Paramedic use and understanding of their professional code of conduct

The role of professional codes in healthcare

The ethical delivery of healthcare is an integral part of the health professions and ensures that the patient’s interests are at the centre of healthcare practice. ⁵ Professional codes are intended to guide professional and ethical behaviour by establishing a profession’s collective values, while also helping to safeguard and promote the provision of equitable patient care. ⁶ Good ethical conduct from health professionals has been linked with their understanding of ethical concepts, ⁵ which underpin the principles of a professional code. ⁷

Professional codes are also an important part of the professionalisation of an occupation. Greenwood ⁸ outlines five distinguishing traits of the professions: systematic theory, professional authority, community sanction, a culture and an ethical code. A professional code is a form of self-regulation; a way for the profession to govern the professional and ethical conduct of those within it. ⁹ This allows those within the profession to be held to the same standard of expected behaviour, allows the public to understand what to expect from those within a profession and allows prospective new entrants into a profession to assess whether their values align with the collective values of the profession they are considering entering. ¹⁰

What is known so far?

A recent scoping literature review was undertaken examining the use, knowledge and understanding of professional codes in medicine, paramedicine and nursing. ¹¹ Despite the long history of professional codes within nursing and medicine, research from those professions shows that although clinicians highly value their codes as reflecting the collective values of the profession, they are poorly understood. ¹¹ Even when practitioners value and understand their codes, the research showed that the codes are seldom used in clinical practice.^{12, 13} This is for a range of reasons, such as a lack of knowledge, workplace conflicts and institutional barriers.^14-16 The literature review found no publications discussing the knowledge, awareness and use of professional codes by paramedics. As such, our understanding of this topic is limited to the experiences of cognate professions.

Significance to paramedicine

Paramedicine in Australia is an emerging profession and has only been categorised legally as a registered health profession since 2018. While health professions such as nursing have had long-established codes, including an international ethical code, ¹⁷ emerging professions such as paramedicine are still establishing these consistent expectations, which are communicated through a professional code. The introduction of the Paramedicine Code of Conduct in Australia was an important step in the professionalisation of paramedicine and is the first nationally consistent code for Australian paramedics. ⁷ The code establishes conduct standards that are consistent with what the profession, other professionals and the public expect of a paramedic practising in Australia. ¹ It contributes to the regulation of the profession and is enforceable by the paramedicine board, ¹⁸ that is, it is utilised as evidence of expected paramedic conduct in disciplinary matters. ¹⁹ As such, sound knowledge of the profession’s code is integral to good paramedic practice. However, despite the importance of the code of conduct to professional identity and good paramedic practice, it is unknown if Australian paramedics understand and use their code. Therefore, this study aims to explore Australian paramedics’ perspectives of their professional code, identify if they understand the purpose of the code and consider whether they believe the code is useful to their practice.

Design

This study used a Qualitative Descriptive (QD) design to investigate Australian paramedic knowledge, awareness and understanding of their professional code of conduct. A QD design is an increasingly used methodology in healthcare research, ²⁰ and is well suited for providing an understanding of participants’ perspectives and worldviews on a topic, describing phenomena where data are gathered directly from participants. ²¹ This approach was seen as appropriate for this question due to a lack of existing literature exploring this topic among paramedic clinicians, allowing for researchers to explore paramedic perceptions of their code in depth and generate hypotheses for future consideration.

Reflexive Thematic Analysis (TA) is described as a TA method that allows for a flexible approach to qualitative data analysis suitable for analysing rich data sets and reporting on patterns in the perspectives and experiences of participants. ²² TA has been criticised for allowing the interpretation of the data to be ‘tainted’ by researcher bias and subjectivity. However, Braun and Clarke acknowledge that the researcher’s subjectivity and interpretation of the data is not only unavoidable, but a strength of this method, stating that ‘researcher subjectivity is conceptualised as a resource for knowledge production, which inevitably sculpts the knowledge produced, rather than a must-be-contained threat to credibility’. (p. 337) ²³

Due to the theoretical flexibility of both QD and reflexive TA, researchers are advised to consider their own theoretical and philosophical assumptions when using these methods.^{24, 25} The authors of this paper have considered their own critical realist position. The theoretical assumptions made in the analysis of the data in this study are guided by hermeneutic theory. George ²⁶ refers to hermeneutics as an interpretive approach to understanding the meaning of text and speech through the examination of the text or dialogue within its context. Hermeneutics recognises the role of the interpreter in understanding a text (or speech) and acknowledges that interpretation must take place in its context to understand the desired meaning and intentions of language. ²⁷ As such, to better understand how Australian paramedics interpret the meaning of the code, it is also important to understand the context in which they interpret it. This includes understanding what purpose paramedics consider the code to have and how it fits into their professional role and identity as a paramedic. Consequently, hermeneutics guided this study as it explored the paramedicine code of conduct and its meaning and interpretation by Australian paramedics.

Study participants

Registered Australian paramedics across all states and territories were invited to participate in this study through advertisements on relevant social media networks and the Australasian College of Paramedicine Web site. The invitation directed potential participants to a Web site where they registered their interest in participating and completed a short demographic survey to screen for eligibility. Participants were eligible for enrolment in this study if they were a currently registered and practicing paramedic in any jurisdiction of Australia. Currently practicing was defined as meeting the registration standard ‘recency of practice’ by the paramedicine board. ²⁸

Participant selection

Non-probability sampling was used to ensure variation across experience and educational background of participants, to capture the range of perceptions amongst clinicians. ²¹ Reflective TA does not ascribe to and is not always compatible with the use of ‘saturation’ to determine sample size. ²⁹ As such this study aimed to recruit enough participants to provide adequate dialogue depth and sufficient ‘information power’. ³⁰

The aim was to select paramedics based primarily on years of experience working as a paramedic with the following minimum quotas:

(1) 2 paramedics with 0–3 years clinical experience (Bachelor-degree trained paramedics who will have always been registered with the Australian Health Practitioner Regulation Agency (AHPRA) and hence the code of conduct introduced from the beginning of their career)

Furthermore, among those selected, a variation of sex and location (by state of practice) was sought to ensure a diversity of perspectives. No participants were well-known by the lead researcher or research team.

Data collection

Semi-structured interviews were utilised to gather data. Semi-structured interviews give the advantage of being flexible and allow the researchers to gain rich data which explores the participants’ perceptions and experiences. ³¹ Individual interviews were conducted by a single interviewer and audio was recorded through videoconferencing software ‘Zoom’. The use of face-to-face interviews has been argued to be the preferred method for semi-structured interviews, ³¹ however, to allow for an Australia wide perspective, feasibility and due to the COVID-19 pandemic, interviews via video-link were determined to be most appropriate. ³²

Data collection occurred throughout August and September 2021. The interviews were based on an interview guide as shown in Appendix 1, although several follow up and probing questions were also used to explore participants responses.

Data analysis

Braun and Clarke ²² suggest that thematic analysis is often undertaken without a clear description of the analytic processes used, can be poorly understood by researchers, and requires a clear framework to ensure transparent and rigorous methods. As such, a structured six-stage framework was used, guided by Braun and Clarke ²⁴ ’s Reflexive TA:

Ethical considerations

Ethics approval was granted by the Monash University Human Research Ethics Committee (MUHREC) Project ID: 28921. All participants were provided with an explanatory statement and provided informed consent.

Theme 1. ‘You don’t know, what you can’t know’

This theme describes the data which indicated paramedics feel that they do not know the content of the code very well and that this may be linked to the perception of the code as quite long, complex and difficult to use or commit to memory.

Participants varied according to self-assessed knowledge of the code. Some felt they had very minimal knowledge of the code, often recalling they had not read it in several years.

Participant 11 - “I think, I when we first got registered, I had a look at it when they first brought it up. And then that was it. And then I’ve not looked at it since, that was God, what 2018–19? So yeah, I’ve not looked at it since.”

Others could not even be sure if they had read the code at all.

Participant 4 – “I guess, you know, it’s not like I’ve read. I haven’t read the codes of conduct. I’m sure I did, maybe in my degree, like, years ago.”

Some participants who had read the code commented on the broadness and complexity of the document. This was seen as a barrier to both understanding and using the code. Some felt the code was too vague, broad or not relevant to ‘actual paramedic work’, citing a lack of detail and specificity to the role paramedics performed to be of any practical use. Because the document was not interpreted as being specific enough, they were concerned it left too much open for interpretation and as such, they felt the application of the code was likely to be difficult and inconsistent.

Participant 3 – “It's not like legislation where it's relatively crystal clear what is and is not, you know, a law. It’s vastly vastly vaguer. And it’s inevitably just been something which is kind of vaguely referred to and from, but every single person is going to have a subjective interpretation of the wording. Which makes applying any kind of objective test as to whether someone’s breached it or not breached it incredibly difficult, if not impossible.”

Those who did use the code more often (notably policymakers or educators) felt they had reasonable knowledge of the code’s content. However, they did state they also do not know the content ‘word-for-word’ and tended to rely on understanding the general principles within the code, only referring directly to the code when seeking specific advice – for example, creating educational content.

Participant 1 – “…again, I go to the code, intermittently. And I’m not across it, of course, word for word.”

A few participants understood that the broadness of the code was necessary to allow for it to cover all possible situations and the varied working environments (including outside of emergency ambulance work) in which paramedics work. There was also a strong desire for the general principles within the code to be more clearly articulated or annotations added to help make the code both more relevant to paramedic practice and user friendly. These general principles were seen as the most important part of the code and some participants felt that understanding the underlying principles rather than memorising the specifics of the code was important.

Participant 7 – “…as someone who’s taught law and ethics and is very interested in it, I still don't think it's relevant that paramedics know it word for word. I think understanding the basic principles is really what's going to keep you registered and keep you practicing professionally, as opposed to going well, you know, subsection 63a states that, you know. But knowing, being able to, if someone says, can you tell me about the implied consent, the informed consent area of the code of conduct? You can go oh, yeah, well, I need to know, layman terms, I need to give, tell him how much it's going to cost, I to tell him how long it's going to take, you know, where I'm going to take them, that they can that they can revoke that consent, bla bla, bla, bla, bla, you know, that, uh, you don’t have to get it word for word.”

The use of general principles, which were easy to understand and communicate, was also thought to be important in embedding professional values in the paramedic profession and some felt this may make the code more practical, easier to understand and hence more likely to be used.

Participant 8 – “…it’s a little bit like the book of rules that sits on the shelf and people pull it down when it’s needed. There's a whole lot more to it than that, you’ve actually got to embed professional principles of professional practice and ethical, ethical practice within paramedic education. So that the Code of Conduct actually becomes the reference point.”

Theme 2. ‘I don’t need the code – the code is for others’

This theme discusses the idea that paramedics assume that the content and principles of the code are ‘common sense’ and that by using their own personal standards they will be meeting or exceeding the code’s standards. Some even felt that unless their personal standards significantly deviated from the code, they would not change their behaviour/practice based on its contents anyhow. Several participants indicated they thought that because the content of the code was either common sense or intuitive, they already met the standards contained within it – even if they had never read it or did not know it well.

Participant 3 – [talking about the standards in the code] “…I’m willing to assume that they’re more or less common sense. And that if I apply common sense, in my day-to-day practice, I won’t run afoul of them.”

When facing dilemmas or making decisions, some felt that their actions would automatically fall within the boundaries of the code, or that the code could not offer them any more guidance than they already had through other means. Respondents felt that as long as they did, ‘what feels right’ they would be acting in line with any professional expectations. There was also a belief that most paramedics would agree on what was considered professional conduct and this was based on an inherent knowledge of ‘right and wrong’ amongst the profession. As such some participants felt acceptable behaviour could be decided by applying a self-administered ‘reasonable person’ test.

Participant 5 – “I think at the basis of it, for me, the Code of Conduct probably just puts into words what we should already be doing, which is thinking is this, like, does it pass the pub test? If this behaviour was reported widely across the state? How would I be perceived?”

This concept of ‘common sense’ standards was also applied when asking to judge what would be considered professional practice in others. Interestingly, when asked how they would identify unprofessional behaviour in other paramedics, several participants stated they would use their personal perceptions of what was reasonable to conclude as to what was considered good practice.

Participant 4 – “I guess you sort of hold yourself as a standard, don’t ya? When, when you don't have any other sort of benchmark.”

When intuition or ‘common sense’ failed them, particularly in difficult ethical decisions, most participants stated they would ask a peer or senior at work their opinion rather than seek answers from the code. They also mentioned that this was how they felt they learnt what was acceptable in the profession when they were new to paramedicine. However, some felt as they progressed in the profession they tended to rely on this less and less, forming their own standards regardless of seniors or peer input. Some expressed that it would be difficult to be the only one doing something different and so eventually everyone just falls in line with the collective.

Participant 3 – “it would be very hard for me to continually be the only person doing a particular practice, when I'm surrounded by people who, who I see things, doing things differently, for years on end. Sooner or later, I would probably fall into either, whether it's right or wrong, into doing it in a way, which is consistent with all of my peers.”

Despite this, one participant reflected on the risks of everyone unquestionably falling in line with the cultural norm, as opposed to the code’s standard.

Participant 4 – “…and if it is part of the culture, and we're all doing it, then it’s like, you know, it's an accepted norm but you know, and no one’s able to pick up on it, because we’re all doing it.”

Most participants stated they did not use the code themselves because they did not need it to make good decisions. As such, there was an assumption that the code was only really used by and useful for students, educators, policymakers or those who ‘fell below the bell curve’ in professional conduct and thus needed guidance. Some suggested that the unprofessional behaviour they had witnessed reflected the (lower) individual standards of those who behaved that way, implying the behaviour was poor because it did not meet their own standards. Regardless, it was felt the code was most useful for ‘others’ who struggle with professional behaviour – but not ‘me’.

Participant 4 – “Making sure that, there's a baseline there for the lowest common denominator, I suppose for those people that don't really, that really struggle with just being a decent human, and treating people with respect and dignity.”

Theme 3. ‘It’s about time’

This theme describes participants’ responses which indicate that having a national standard such as the code of conduct is important to the paramedic profession, its identity and that it is long overdue.

This was particularly the case when discussing how participants thought the public viewed the profession and if they felt having a set of clearly defined standards was important. There was a strong sense of perceived trust from the public and this appears very important to paramedics, both for the identity of the profession and the practicalities of being able to ‘do the work’ of a paramedic.

Participant 3 – “…one of the things that I think is really impacting, that that element of trust from the public is just so huge and unbelievably solid, it's incredible. You go out to pretty much any person, and they've never met you before and you are instantly privy to anything, like just you can ask them any question and they will tell you, you know, with very minor exceptions, because this unbelievable degree of trust in you.”

The use of a clearly demarcated set of standards, underpinned by a regulatory body appears to be interpreted as important to maintaining this trust and communicating to the public the standards they can expect from a paramedic. Even if the public were not aware of who regulates the profession, participants felt it was important that it was perceived they were being overseen by a regulatory body.

Participant 3 – [talking about the code of conduct] “So the fact that we have one of itself, I don't think necessarily is, will particularly influence how people view us. I think, the fact that we actually to some extent use it, and that they have the fact that it's seen to be used will be what will influence the general public’s opinion.”

There was also repeated mention of the code’s importance to set a consistent national standard – both between the jurisdictional ambulance services and between the private and public sectors. Participants often described the code as ‘setting a minimum standard’ regardless of where or in what role a paramedic practiced. This was considered particularly important as participants reflected on the expanding use of paramedics outside of the traditional emergency ambulance role, both within jurisdictional ambulance services and in the private sector.

Participant 6 – “…so it does set a, a standard that we are all held to and should all be held to. And it’s not just across the private sector, and we have paramedics working in all kinds of different environments.”

Participants also considered that before becoming a registered profession there was no national standard and although the profession may have considered it knew what the expected professional standards were, it was important to have this articulated in a document so that those both within and outside the profession could understand the professional expectations and standards placed on paramedics.

Participant 1 – “…it probably goes back to my comment about how we needed to have something that was written, and that we could hold and, and look at and cite, rather than, than just having this unwritten rule, which is what I think we went by previously. I think we all as a profession, we thought we knew what professional paramedic practice looked like. But there was nothing specific that really explained it and put it into words. So, I think, for the profession, it’s really, really important.”

Overall, the code was interpreted as being an important part of the profession and paramedicine needed to join other health professions in setting clear standards. It was acknowledged that similar professions such as medicine and nursing have had long-standing professional codes which form part of their education and professional culture. The theme title ‘it’s about time’ was inspired by the following quote from one paramedic who expressed that they felt it was overdue that paramedicine had a professional code.

Participant 5 – “We don't have the same sort of long-standing professional codes of conduct that say medicine or nursing has had, because we simply haven’t been as established. So, it's about time, I suppose.”

Theme 4. ‘Navigating the New Profession’

This theme encapsulates the responses from paramedics who sought to make sense of how professional registration and the new professional standards (the code) fit into their role as a health professional.

Participants frequently talked about the new professional paradigm as being fraught with conflicts between personal values, employer expectations and the new professional expectations and values. There was the assumption by some if they maintained their employers’ guidelines and policies that they would also be within the standards of their professional code of conduct. Others noted there could be a conflict between employer policy and professional standards. Most participants stated that professional standards should supersede employer expectations when this occurs, however, participants appear to find this difficult to navigate, with some stating that they are more fearful of employer sanctions than regulatory sanctions.

Participant 7 – “…frankly, I'm more worried about my employer sacking me if something goes wrong, that's far more likely, I don’t think AHPRA would deregister me”

Conversely, some found that having a written code empowered them to approach their employer and contest policy which they felt was in breach of the code. This was demonstrated when several participants spoke about how either themselves or someone in their respective services had approached their employer regarding discussing the billing of ambulance services with patients.

Participant 11 – “I think we got an email from one of the managers saying, don’t mention, we’ve always been told, don’t mention the bill, or don’t talk to patients about billing. Then someone mentioned, oh as registered professionals, in our code of conduct we’re supposed to be clear and talk to them about billing. So that's where I thought it’d be good to know the code then and go and look at that and see what is expected of us, as you know, registered paramedics. Yeah, that would be one instance where the employer is asking you to do something against our registration.”

Regulation of the profession was mentioned as an important role of the code and there was also an acknowledgement that with professional registration came an increase in personal responsibility. This included the reflection of how professional standards enter into personal lives and that the expectations of the code extend beyond when professionals are at work. Social media was an example cited here, where it was clear that although some may consider this their personal lives, the lines of when you are considered a health professional are blurred – and bringing the profession into disrepute by breaching the code at any time is a serious issue.

Participant 8 – “You know, some other health professionals have come to grief because they’ve been doing some pretty outrageous things on social media. And people have been able to identify them as registered health professionals. And, you know, I have had people say to me, well, so what they’re not at work, they’re not on duty. They’re, they’re doing this in their personal space. There’s no such thing. Because if people can identify you, as a health professional that’s behaving badly, it reflects badly on the entire profession and brings potentially the entire profession into disrepute.”

Others mentioned seeing conflict arising between professional standards and personal values – citing the rise of antivaccination views within the profession as a prominent conflict at present. However, most participants felt it was important that paramedics upheld professional values and standards, even if this meant it conflicted with personal values, indicating if irreconcilable differences occurred, that those individuals would be best leaving the profession.

Participant 4 – “I think that they should put the professional values above their own. Otherwise, they should get another profession. Really, you know like, no one’s keeping you here. No one’s no one’s making you do the role.”

Despite this increased personal responsibility and belief that paramedics now needed to act as independent professionals when navigating conflicts with employer policy or personal values, one participant felt there was still quite some way to go before Australian paramedics would understand their new obligations under the national code.

Participant 8 – “I mean, one of the things that’s changed with registration is that people are now health professionals. You know, prior to that, you were a paramedic, employed by an ambulance service. And so, getting to that level of being registered as a health professional, has added to the obligations that you need to comply with, to practice as a registered health professional and to maintain your registration. So, there’s a new level of obligation if you like, post registration. And I think some people are trying to still get their head around that.”

Limitations and recommendations

This study is not without its limitations. Although QD research does not aim to be generalisable to the population, a broad range of views is important to gain as much depth into the topic as possible. ²¹ This study was limited by its lack of representation from several states and territories within Australia that may have different perspectives due to workplace and cultural differences. No participants indicated their highest education as vocationally trained (although some participants indicate their initial training was vocational), to seek responses from this cohort future researchers should consider recruiting specifically by educational background. There was also a notable shortage of representation from both paramedics in the private sector and female paramedics – both of whom make up a significant portion of the paramedic profession in Australia. Self-selection bias also may have been present in the participants of this study and several participants stated they expressed interest in participation due to an existing interest in the subject matter. Thus, the results of this study may not adequately capture the broad views of those who practice within the Australian paramedic profession.

The use of clear explanatory statements, examples or annotations to further guide professionals on the use of their respective codes can be seen in similar professions.^{4, 51} It would appear that Australian paramedics may also benefit from a similar explanation of the general principles contained within their code, to clearly define the underlying principles, increase their understanding of those principles and allow the profession to embed the same principles within its education and culture. However, further research should establish the best method for implementing further guidance (for example, annotations compared with explanatory guides) and if the introduction of these explanatory methods does in fact result in an increase in health professional understanding and use of professional codes. Moral complacency within the health professions can likely be improved through education, encouraging self-reflection on moral values – although how this education should take place to be most effective will also require further investigation. ⁴¹ Future research should also continue to examine the role of professional codes in the paramedic profession, with a particular focus on how to increase the awareness and knowledge of the content and principles contained within their codes. There currently exists a unique opportunity to examine the introduction of regulation and a professional code both within Australia and Aotearoa New Zealand. In addition, future research should examine in depth the navigation of the new professional responsibilities within the paramedic profession as it is occurring, what is guiding it and what can be learnt from this.