A qualitative assessment of practitioner perspectives post-introduction of the first Continuous Professional Competence (CPC) guidelines for emergency medical technicians in Ireland

It was established that all five groups unequivocally support the introduction of
CPC, however, there is a requirement to provide clarification in specific areas relating
to the required CPC activities. From the fora, it can be determined that some of the
most challenging or questionable areas relate to: the requirement to complete twelve
patient encounters; what is classed as a patient encounter and how to achieve this.
This, they suggest, could be facilitated if front-line ambulance placements were made
available to them. However, ambulance placements by themselves may not be adequate
unless the placements are in a busy area, in order to maximise the potential for varied
and numerous patient contacts.

Patient contacts and on-the–job learning facilitated through front-line ambulance
placements

The facilitation of front-line ambulance placements could have many benefits, and
not just related to more patient contacts. Placing EMTs with other professional colleagues
would also provide the opportunity for additional experience and learning. There is
value in such on-the-job learning, whilst there may be considerable difficulties in
evaluating its effectiveness 25]. Regehr and Mylopoulos 26] suggest that education research emphasises the importance of context-based learning:
if we shift our perspective from a focus on education to a focus on learning, we will
be able to direct additional efforts at understanding how professional learning not
only arise from practice, but actually occurs in practice and is informed by practice. These authors further suggest that apart from formal continuing educational delivery
practitioners should learn from their own personal experiences of solving problems
in their daily practice. Irish pre-hospital practitioners support the practical-based
and operational context of learning 2], 17] and international evidence also emphasises the importance of work-based learning
27]–31].

It would seem reasonable to suggest that EMTs are in favour of more patient contacts,
not only to fulfil their CPC regulatory requirements but also to increase their interaction
as pre-hospital practitioners and, thus, gain further experience. This is supported
by their responses: “it is very important for EMTs to get ambulance placements”; “Do
you see PHECC [Regulator] organising placements for us with HSE [Health Authority]
so that we can get experience to build up our patient contact?” Their comments support
the findings of previous studies, which demonstrated the preference of EMTs for participation
in frontline ambulance duties with paramedics/advanced paramedics 2].

One of the major threats to patient safety in the pre-hospital environment is errors
in decision-making and clinical judgement 32], 33]. Increasing their exposure to managing patients, through placements on frontline
emergency ambulances or in an appropriately supervised relevant hospital department,
would improve confidence and improve their ability in decision-making.

Linked to patient interaction is the ability to generate case studies and to encourage
reflective practice as part of the CPC process. Therefore the more patient contacts
the greater the opportunity to complete more case studies and encourage more reflective
practice. This is supported by comments from our participants who questioned: “How
do we get a case study, we need patient contacts and a case study may be difficult
for us?”

The learning portfolio

The learning portfolio is a collection of material that reflects on key events and
processes in a professional’s career 34]. By ensuring a learning portfolio is an integral part of the CPC process, the practitioner
can not only demonstrate evidence of proficiency but also should be able to identify
areas for improvement or for future enhancement. Self evaluation is an essential part
of continuous development 35]; the competent practitioner pursues lifelong learning through the recognition of
deficiencies and the formulation of appropriate learning goals. Hence, the ability
to assess one’s strengths and weaknesses is critical to the enterprise of lifelong
learning 36]. There is a requirement for reflection and maintaining a learning portfolio. Reflection
appears to be the ‘engine’ that shifts surface learning to deep learning 37] and transforms knowing in action into knowledge in action 38]. However, to encourage portfolio development, case study completion and reflective
practice there is a need to address the current deficit of examples and information
to maximise the proposed effect.

In our study, both cohorts appear to have a reasonable understanding of what a Learning
Portfolio is and what it should be used for. However, again, they would like to see
samples and clarification of what the Regulator would like to see them include in
their learning portfolios.

The role and function of the regulator – the Pre-Hospital Emergency Care Council (PHECC)

Participants believed that the Regulator could do more to assist with the effective
implementation of CPC. This theme involved a substantial amount of interaction and
response and detailed a considerable number of concerns. The areas of concern stated
most frequently related to the Regulator not providing clarification on specific areas
of CPC activities; not supplying templates for case studies or reflective practice;
not providing portfolio requirements or samples; not providing a facility that directs
registrants to national CPC programmes; and not providing details about auditing of
CPC portfolios.

It would not be unusual for a Regulator of a healthcare profession or professions
to provide information on Continuous Professional Competence/Education/Development.
Many Regulatory bodies have a dedicated department to manage queries, provide the
detail of audit and to interact generally with registrants. The Health and Care Professions
Council (UK) (HCPC) have considerable resources related to Continuous Professional
Development (CPD): information documents; templates; CPD video guides; audit process
video; constructing your CPD profile video; glossary of terms; CPD evidence examples;
CPD activity examples; audit dates; Standards of CPD; and a section on Frequently
Asked Questions 5]. However, the HCPC is a multi-healthcare professions regulator with 16 professions
and over 320,000 registrants and a much larger Regulator than the Irish Regulator.
In Ireland, the Health and Social Care Professionals Council, has published a CPD
Framework document as a template for each of their proposed registrant professional
groups 39] but this does not include pre-hospital practitioners. Of note, guidance provided
in their document contains information pertinent to CPD: templates; audit process;
assessment outline; examples and supporting documentation. Furthermore, the Irish
Medical Council, the body responsible for registering doctors, provides guidelines
on the maintenance of professional competence and gives an outline of medical practitioners’
requirements to enrol in professional competence schemes accredited by the Medical
Council 40].

Overall, there appears to be a consensus between both cohorts in our study that further
clarification in the areas described above should be addressed by the Regulator (as
done by the HCPC and Medical Council) to allow an effective model of CPC to be maintained
and standardised amongst participating cohorts.

Study limitations

As these were large fora comprising five groups with a total of 193 EMTs, this may
have prevented everyone from participating in the discussions. Also, as the questions
presented were pre-selected, these specific topics may have restricted other topics
from further discussion. While the group was drawn from many regions, it was representative
of only one EMT organisation, the Civil Defence, and while key areas were identified
for further clarification or requiring additional information from the Regulator,
the views are only that of one organisation’s members.