- Research
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Looking back to inform the future: a review of published paramedicine research
BMC Health Services Research volume 23, Article number: 108 (2023)
Abstract
Objective
Paramedicine has evolved in ways that may outpace the science informing these changes. Examining the scholarly pursuits of paramedicine may provide insights into the historical academic focus, which may inform future endeavors and evolution of paramedicine. The objective of this study was to explore the existing discourse in paramedicine research to reflect on the academic pursuits of this community.
Methods
We searched Medline, Embase, CINAHL, Google Scholar and Web of Science from January, 2006 to April, 2019. We further refined the yield using a ranking formula that prioritized journals most relevant to paramedicine, then sampled randomly in two-year clusters for full text review. We extracted literature type, study topic and context, then used elements of qualitative content, thematic, and discourse analysis to further describe the sample.
Results
The initial search yielded 99,124 citations, leaving 54,638 after removing duplicates and 7084 relevant articles from nine journals after ranking. Subsequently, 2058 articles were included for topic categorization, and 241 papers were included for full text analysis after random sampling. Overall, this literature reveals: 1) a relatively narrow topic focus, given the majority of research has concentrated on general operational activities and specific clinical conditions and interventions (e.g., resuscitation, airway management, etc.); 2) a limited methodological (and possibly philosophical) focus, given that most were observational studies (e.g., cohort, case control, and case series) or editorial/commentary; 3) a variety of observed trajectories of academic attention, indicating where the evolution of paramedicine is evident, areas where scope of practice is uncertain, and areas that aim to improve skills historically considered core to paramedic clinical practice.
Conclusions
Included articles suggest a relatively narrow topic focus, a limited methodological focus, and observed trajectories of academic attention indicating where research pursuits and priorities are shifting. We have highlighted that the academic focus may require an alignment with aspirational and direction setting documents aimed at developing paramedicine. This review may be a snapshot of scholarly activity that reflects a young medically directed profession and systems focusing on a few high acuity conditions, with aspirations of professional autonomy contributing to the health and social well-being of communities.
Background
Paramedicine is a rapidly evolving profession that encompasses not only paramedics working in emergency and non-emergency roles [1, 2], but for the purposes of this study the system in which paramedics work.Footnote 1 There is a question globally as to whether the changes within paramedicine may now outpace the evidence that informs it [3,4,5], which is especially evident in Canada.
National efforts to guide change in paramedicine have in some cases been in the form of reports proffering new directions but limited in the evidence used to support these recommendations. For instance, in Canada the 2006 Emergency Medical Services (EMS) Chiefs of Canada, now Paramedic Chiefs of Canada (PCC), disseminated a report entitled “The Future of EMS in Canada: Defining the New Road Ahead” [6]. Community paramedicine, or the provision of community care by specially trained paramedics, was recommended in the report. However, Bigham et al. in a systematic review published 7 years after the report included only 11 community paramedicine publications [7], and Thurman et al. [8] in a scoping review 14 years later included 29 publications. Both studies argued that making conclusions about the value and effectiveness of community paramedicine programs is difficult given the paucity and rigor of available evidence. Since 2006, research capacity and productivity in paramedicine has expanded [9], and evidence-based approaches are more common and expected. As a result, today it is more likely that any existing and future directions are guided by evidence, but in what areas and to what extent research or evidence supports or aligns with emerging directions for the profession remains unclear.
In Canada, at least two seminal documents related to supporting knowledge production and future directions for the profession have been published since 2006. One is a report titled the “Canadian National EMS Research Agenda” (2013) [10]. This research agenda was based on a mixed methods study [4, 11,12,13] and came about from the recognition of the need for evidence to drive decision-making related to clinical care and system-wide policy decisions. It provided a targeted effort to build the research enterprise in paramedicine, and made 19 recommendations in five categories (time, opportunities, and funding; education and mentorship; culture of research and research collaboration; structure, process, and outcomes; and future directions). It also achieved consensus from experts on 36 topics that required increased research effort.
The second is a recent publication titled “Principles Guiding the Future of Paramedicine in Canada” (2021) [14]. This publication was based on a qualitative study and recognized the broad changes that were occurring nationally in models of care, scope of practice, and policy. It also recognized that the 2006 visioning document was now outdated, and that the system was in need of a consolidated and shared framework to effectively guide future directions for the profession. It identified 10 principles:
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healthy professionals,
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professional autonomy,
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integrated healthcare framework,
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social responsiveness,
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continuous learning environment,
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quality based framework,
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patients and communities first,
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evidence informed practice and systems,
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intelligent distribution of services,
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and healthcare along a health and social continuum.
These principles promote more accountability to the professions of paramedicine, and the public and the healthcare system it intends to contribute to.
Collectively these publications, along with other published material such as standards developed by the Canadian Standards Association [15], have influenced, and are influencing the trajectory of paramedicine in Canada and other countries. However, as paramedicine strives to align its activities with the strongest empirical evidence, tracking the narrative on what is being published, and understanding where the paramedicine community is positioning its academic capital is needed. Recent bibliometric studies have highlighted where citations are greatest, and what journals, geographical location, methodologies, and contributors they represent, but they have yet to explicitly focus on the conversations and content of the citations [9, 16]. Collectively, these types of literature summaries can provide additional insights into the academic priority of the paramedicine research community, the state of the evidence base informing its advances, and where there may be gaps supporting its intended and unintended growth or evolution. Our aim is to contribute to this growing reflection on paramedicine’s academic pursuits.
The objective of this literature review was to broadly support initiatives to create a new vision for paramedicine in Canada by exploring the existing discourse in paramedicine research to reflect on the academic pursuits of this community. The research question guiding our work was: What research pursuits are being engaged in by the paramedicine community? Attending to the academic discourse provides a means of reflecting on whether existing or new directions can be supported by an evidence base and where additional attention may be necessary.
Methods
Our goal was to conduct a review of paramedicine research through use of a wide-ranging search strategy and elements of discourse analysis to contribute to a discussion of the most prevalent topics. As this review attempted to explore emergent discourse across an expansive literature with varying publication sources, we required a methodology that would: 1) provide a degree of rigor in search and selection of this broad field of potential literature; and 2) allow flexibility and iteration in the process around determining which literature was most relevant to our research objective. To structure our search, selection, and analysis we turned to the 2016 discourse analysis by Rangel et al. This research team had the similar task of considering an expansive literature (50 years’ worth) in medical education [17].
Rangel et al., applied a discourse analysis to “identify emergent thematic trends, the use of words and concepts, and how they are made and used by persons and institutions…”. Our aim was to examine the discourse derived from the academic pursuits of the paramedicine community, while using a systematic approach. When “a discourse is prominent it will be replicated and reproduced, and so it will be possible to pick up and trace its origins and evolution through a period of time” [17]. In this study, we identified articles focusing on paramedicine, then examined a sample of these articles using elements of discourse analysis as outlined by JP Gee [18] and leveraged by Rangel et al. [19]. To further guide our analysis we also used qualitative content and thematic analysis to help group and categorize topic areas [20,21,22].
Search strategy
In collaboration with a research librarian, we searched English language journals using Medline and Embase (Ovid interface), and CINAHL (EBSCO interface) from January, 2006 to April, 2019. We used a start date for the search of 2006 to align with the publication of the initial PCC report [23]. As the search was intended to identify the breadth of subjects in the literature related to paramedicine rather than a specific topic, broad search terms were used. These terms were based on common search terms employed in paramedicine [24, 25], and included “prehospital”, “paramedicine”, “emergency medical services”, “paramedic”, and “ambulance”; terms were combined using the Boolean operator “OR”. We also conducted a reverse citation search that identified literature citing the 2006 PCC report using Google, Google Scholar, and Web of Science.
Selection of articles
We anticipated that the total citation yield would be excessively large, and it would be neither feasible nor necessary to review all of it. We determined that a “systematic cluster sample” approach like that taken by Rangel et al. would be appropriate as it would identify articles relevant to our topic, but not assume that topics occur uniformly over time; an assumption that could end up excluding or underrepresenting topics that become prevalent for a particular and finite period.
Our first step was to reduce the yield by identifying the citations that were most relevant to paramedicine through application of the above-mentioned search terms to titles and abstracts. Then, we took the reduced yield and stratified by journal, identifying the journals that most frequently published paramedicine relevant citations. Finally, we took a sample of articles from those journals by grouping all citations into two-year clusters from 2006 to 2017, and each of 2018 and 2019, and taking a sample from each journal in each cluster. To include as much potential discourse as possible, we also elected to include all types of review articles. Based on the results of the cluster sampling, we further elected to include the top six peer reviewed journals. “Top” journals were identified by how many relevant citations were retrieved relative to the journal’s total citations, the impact factor, and the country of publication. In addition to peer reviewed journals, three non-peer reviewed paramedicine trade journals were included as they were deemed important to augment the written conversation through primarily editorial and commentary type articles. Collectively selecting a sample in this way provided an opportunity to balance the inclusion of sufficient information, representation, and opportunities for interpretation, with feasibility given the expansive literature base.
Data extraction and coding
In qualitative analysis, immersion in the data is a key component of identifying emerging concepts. Through immersion, “researchers reach an overall understanding of data and also the main issues in the phenomenon under study. This understanding prepares them to focus on the most important constructs recognized and presented in data” (pg. 103) [20]. Therefore, initial identification of potential discourse began while titles and abstracts were being reviewed. A data extraction form was developed collaboratively between one author (NC) and a research associate iteratively during this process. After some piloting, the extraction form was reviewed by two other researchers (WT and IEB), resulting in a final data extraction form. As we intended to both describe the literature, then use content, thematic, and elements of discourse analysis to understand the data, the form included fields for demographic data, literature type, study results, and context.
Four research associates were trained to perform full text coding of articles; articles were split evenly, and coding was completed independently. One additional reviewer (NC) performed quality checks as the coding was completed in order to ensure consistency and trustworthiness [26]. The team met periodically to discuss progress and reconcile issues through consensus.
Analysis
Our analysis plan included elements of content, thematic and discourse analysis as we required techniques that could both describe the data (through orderly search, selection, and extraction) and explain the meaning and context (through development and analysis of discourses). Overall, we were able to categorize each article under an emergent discourse, and then provide a narrative summary and description of the circumstances and conditions associated with the discourse (‘context’). Because of our approach, we were also able to attend to the trajectory of discourses over time.
To gain an initial understanding of the data, we employed qualitative content analysis, which permits a systematic approach while also flexibility according to the material being reviewed [21]. The purpose of the content analysis was to allow emergent and prevalent concepts to be iteratively identified [22]. We then sought to employ elements of critical discourse analysis as described above [19] which would allow us to both identify within the concepts what topics and discussions exist, how they have evolved, and how one discussion may have led to the next. In traditional discourse analysis, researchers may have “objects” or categories in mind; in this study these were not identified or outlined in advance. As with Rangel et al., we identified categories through careful reading of the literature and identified discourses around them. We conceptualized “discourses” as themes, how they were talked about and studied, as well as their trajectory.
Using this process, we were able to recognize and explore repeated concepts by defining, and stratifying them, drawing out prevalent discussions and themes, examining the context, and observing shifts in knowledge. In order to ensure trustworthiness of analysis, we worked in consultation with each other as we had during data extraction [26]. Triangulation of both methods (content, thematic, and discourse analysis) and reviewer interpretation during analysis allowed us to highlight and describe the key features of this expansive data set while moving iteratively back and forth through the data and our analysis [27].
Results
The search strategy returned 99,124 citations, which identified 54,638 non-duplicated citations for screening (Fig. 1). After applying eligibility criteria (described above) and searching for key words, we were left with 50,446 relevant citations, 7084 relevant citations from the nine selected journals, of which 2158 were reviewed for topic and summarized in Table 1, and 241 were retrieved and included for full text review and summarized in Tables 2 and 3.
Modified PRISMA diagram of search and selection
< 10;
10 to 14;
15 to 19;
20 to 24;
25 to 29;
> = 30The six peer reviewed journals included in the review were: The Journal of The American Medical Association, Prehospital Emergency Care, Academic Emergency Medicine, Emergency Medicine Journal, the Canadian Journal of Emergency Medicine, and BMC Emergency Medicine. The three trade journals selected for the review were: Journal of Emergency Medical Services, Journal of Paramedic Practice, and Canadian Paramedicine.
The categorization of peer reviewed citations from the 2158 relevant citations is summarized in Table 1. This table describes the frequency and publication year for the 26 identified topic categories. Briefly, the top three categories were operations (n = 262, 12.1%), resuscitation (n = 227, 10.5%) and airway management (n = 199, 9.2%). Certain topics (e.g., Operations, Resuscitation, and Pharmacology) appear to have more attention in recent years, whereas others (e.g., Airway Management, Education and Simulation, and Research) saw publication activity decline. The top 10 categories (Operations, Resuscitation, Airway Management, Pharmacology, Trauma Care, Clinical Skills, Education/Simulation, Practitioner Health and Wellness, Transport/Destination, and Myocardial Infarction) accounted for 74% of the 2158 citations. Table 2 provides a full narrative summary and description of context, based on the final sample of 241 citations. Trade journal citations were successfully mapped to the top 10 peer reviewed topic categories in all cases, except two. These two articles described the development of the paramedic profession (one describing a strategic plan for a college of paramedicine, and the other describing self-regulation). Each category presented in Table 2 was defined and further described through theming, resulting in between two and four themes per category (n = 30 total themes). For example, the Operations category was defined as “How paramedicine functions within itself, and within a larger health system”; there were four themes identified including System Impact and Costs, Resource Utilization, Triage in Dispatch, and Disaster Management. Additional detail is also provided on the context of the articles in each category, and a summary of those articles in terms of detailed study subject. We reflect further on the context of these findings in our discussion.
Table 3 describes the article types and research methods that were used in the final sample of 241 citations. The most common was observational research approaches (n = 96, 40%), which included cohort, case control, and case series. The second most common was editorial/commentary (n = 68, 28%), followed by knowledge synthesis activities (n = 27, 11%), which included systematic reviews, scoping reviews, etc.
Discussion
In this study we attempted to reveal the academic pursuits and research conversations the paramedicine community has focused on by exploring the literature since 2006. Trends, and frequency related to what has been published in recent history provide an opportunity to reflect on what has been deemed important to those aiming to advance paramedicine and where intended future directions for the profession may be attended to or not. Our results suggest: 1) a relatively narrow topic focus that does not entirely align with the priorities in aspirational and direction setting reports, given the majority of research has concentrated on general operational activities and specific clinical conditions and interventions (e.g., resuscitation, airway management, etc.); 2) a limited methodological (and possibly philosophical) focus, given that many were observational studies and editorial or commentary; and 3) a variety of observed trajectories of academic attention, indicating where research pursuits and priorities are shifting, and where confidence in the profession is situated. We discuss each in turn with implications for the profession to consider.
Scope of literature
The literature included in this study presents a narrow scope of primarily clinically focused topics such as resuscitation, airway management, and pharmacology. We also saw numerous articles that discussed how operations support clinical care. This appears to align, at least superficially, with priorities identified in the Canadian National Research Agenda, where 21 out of the 36 priority areas requiring additional or increased research attention fit into these topics [4, 10]. However, this finding does not directly support many priorities presented in a number of seminal reports published over the years that have endeavored to set a strategy for the future of paramedicine [6,7,8,9, 20], including the recently published principles document in Canada [14]. These seminal reports tended to focus on issues that highlighted the adaptability and advancement of paramedicine, which included concepts such as how paramedicine can provide novel approaches to primary and community care, how to improve quality of emergency services using evidence, how to develop and diversify the paramedicine workforce, how to create safe and sustainable workplaces, how to integrate paramedic care in the health system, and how to support a change in culture that will lead to new directions and models of care. Some of the literature topics can indeed be mapped to these aspirational and direction setting reports (e.g., a small amount of literature in the Operations category discussed paramedic system impact, and literature in some clinical areas that looked to improve interventions). However, this leaves other areas under-represented. These may include for example, ways in which paramedicine can leverage its adaptability and develop models, practitioners, and leaders that support an autonomous profession providing health care in a variety of settings, and meaningfully contributing to the health and social well-being of communities.
Scope of article types and methods
In addition to a narrow focus of topics, we also observed a narrow methodological focus. The primarily observational study methods, as opposed to methods that provide explanations (e.g., qualitative and mixed methods), suggested more of a focus on the “what” rather than the “why”. The attention on observational studies highlights two insights: first, the feasibility of certain types of study methods may be a challenge in paramedicine. For example, randomized control trials are complex and expensive to implement in the relatively austere environment in which paramedicine is practiced. Additionally, unlike many areas of medicine, there is a limited evidence base making it difficult to determine the ethical appropriateness of randomizing interventions in paramedicine care. Second, the methods likely reflect the philosophical positions informing research contributions and the research questions asked. As stated above, the types of clinical questions studied generally lend themselves to quantitative methods or perhaps positivist or post-positivist approaches. However, as mentioned in the discussion of the seminal aspirational and direction setting reports, most often written by paramedic leaders rather than academic researchers, future research questions may tend toward topics related to the development of the profession (e.g., development and diversification of the paramedic workforce, creation of safe and sustainable workplaces, etc.); meaning we may see the use of broader methodologies (e.g., qualitative and mixed methods) and philosophical lenses as time goes on.
Trajectory of research and conversations
Evolution of research questions and methods, as well as shifts seen within topics, help us gain insight into the trajectory of the paramedic profession itself. The literature highlights areas where the evolution of paramedicine is evident, areas where scope of practice is uncertain, and areas that aim to improve skills that have historically been considered core to paramedic clinical practice. Some of the topics in the literature clearly indicate where the conversation has evolved. An example is in the use of naloxone in paramedicine. In 2013, we see validation of criteria for the use of naloxone by paramedics and a conclusion that the drug is underutilized in the treatment of drug-related altered mental status [123]. In 2014, the evidence evolves to suggest that the scope and route of administration for naloxone must be cautiously considered to address the proliferation of opioid overdose [124]. Finally in 2019, a systematic review further progresses the discussion to ask if patients treated with naloxone can be safely left on scene [125]. There are also topics that highlight uncertainty around the scope of paramedicine care. This research tends to persistently focus on questions of whether paramedics can safely administer a treatment. For example, endotracheal intubation (ETI) has long been held as the gold standard for airway management. The language in some articles related to paramedicine suggest the authors remain unsure whether paramedics should be providing the intervention [93, 267, 268]. Finally, and in contrast to the topics where uncertainty existed, there are topics that continue to advance traditional paramedic skills. Studies that investigated subjects like trauma care and resuscitation tended to focus on new and innovative techniques, or improving existing techniques, with no questioning of whether paramedics should perform the skill (e.g., spinal immobilization) [158,159,160]. To be clear, we are not suggesting that interventions administered by paramedics should not be scrutinized, in fact it is critical that all health professions study what they do and how they do it. Our observation is that there were certain types of interventions where questions were persistently more focused on asking if a paramedic should do something, and others where the focus was around how it could be done better.
Implications
Paramedicine is full of potential, and uniquely positioned in the health care system to provide community care that ranges from emergency response to chronic disease management and palliative care. This review highlights that while paramedicine is in a state of rapid change as evidenced from aspirational and visioning documents, the evidence and knowledge generation to inform these changes may not be keeping pace as evidenced by the narrow topic and methodological focus described in this review. If we are to build evidence informed practice and systems in paramedicine, which was one of the principles identified by Canadian paramedicine stakeholders [14], the scholarly paramedicine community must connect aspirational and visioning documents with evidence that will inform the vision, and translation of knowledge to achieve the vision. This may lead stakeholders to consider the capacity that is presently available to create knowledge, and whether it is sufficiently resourced and focused to support paramedicine into the future. For example, do we have sufficient numbers of PhD trained researchers to support the research enterprise, and do we have a robust foundation of leadership science to move paramedicine into the future? It may also lead to questions such as what research questions are being asked, why are these questions being asked, and who is asking them?
To meet this potential, researchers can leverage the existing areas of strength (e.g., evidence from topics that have been studied extensively, and activities that have been shown to be effective and efficient) and broaden both focus and capacity. This could be achieved by looking to aspirational and direction setting reports to identify organizational and professional priorities, which may require refreshing extant documents (e.g., Canadian National EMS Research Agenda, PCC visioning document, National Occupational Competency Profile, etc.), and expanding the topic and methodological foci by creating communities of practice that include diverse skill sets and expertise. Through knowledge of our current evidence, careful examination of how paramedicine is moving forward, and purposeful collaboration, we can ensure that the evidence base for paramedicine supports all aspects of this adaptable and innovative profession and systems.
Limitations
The database was extensive (over 50,000 citations), which required distilling to a representative sample, risking some loss of information and introduction of selection bias. While our intention was to be reflective and stimulate discussion on what is being attended, rather than an exact map of every publication in paramedicine, it is important to consider how the sample was generated. For example, we recognize that there are some issues with Journal Impact Factor [269]. We de-emphasized the weight of the impact factor by emphasizing the proportion of paramedicine articles published by the journal, as well as the country of publication. The selection of largely North American journals may have captured Directive systems, where there is strong medical oversight and control of paramedics, compared to Professionally Autonomous systems, where there has been focused development of the role of paramedicine [270, 271]. This may have influenced the content of those journals. We did not include the Medical Subject Heading (MeSH) term “emergency medical technician” which may have systematically excluded articles related to basic life support care in the US. We feel the magnitude of this exclusion is small (i.e., approximately 60% of citations that include the “emergency medical technician” term were retrieved using the search strategy), and would likely not have influenced the reported topics, though it could conceivably have added to the level of detail discussed in certain categories.
The data required some degree of subjectivity, but wherever possible this was discussed thoroughly between research team members to ensure consistency and trustworthiness. For example, in the Operations category, extensive discussion ensued over what this meant and how to ensure consistent leveling of this category with other categories that were similar (e.g., response time, etc.). Additionally, it should be noted that we were not attempting to infer importance of the topics, but to reflect the breadth of topics that were retrieved. We approached this study as readers and consumers of the information and believe our process of having more than one reviewer per article provided assurances that our interpretations as knowledge users were appropriate. We did not consider the quality of the evidence or what direction the evidence was pointing: instead, we focused on what questions and topics were being attended to in the literature, and how and when it was studied.
Conclusions
Included articles suggest a relatively narrow topic focus, a limited methodological (and possibly philosophical) focus, and a variety of observed trajectories of academic attention, indicating where research pursuits and priorities are shifting, and where confidence in the profession is situated. We have highlighted that the academic focus may require an alignment with aspirational and direction setting documents aimed at developing paramedicine. This review when placed in historical context may be a snapshot of scholarly activity that reflects a young medically directed profession and systems focusing on a few high acuity conditions, with aspirations of professional autonomy in a supportive system collaborating with medicine to provide health care in a variety of settings and contributing to the health and social well-being of communities.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Notes
We are defining paramedicine in the broadest possible sense, which includes multiple specialized services and professions within the broader system, including communications officers (i.e., emergency and community paramedic call taking, and dispatch and strategic organization of paramedic units), medical consultation, supply chain, education, quality improvement, data analytics, infection prevention and control, employee programs (i.e., peer and professional support), specialized operational teams (e.g., tactical, CBRNE, air ambulance, etc.), and research.
Abbreviations
- EMS:
-
Emergency Medical Services
- MeSH:
-
Medical Subject Heading
- PCC:
-
Paramedic Chiefs of Canada
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Acknowledgements
We offer thanks to the Paramedic Chiefs of Canada for their leadership and funding of this study, and to the advisory group (Angela Graham, Jeremy Measham, Charles Dallaire, Neil McDonald, and Renee Boulay) for their ongoing assistance with data extraction, analysis, and review. We also thank Sarah Logan, Anna Li, Alanna Vaugeois, and Rebecca Bulmer for their support with search, selection, and data management. We thank Susanne Matthon and Pat Weigel for their administrative support. Finally, we offer thanks to Dr. Paul Ronksley and Leslie Fisher for their review and improvement of our manuscript.
Funding
Funding for this study included in-kind contribution of time for IEB and NC by Alberta Health Services, and payment of open access publication fees for this manuscript by the Paramedic Chiefs of Canada.
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NC: Project lead, study design, analysis, manuscript preparation, and knowledge translation. IEB: Initial concept, study design, analysis, manuscript preparation, and knowledge translation, co-senior most responsible author. DW: Initial concept, manuscript preparation, and knowledge translation. WT: Initial concept, study design, analysis, manuscript preparation, and knowledge translation, co-senior most responsible author. The author(s) read and approved the final manuscript.
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Cavanagh, N., Blanchard, I.E., Weiss, D. et al. Looking back to inform the future: a review of published paramedicine research. BMC Health Serv Res 23, 108 (2023). https://doi.org/10.1186/s12913-022-08893-4
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DOI: https://doi.org/10.1186/s12913-022-08893-4