramedics identify an appropriate scope.
Thanks. Interested in your thoughts re this person being in Victoria and my presumption that they are working for a first aid service licenced under the Non-emergency patient transport and first aid services act 2003 (vic).
Your say ‘A paramedic is required to practice within their scope of practice’,in the case of working for a licenced first aid service, these organisations set the scope of practice for individuals in accordance with the scope of practice of the licence class. If the licence class limits the individuals scope of practice, then surely the individual is to work to that scope, irrespective of registered status and competence?
The Non-Emergency Patient Transport and First Aid Services Act 2003 (Vic) requires a licensed provider to have in place “clinical governance arrangements” (ss 3 and 42T):
The licence does not ‘set the scope of practice for individuals in accordance with the scope of practice of the licence class’ rather it sets the minimum, it does not mean that the individuals are not in fact qualified to provide a higher level of care.
In the context of an organisation that is licensed to provide first aid services it would be required to identify the scope of practice that is the level of service that they will contract to provide, but that does not mean that the people they send along are not competent to provide higher level care or that they cannot provide higher level care if it is required. Just that they cannot and do not contract to provide that care.
Equally they may say that to practice as a ‘First Responder/First Aider’ a person must have a certain qualification but in this case our correspondent is going to be a qualified paramedic, that is a (probably) higher qualification than the employer requires for their first responders/first aiders. It follows that if the paramedic does something that is beyond the scope of a first responder/first aider it does not mean that he or she is working ‘beyond their level of qualification, competence and training’.
To reiterate, the standard against which a paramedic is judged to is the standard to be expected of a similarly qualified and experienced paramedic. All paramedics would consider any limits set by their employer. In limited circumstances – and I want to stress this – in limited circumstances where a person is expected to die without intervention, the person treating the patient has the skills, knowledge and experience to intervene – they know what the problem is and what is required to give the patient the best chance and the equipment is there at hand – the practice is within their scope of practice in that it is within their skills, knowledge and experience regardless of whether it is the list of approved procedures set by their employer, then I don’t think the law says they should not intervene. And if they are a paramedic worried about legal consequences, they are more likely to get sued and disciplined for not acting in those circumstances than they are for taking action to save a life.
If it’s just a matter of convenience – in a perfect world, in another workplace I’d do procedure ‘x’ because it would make the patient more comfortable, or I know how to do it but it could wait 20 minutes until the on-duty paramedics arrive and there will be no significant impact on the patient, then it’s a different matter.
But if it’s life and death, you know the diagnosis, you know the treatment, you have the equipment available, the don’t let the patient die. And if your employer would prefer you to let the patient die think about whether you want to keep working there.