Australian paramedic graduate attributes: a pilot study using exploratory factor analysis

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Australian paramedic graduate attributes: a pilot study using exploratory factor analysis Brett Williams, Andrys Onsman and Ted Brown Emerg Med J 2010 27: 794-799 originally published online July 26, 2010

doi: 10.1136/emj.2010.091751

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Prehospital care

Australian paramedic graduate attributes: a pilot study using exploratory factor analysis Brett Williams,1 Andrys Onsman,2 Ted Brown3 1

Department of Community Emergency Health and Paramedic Practice, School of Primary Health Care, Nursing and Health Sciences, Monash University, Frankston, Victoria, Australia 2 Centre for the Advancement of Learning and Teaching, Faculty of Education, Monash University, Caulfield, Victoria, Australia 3 Department of Occupational Therapy, School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria, Australia Correspondence to Brett Williams, Department of Community Emergency Health and Paramedic Practice, School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University e Peninsula Campus, Frankston, Victoria 3199, Australia; brett. [email protected] Accepted 4 June 2010 Published Online First 26 July 2010

ABSTRACT Background The Australian healthcare system at all levels is under increasing pressure. The Australian paramedic discipline has seen a remarkable change in a number of areas including education, training, healthcare identity and clinical practice, particularly over the past three decades. Preparing future healthcare graduates for these expected changes therefore requires careful alignment of graduate attributes to core curriculum. Objectives To establish which graduate attributes best meet the current and future needs of the Australian paramedic discipline. Methods A convenience sample was used for the pilot study involving context experts from paramedic education and training sectors in Australia. Participants rated 56 items using a Likert scale on a paper-based self-reporting questionnaire. Exploratory factor analysis was undertaken on 50 items using principal components analysis (PCA) followed by varimax rotation. Findings A total of 63 content and knowledge experts participated in the study; 40 (63.5%) were male and 23 (36.5%) were female, with 28 (44%) aged 35e44 years. PCA of the 50 items revealed 10 factors with eigenvalues >1, accounting for 77.3% of the total variance. Items with loadings more than 60.40 with the factor in question were used to characterise the factor solutions. Conclusions It is critical that empirically-based paramedic graduate attributes are developed and agreed upon by both the industry and teaching institutions. Until this occurs, the national standardisation, accreditation and benchmarking of Australian paramedic education programmes will not be possible.

INTRODUCTION Paramedic education and training in Australia has undergone significant transformation over the past 130-year period. For over 30 years most Australian paramedic education and training was provided by Technical and Further Education organisations and/ or in-house Ambulance Officer Training Centres that acted as registered training organisations.1 The original programmes during the 1950e1970 period included short advanced first aid training programmes (bronze medallion). The short programmes eventually progressed to basic certificates in applied science (1970e1990s) that were underpinned by vocational education and training principles.2 Currently, entry-level paramedic qualifications are now offered at a bachelor undergraduate degree level, with some Australian universities offering postgraduate study at both the masters and PhD level.3 University-level paramedic 794

education programmes are now offered using contemporary models of educational theory and are in the early stages of integrating research-led teaching into the undergraduate curricula. The Australian paramedic discipline has seen a remarkable change in a number of its facets in education, training, healthcare identity and clinical practice, particularly over the past three decades. The move into the higher education sector has meant that questions such as benchmarking Australian undergraduate paramedic programmes, graduate attributes, skills, competencies and qualifications have yet to be undertaken at an undergraduate bachelor level at the 10 universities nationwide. The transition to the higher education sector has seen dramatic changes in some state ambulance services, with the loss of educational, training and employability controldcontrol and sovereignty that had previously always been held by the discipline itself. There has been a re-allocation of the traditional areas of professional jurisdiction and authority. In other words, traditional zones of professional turf and dominion have been reshaped. These changes have led to three features: (1) a duplication of education and training that new university graduates receive once they are employed by an ambulance service (ie, internship or graduate programme); (2) a lack of consistency about educational ideology between university providers and industry stakeholders; and (3) in turn, a mismatch and divergence between professional training and on-the-job paramedic roles. The net result of these features is educational duplication, financial inefficiencies and uncertainty if the current university graduates are meeting industry and community expectations. These features are occurring on a national scale, which is ultimately limiting the capacity for the Australian paramedic discipline to actualise itself as a fully developed and recognised healthcare profession.4 Throughout the higher education literature, the nomenclature surrounding ‘graduate attributes’ has many and varied meanings.5 6 To highlight this confusion, the term is considered interchangeable with ‘generic skills’, ‘core competencies’ and ‘graduate qualities’. Scanlon6 appropriately describes graduate attributes as ‘the generic skills, knowledge, dispositions and attitudes undergraduates develop during their university studies’ (p 125). This paper will use the term ‘graduate attributes’. While previous paramedic graduate attribute and curriculum research has been undertaken in the UK,7 8 currently no national graduate attributes formally exist that inform the Australian paramedic undergraduate curriculum. The purpose of this paper is therefore to identify what paramedic Emerg Med J 2010;27:794e799. doi:10.1136/emj.2010.091751

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Prehospital care graduate attributes will best meet the current and future needs of the Australian ambulance service and primary healthcare system.

METHODS Design This pilot study used a convenience sample involving participants at the inaugural National Association of Paramedic Academics in September 2008. The meeting aimed to form a collaborative network of paramedic academics from Australia and New Zealand for the enrichment of education and research within the discipline. Investigations into the most desirable graduate attributes were studied using a paper-based selfreporting questionnaire.

Participants Seventy-five staff from all universities/polytechnics in Australia and New Zealand that offer degree courses in paramedics attended the meeting, each of whom were professionally qualified and currently in positions directly involved in the education and training or paramedic personnel from the ambulance or health industry and/or university or polytechnic sector. The participants included all current university course coordinators, heads of departments and a majority of paramedic academics and senior ambulance educators. In summary, a large proportion of Australia’s and New Zealand’s content experts were in attendance.

Instrumentation A self-reporting instrument designed to assess which graduate attributes were best suited to the paramedic sector. Participants were asked to complete a 5-point Likert scale (1¼strongly disagree to 5¼strongly agree) 56-item questionnaire. Section 1 asked participants about their personal and professional characteristics while section 2 asked participants about their views on the most desirable graduate attributes. The graduate attributes were sourced from national and international literature7e14 including both paramedic and other cognate healthcare sources (eg, nursing, medicine, dentistry, occupational therapy, physiotherapy, pharmacy and physician assistants). This ensured that the attributes were sourced from all aspects within the healthcare system, providing a multidimensional, comprehensive and relevant set of graduate attributes.

Procedures Participants were informed about the study via an explanatory letter prior to completing the questionnaire. There were no exclusion criteria. Participants were advised of the anonymous and confidential nature of the study and that they could withdraw from the study prior to submitting the questionnaire. No incentives were offered and one questionnaire format was used for all participants who agreed to take part. All questionnaires were collected by an individual not directly involved in the study.

length of current professional role. The response rate was 96.9%. Of the 63 participants in the study, 28 (44%) were aged 35e44 years while only 4.8% were 1, accounting for 77.3% of the total variance. Items with loadings greater than 60.40 with the factor in question were used to characterise the factor solutions. Inspection of the screen plot and eigenvalues produced a departure from linearity coinciding with a 10-factor construct. The 10 resultant factors were descriptively labelled as indicated below (see table 2). Factor 1 was labelled Personal characteristics. There were eight items that loaded on this factor, with loadings ranging from 0.76 to 0.58 (explained variance 29.5%). The top item within the factor was: ‘A professional paramedic should be non-judgemental and non-discriminatory’. Factor 1 included characteristics such as trustworthy, caring, empathetic, self-aware and respectful of others. Factor 2 was labelled Clinical reasoning skills. There were eight items that loaded on this factor, with loadings ranging from 0.80 to 0.46 (explained variance 9.4%). The top item within the factor was: ‘A professional paramedic should understand their role in providing a primary healthcare service’. Factor 2 included characteristics such as critical thinking, counselling skills, clinical competence and adaptable to changes in clinical practice. Factor 3 was given the label Interpersonal and team skills. There were eight items that loaded on this factor, with loadings ranging from 0.82 to 0.51 (explained variance 6.0%). The top item within the factor was: ‘A professional paramedic should be literate and numerate’. Factor 3 included characteristics such as effective communicators and listeners, able to work in interdisciplinary teams and work independently as a member of a team. Factor 4 was labelled Professionalism. There were four items that loaded on this factor, with loadings ranging from 0.79 to 0.47 (explained variance 4.6%). The top item within the factor Table 1 Age of participants (n¼63)

Data analysis

Age group

N

%

SPSS Version 17.0 was used for data storage, tabulation and the generation of statistics. The data were also analysed by exploratory factor analysis using principal components analysis (PCA) followed by varimax rotation.

25e29 30e34 35e39 40e44 45e49 50e54 55e59 >60 Total

3 4 13 15 12 9 3 4 63

4.8 6.3 20.6 23.8 19.0 14.3 4.8 6.3 100

RESULTS Participant demographics The characteristics of the participants are described in relation to age, gender, employment status, current professional role and Emerg Med J 2010;27:794e799. doi:10.1136/emj.2010.091751

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Prehospital care Table 2

Correlation matrix (principal components analysis with varimax rotation)

Item

1

3.44 Non-judgemental and nondiscriminatory 3.46 Self-aware, recognising personal responsibilities and limitations 3.47 Respectful and consider moral, ethical, social, religious aspects of healthcare 3.48 Responsible for their actions 3.42 Trustworthy 3.45 Caring and empathic 3.50 Culturally sensitive and have an inclusive approach to differences 3.43 Able to see things from the patients’ point of view 3.07 Understand their role in providing a primary care health service 3.04 Good understanding of their patients’ welfare 3.08 Critical thinking 3.16 Operate within appropriate ethical and legal boundaries 3.03 Think critically 3.02 Counselling skills 3.13 Adaptable to changes in clinical practice 3.01 Clinical competence 3.33 Literate and numerate

2

6

7

8

9

10

h2 .743

.734

.742

.692

.713

.656 .631 .616

.459

.807 .794 .762

.605

.401

.392

.763 .679

.508 .803

.777

.742

.734 .866

.689 .440

.681

.824 .791 .768 .742 .649 .902 .773

.591 .581 .559 .467 .823 .701

.419

.404

.687

.729

.645

.727

.638 .590

.717 .822

.535

.788 .790

.742 .822

.717

.812

.596 .710

.751 .782 .841

.701

.709

.663

.814

.518

3.18 Committed to the discipline 3.30 Commitment to self-development 3.14 Attempt to attain high clinical status within the healthcare system 3.39 Able to provide leadership, mentoring and supervision skills 3.27 Capacity to undertake self-directed approaches to learning 3.29 Theoretical knowledge 3.12 Contribute to continuous improvement within the healthcare system 3.49 Embrace social responsibility 3.26 Continue to learn and to help others to learn 3.24 Apply knowledge of the basic sciences 3.25 Respond to changes in the provision of health care due to evolving community expectations 3.23 Willing to undertake ongoing education 3.15 Understand the role of paramedic care within the broader healthcare system 3.40 Able to take responsibility for quality of care and health outcomes 3.09 Clinical reasoning skills 3.06 Integrate population-based care into their practice 3.05 Practice preventative healthcare 3.28 Capacity for enquiry and research 3.21 Specialist knowledge (e.g. Practitioner or extended scope roles) 3.22 Ability to learn including the ability to use reflection and learn from experience

Eigenvalues Explained Variance

5

.761

3.37 Able to work in interdisciplinary teams 3.31 Capacity to use communication and information technology effectively and appropriately 3.32 Effective written and oral communication skills 3.35 Accept guidance from colleagues 3.34 Good listener 3.38 Ability to work independently as well as a member of a team 3.36 Value the importance of teamwork 3.19 Adhere to a code of ethics 3.20 Aware of, and regard for, professional issues such as; accountability and confidentiality 3.17 Follow evidence-based practice

Factors 3 4

.438

.476

.419

.459

.438

.663 .741

.456 .697

.850

.668

.713 .691

.584 .763

.733

.722

.818

.701

.790 .759

.514 .788

.766

.641

.463

.540

.884 .836

.833

.545 .408

.730 .802 .785 .842 .535 .826

14.9 29.5%

4.7 9.4%

3.0 6.0%

2.3 4.6%

2.2 4.4%

1.9 3.8%

1.8 3.7%

1.5 1.3 3.0% 2.7%

1.2 2.5%

Note. Bolded loadings highlight item allocation for each factor h2 = communality.

796

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Prehospital care was: ‘A professional paramedic should adhere to a code of ethics’. Factor 4 included characteristics such as adhering to a code of ethics, committed to the discipline and respecting issues such as confidentiality. Factor 5 was labelled Continuing professional development. There were five items that loaded on this factor, with loadings ranging from 0.71 to 0.45 (explained variance 4.4%). The top item within the factor was: ‘A professional paramedic should have a commitment to self-development’. Factor 5 included characteristics such as committed to self-development, self-directedness and providing leadership and mentorship. Factor 6 was given the label Social awareness. There were three items that loaded on this factor, with loadings ranging from 0.69 to 0.58 (explained variance 3.8%). The top item within the factor was: ‘A professional paramedic should contribute to continuous improvement within the healthcare system’. Factor 6 included characteristics such as social responsibility and empowering others to learn. Factor 7 was labelled Flexible learning. There were four items that loaded on this factor, with loadings ranging from 0.76 to 0.51 (explained variance 3.7%). The top item within the factor was: ‘A professional paramedic should be able to apply knowledge of the basic sciences’. Factor 7 included characteristics such as undertaking ongoing education and training and application of basic sciences in the broader healthcare sector. Factor 8 was labelled Accountability. There were two items that loaded on this factor, with loadings ranging from 0.78 to 0.64 (explained variance 3.0%). The top item within the factor was: ‘A professional paramedic should be able to take responsibility for quality of care and health outcomes’. Factor 8 included characteristics such as taking responsibility for quality care and clinical reasoning skills. Factor 9 was labelled Evidence base practice. There were three items that loaded on this factor, with loadings ranging from 0.83 to 0.40 (explained variance 2.7%). The top item within the factor was: ‘A professional paramedic should be able to integrate population-based care into their practice’. Factor 9 included characteristics such as integrating preventive healthcare into practice and enquiry and research-led practice. Factor 10 was labelled Self-directed practice. There were two items that loaded on this factor, with loadings ranging from 0.78 to 0.53 (explained variance 2.5%). The top item within the factor was: ‘A professional paramedic should have specialist knowledge (eg, practitioner or extended scope roles)’. Factor 10 included characteristics such as implementing critical reflection into practice and working independently. Cronbach’s a coefficients were used to assess the internal consistency of each of the 10 factors identified from the PCA. The Cronbach a calculation produced a high reliability (0.83). Seven of the 10 factors produced Cronbach a coefficients >0.7, indicating good internal consistency, particularly in the context of exploratory research (factor 1: 0.87; factor 2: 0.83; factor 3: 0.88; factor 4: 0.79; factor 5: 0.82; factor 6: 0.73; factor 7: 0.77).15 16

DISCUSSION The relatively recent decision to move training programmes into the higher education sector has meant that questions such as benchmarking Australian undergraduate paramedic education programmes by means of graduate attributes have yet to be formally addressed. Without national standardised curriculum guidelines, this continues to cause educational duplication, uncertainty and financial inefficiencies in many sectors of the paramedic discipline. The findings of this study help to address Emerg Med J 2010;27:794e799. doi:10.1136/emj.2010.091751

some of these issues by providing a preliminary set of graduate attribute factors that can be built upon. Given the exploratory intent of this pilot study, only three items failed to load onto a factor solution, indicating that most of the attributes were deemed to be acceptable for Australian paramedics. This is perhaps not surprising since the original 50 graduate items were sourced from well-established cognate healthcare professions, suggesting the graduate attributes are well recognised by other health disciplines. In 2004 a set of ‘national ambulance competencies’ were created that were benchmarked at a vocational diploma level.17 However, these competencies are not applicable to the higher bachelor level learning expectations and requirements of paramedic students and thus have emphasised a need for graduate competency reform, particularly as broader healthcare issues including intradisciplinary health management and extended scope practitioner models are currently being considered. Factor solution 3 (Interpersonal and team skills) embraces attributes supportive of the mounting interest in intradisciplinary education and practice in Australia, with items such as being able to work in intradisciplinary teams and valuing the importance of teamwork being identified. These attributes have also been acknowledged by Hammick et al18 as being important characteristics of intradisciplinary practitioners for the 21st century. Without graduate attribute reform, three major issues come to the fore. First, a new set of empirically-based national attributes needs to be developed, validated, trialled and revised that are at a higher level than a vocational diploma. Present undergraduate diploma competencies, while providing foundational skills and knowledge at a novice level, are quickly superseded (usually in the first year of study) by the higher bachelor level qualifications. The reality is the undergraduate diploma level competencies have become educationally incongruent since a clear linkage between learning objectives and activities cannot be achieved or matched in the final years of study, both in coursework and clinical placement learning contexts. The findings of this pilot study provide the Australian paramedic discipline with a set of national graduate attributes that are (1) empirically-based for the Australian context and (2) geared for reforming tertiary level curriculum and employment requirements. This offers a potential solution to the ongoing issue surrounding the notion of work-readiness versus job-readiness, as the expectations of the paramedic industry would match the quality of paramedic graduates.19 Second, this educational ambiguity creates the potential for professional encroachment, with the notion of a non-professional identity continuing to create an imbalance in national education, training and provision of standards. This uncertainty not only impacts the potential transition into extended scope of practice roles such as physician assistant and paramedic practitioner, but is fundamentally undermining what is defined as a paramedic. Other professions such as nursing, medicine, dentistry and physiotherapy have achieved national standards, national accreditation, a sense of work-readiness versus jobreadiness and fitness for practice and a set of prescribed graduate attributes. The Australian paramedic discipline presently has none of these and consequently remains a semi-profession without national registration or regulation.20 Third, greater communication must occur between universities, ambulance services, paramedic peak bodies, state health departments, state and federal governments and registration/ regulation boards. This will ensure the employability of paramedic graduates and that graduates have the necessary skills, knowledge and attributes that best meet their local needs, but 797

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Prehospital care also the broader healthcare requirements. At present this does not effectively occur on a local, state or national basis. The product of this ineffectiveness and uncertainty of graduate attributes is manifested by education and training inefficiencies and reinforces the confusion surrounding work-ready versus jobready and notion of fitness for practice.19 For example, university graduates, once employed, are generally retrained by the ambulance service that employs them over a lengthy period (often 12e18 months), creating extensive educational overlap and the potential for ‘de-learning’. The first paper7 of the two-part series concluded that paramedic education and training continued to develop a curriculum without being informed, clearly articulating or acknowledging what desirable attributes staff would have on completion of their training programmes. In the second part of this series, informed by earlier findings from a Delphi study, Kilner8 used factor analysis to explore the inter-relations between three paramedic occupational groups. Kilner argued that paramedic education and training has not responded to changes either from within the paramedic discipline or from the broader healthcare sector, views that are held by many in paramedic circles in Australia. Similar educational imbalances between pedagogical purpose and desirable professional attributes were also highlighted by Kilner8 where he argued that similar curriculum disparity occurred due to large components of the curriculum not being linked between what was taught and what was needed. While different benchmarks exist between paramedic education and training in the UK and Australia, parallels do exist with what should be included in the core paramedic curriculum. These parallels are reflected in similar item loading between Kilner ’s study8 and this pilot study. For example, factor 1 (Personal characteristics) in both studies included items such as non-judgemental, non-discriminatory, caring, empathic and recognising personal limitations, again indicating that graduate attributes between the two countries have some unity. Given the differences in governance, educational models and when these two studies were undertaken, opportunities exist for the investigation of an international paramedic curriculum in determining if correlations or associations exist. In other words, should an international paramedic curriculum blueprint or educational consensus be created? It is argued that the Australian paramedic discipline has not established its own unique body of knowledge.20 The establishment of these attributes will assist the paramedic discipline in its quest to becoming a fully recognised profession by developing a defined standardised and specialised unique body of knowledge base based on research-led evidence-based practice. For example, factor solution 9 (Evidence base practice) included attributes such as integrating preventive healthcare into clinical care and incorporating enquiry and research into practice. Reynolds21 has argued that research-led practice not only generates unique knowledge, but also importantly differentiates paramedics from others in the divisions of labour. Many other healthcare disciplines such as nursing, midwifery, medicine, dentistry, occupational therapy, physiotherapy, pharmacy, optometry and speech pathology provide examples of the use and necessity for both generic graduate attributes and discipline-specific competencies. Graduate attributes are required to underpin registration and regulation requirements.22 Some of these disciplines emphasise the need for explicit graduate attributes and competencies that establish the relevant learning outcomes that best meet professional, industry, societal and healthcare needs. This point is illustrated by the work undertaken by Kilner.7 8 798

A range of issues and potential strategies have been raised in the rhetoric and arenas of critical debate. However, a number of areas are most applicable to the paramedic discipline including understanding employer and graduate needs and how to ensure graduate attributes are integrated into the undergraduate curriculum. These areas have yet to be adequately articulated and researched from an Australian paramedic context. While results from the pilot study have guided and informed the researcher of the potential strengths and weaknesses of the research project and therefore the basis to undertake a larger national study, specific results and generalisability should be interpreted with caution, particularly given the small sample size. Another limitation of the study was the use of convenience sampling. Despite this limitation, the results between different groups have raised some interesting questions. Recommendations for future research include establishing further construct and content validity using a larger sample size from a broader cross-section of the paramedic population, and using these graduate attributes in the development of a paramedic curriculum framework.

CONCLUSION It is critical that empirically-based paramedic graduate attributes are developed and agreed upon by both the industry and teaching institutions within Australia. Until this occurs, the national standardisation, accreditation and benchmarking of paramedic programmes as well as the registration of individual paramedic practitioners will not be possible. Findings from the exploratory factor analysis in this study provide the basis for the development of a reliable and valid graduate attribute instrument that can provide the necessary curriculum blueprint, offering the discipline a potential solution to its standardisation and accreditation issues. Competing interests None. Ethics approval This study was conducted with the approval of the Monash University Committee on Ethics in Research Involving Humans (SCERH). Provenance and peer review Not commissioned; externally peer reviewed.

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