Exploring alternative paramedic roles: a multinational mixed-methods survey

Abstract

Background

While paramedicine is an evolving profession globally, there remain many disparities around titles and roles within the various jurisdictions that may not be fully captured in the literature.

Aim

The aim of this study is to gain a multi-national perspective on the current and future roles within paramedicine, highlighting the challenges and opportunities that shape the profession’s ongoing evolution.

Methods

A mixed-methods approach was adopted for this survey, incorporating both quantitative and qualitative data. A survey link was distributed internationally to paramedicine professionals via email, journals, and social media. Quantitative data were analysed using Microsoft Excel’s statistical functions, with results presented as frequencies, percentages, and numerical summaries. Qualitative data were analysed using narrative synthesis and integrated with quantitative findings to provide a comprehensive overview.

Results

The study gathered responses from 158 participants representing 59 organisations across 16 countries. Ireland had the highest number of respondents (n = 56) followed by Australia (n = 41) and England (n = 21). Participants outlined current paramedic roles (n = 54) and future roles planned within their respective organisations (n = 39). Participants described aspirational, non-traditional roles that they felt paramedics may adopt into the future (n = 86). Respondents practitioner titles varied across a range of clinical, managerial, and academic specialties, with examples provided (n = 33). Respondents provided various descriptions of the clinical levels of practitioners available within their organisations (n = 41).Various ambulance care models were identified with various combinations (n = 24). Paramedic medical oversight was predominantly provided by a physician (n = 56) although (n = 22) other examples were described. Regulation of paramedic practice provided descriptions of various regulatory bodies (n = 8) with examples of paramedic models of regulation described (n = 9). Respondents described various patient safety framework models implemented within their respective organisations (n = 10).

Conclusion

The findings from this study highlight that paramedicine is rapidly evolving in response to varying local healthcare needs and sector-specific challenges. Rather than striving for a uniform standard of practice, the results suggest that paramedicine should be viewed as a flexible and adaptive domain, capable of specialising across diverse clinical, managerial, and academic settings. The diverse titles, roles, and models described by participants reflect the growing complexity of the profession. Furthermore, the study indicates that paramedic practice is often shaped by local contexts, such as organisational needs and healthcare gaps, which create innovative opportunities for expanding the scope of the profession. By embracing this variability and focusing on the development of versatile healthcare practitioners who can adapt to societal needs, paramedicine can continue to evolve effectively within well-governed healthcare systems.

Introduction

Significant strides have been made in the professionalisation of paramedicine across countries such as the Republic of Ireland (ROI), the United Kingdom (UK), North America, Canada, Australia, New Zealand, and South Africa. These advancements encompass improvements in professional recognition, education, and regulatory frameworks [1]. Despite this progress, global inconsistencies persist in professional titles, educational standards, and scope of practice, roles, and registration, highlighting the ongoing challenges in achieving a unified professional identity. Although some jurisdictions have secured formal recognition for paramedics, the pace of professionalisation has not kept up with the evolving demands of healthcare systems worldwide. The development of paramedicine continues to be influenced by healthcare priorities, societal needs, technological advancements, and the ongoing balance between heterogeneity and homogeneity in practice models [2].

Defining the paramedic profession

The lack of a universally accepted definition of paramedicine has been a longstanding challenge. Eaton [3] identified nine different dictionary definitions of a paramedic, each sharing similarities yet lacking a unified consensus. Williams et al. [4], following a Delphi study, proposed a standardised definition of paramedicine, though acknowledged that global adoption would be difficult due to existing disparities. The 2016 National Emergency Medical Service Advisory Council (USA) report [5] documented 37 distinct terms describing pre-hospital practitioners, ranging from emergency medical technicians to paramedics. Long [6] highlights the need for an internationally agreed-upon definition, emphasizing its significance in strengthening the profession’s path toward global professionalisation. Despite decades of debate, consensus remains elusive [7,8,9].

Disparities in educational standards

Variations in paramedic education continue to present challenges. In the UK, professionalisation evolved significantly from the Pantridge Report (1966) [10], which laid the foundation for advanced life support (ALS) paramedic training. This led to professional recognition in 1999, the establishment of national standards in 2003, and the introduction of higher-degree education in 2004 [11,12,13]. Brooks et al. [14] attribute the evolution of paramedicine in the UK to higher education, specialist training, clinical advancements, and political reforms spanning five decades. Similarly, Australia’s paramedicine sector emerged in the 1960 s, with ALS developments and the introduction of degree-based qualifications in 1987. These advancements facilitated the National Health Workforce Innovation and Reform Strategic Framework for Action (2011–2015), which expanded paramedic roles and culminated in national registration in 2018 [15,16,17].

The USA and Canada followed different trajectories. The 1960 s"White Paper"report by the Department of Transportation [18] called for substantial improvements in emergency medical services, laying the groundwork for paramedicine in the USA. However, despite early recognition, standardisation of paramedic education and licensure remains fragmented due to complex state, provincial, and municipal regulations [19]. In contrast, Australia, the UK, and ROI have achieved national paramedic regulation, yet differences in educational requirements and scope of practice persist [20, 21].

Challenges in registration, licensing, and regulation

Disparities in paramedic registration, licensing, and regulation continue to hinder the profession’s global mobility and recognition, particularly when compared to nursing and medicine [22]. Even in countries with national regulation, challenges remain. In Australia, Reed [23] reports ongoing discord within the profession, suggesting that many practitioners struggle with their professional identity despite regulatory advancements. In Ireland, Knox [24] highlighted the need to integrate continuing professional competence (CPC) with paramedic registration over a decade ago, yet the Pre-Hospital Emergency Care Council (PHECC) has yet to implement such changes. Hill [25] argues that for paramedicine to advance, policymakers and allied healthcare professions must acknowledge and address the barriers limiting its development. This study aims to gain an international perspective on the current and future roles within paramedicine, highlighting the challenges and opportunities that shape the profession’s ongoing evolution.

Methods

Study design

This study employed a mixed-methods approach underpinned by a pragmatic paradigm, leveraging both quantitative and qualitative data collection methods [26]. As no pre-validated survey was available, the primary author developed a questionnaire, which was refined and validated through an expert peer-review process until consensus was reached. The peer review group comprised co-authors with extensive experience in paramedicine research and publication. Prior to dissemination, the survey was piloted with a convenience sample of senior academics at University College Cork (UCC) and revised accordingly (Supplementary File 1). A mixed-methods approach was used to capture a broad range of insights. The survey was distributed internationally to paramedicine professionals via email, academic journals, and social media platforms. Quantitative data were analysed using Microsoft Excel’s statistical functions, with results reported as frequencies, percentages, and numerical summaries. Qualitative data were analysed through narrative synthesis and integrated with quantitative findings to enhance overall interpretation.

Sampling

A digital survey link was distributed internationally using a convenience sampling approach to recruit participants working in the field of Paramedicine. Invitations were shared through email, social media platforms (e.g., Twitter, Facebook, LinkedIn), and the Australasian College of Paramedicine Journal, following approval by the Research Advisory Committee of the Australasian College of Paramedicine. To maximise engagement and response rates, these distribution channels were strategically re-engaged on three separate occasions over a three-month period (March–May 2023). This iterative approach ensured broader outreach and sufficient data collection. While the sample was self-selecting, efforts were made to enhance diversity in participation across geographical and professional demographics [27].

Data analysis

The survey employed a combination of open-ended and closed ended questions to capture both quantitative data for statistical analysis and qualitative insights to provide richer context to participants’ experiences. Narrative synthesis was utilised for conducting analysis, guided by the works of Popay et al. (2006), allowing us to systematically summarise and integrate findings from diverse data sources [28]. Quantitative data were analysed using Microsoft Excel’s statistical functions, with results presented in tables and graphs using frequencies, percentages, and numerical summaries to provide a clear overview of the findings. Qualitative data, consisting of respondents’ free-text responses, were analysed using narrative synthesis to integrate key insights within the quantitative findings. Instead, qualitative insights were directly integrated to support and contextualise the quantitative results. The combination of quantitative and qualitative data enhanced the depth and validity of the findings, offering a more comprehensive understanding than either approach alone [29].

Results

This study captured the responses of 158 participants, in 59 organisations, across 16 countries. The largest number of respondents originated from Ireland, (n = 56), Australia, (n = 41), and England, (n = 21), accounting for 75% of the overall results combined. The remaining 25% of respondents originated from South Africa, USA, Canada, Germany, Scotland, Northern Ireland, Papua New Guinea, Saudi Arabia, Wales, New Zealand, Norway, Switzerland, and Tasmania, combined (Table 1). Qualitative results are integrated with the quantitative results to provide a more comprehensive analysis.

Table 1 Demographic of respondents

Current paramedic roles

A variety of current paramedic roles were described within the respondent’s organisations, with (n = 54), examples provided. All 158 respondents completed the question providing multiple examples of all applicable roles available within their organisation with 665 responses recorded. Non-urgent patient transport was described as the most common role 16%, (n = 105), followed by community engagement, 19%, (n = 127), and flight paramedic 12%, (n = 79). Emergency response paramedic was 15 th, accounting for 2%, (n = 13), of the overall responses. A diverse range of specialist roles were described including mental health paramedic, 3%, (n = 21), prison service paramedic, retrieval paramedic, general practice paramedic, among others.

“Minimal available opportunities for diversification in paramedicine currently in the Northern Territory of Australia”.P13

Future paramedic roles

Respondents were asked to describe future roles planned for paramedics within their organisation, with (n = 39), roles identified. Community paramedic was the most common role described with 16%, (n = 33), followed by mental health paramedic and critical care paramedic at 9%, (n = 19) each. A range of alternative roles were identified equating for less than 2% each of overall responses that included pathfinder, search and rescue, advanced care, independent prescribing, cardiac arrest specialist, clinical hub, clinical leadership roles, consultant paramedic, registrar paramedic, diagnostic imaging, emergency care practitioner, minor injuries, emerging threat, enhanced low acuity care, expansion of existing roles, falls assessment, local referral, mental health expansion, military, offshore, social work, among others. A diverse range of roles were described by individual respondents with 24%, (n = 51), reporting to be either not applicable or not know of any future planned roles within their organisation.

“The future is exciting and very bright”.P112

Aspiring future paramedic roles

This question asked respondents in their opinion, to describe potential non-traditional roles that they might envisage the paramedic profession may aspire into the future. A broad range of roles were described across diverse specialities, (n = 86), in total. A number of respondents described the question to be not applicable or did not know, 16%, (n = 43). Roles within primary care were described 7%, (n = 18), emergency department, and community care programmes with 6%, (n = 17), each. While there were similarities with future roles described, a broad range of examples were described beyond the traditional norms such as palliative care paramedic, school-based paramedic, nurse paramedic model, physicians associate paramedic, PACER (Police, Ambulance, Clinician Emergency Response), dog peer support, among others.

“Hopefully more opportunities will become available within Ireland for paramedics, other than working on emergency ambulances”P108.

Practitioner title

When asked to describe their practitioner title, respondents provided (n = 33) descriptions. The largest number of respondents described themselves as paramedic (n = 67), 42%, with (n = 33), 20% described as advanced paramedic and (n = 6), 4%, described as critical care paramedic. A range of alternative titles were provided including critical care flight paramedic, (n = 5), 3%, emergency care paramedic, (n = 4), 2%, among others.

“Around one-third of paramedics in Australia do not work for an emergency service…. expansion of paramedic roles seems to be heavily political…….roles are also complicated by confusion about terminology”P144.

Clinical level within organisations

Table 2 details the distribution of clinical roles across organisations (n = 496). The most common positions are Advanced Paramedic (28.2%), Basic Life Support Provider (24.0%), and Critical Care Paramedic (18.5%), with a long tail of 38 additional roles each representing 0.2–3.6% of the responses. This wide variety of roles highlights the diversity in clinical staffing within the organisations (Table 2).

Table 2 Clinical level within organisations

Ambulance care model

Respondents provided (n = 24), examples of ambulance care models provided by their organisations. A paramedic-led care model with clinical practice guidelines (CPGs) was described by (n = 73), 46%, however the largest number of responses originated from jurisdictions Ireland, Australia, and England (75%), where this care model is long established. A range of discreet care models were provided including autonomous paramedic practice to physician led with examples of local and regional protocols and standing operating procedures (SOPs).

“Australia varies state by state, but paramedicine is jointly lead by doctors and paramedics. Doctors serve in a consultant/advisory role whereby they provide clinical governance functions but paramedics practice autonomously. Each state law allows certain degrees of private practice”P67.

Professional regulatory body/institution

Table 3 presents the distribution of professional regulatory bodies or institutions among respondents (n = 158). The largest group is affiliated with the Pre-Hospital Emergency Care Council (PHECC) in Ireland (32.9%), followed by the Australian Health Practitioner Regulation Agency (AHPRA) at 18.4%, and the Health and Care Professions Council (HCPC) in the UK at 14.6%. The table also includes smaller percentages from various other bodies, with some respondents reporting"Not Applicable/Not known"(15.2%), (Table 3).

Table 3 Professional Regulatory Body/Institution

Medical oversight

A range of examples were described by respondents when asked to describe the clinical level of medical oversight available within their organisation, with (n = 23), examples provided. Though medical oversite was routinely provided by a physician, 56%, (n = 89), alternative models were described such as advanced paramedics (n = 7), 4%, critical care paramedics, (n = 4), 2%, nurse and/or general practitioner, (n = 1), 0.6%, with many combinations of multidisciplinary teams including doctors, nurses, and paramedics. The remainder of responses varied from telephone support to consultant-led oversite. Some of the respondents reported the question to not applicable, not known to their practice (n = 11), 7%, as some respondents are university based academic roles.

Patient safety framework

The following graph summarises the patient safety framework responses (n = 325). The most frequently cited frameworks were Clinical Audit (36.0%) and Continuous Professional Development (28.0%), followed by Clinical Governance (11.7%). Other frameworks, including Mandatory Training, Professional Registration/Regulation, and various quality assurance measures, were mentioned less frequently (Fig 1). Figs. 2, 3, 4, 5, 6, 7, 8, 9.

Fig. 1

Patient safety framework

Fig. 2

Respondents organisation & country of origin

Fig. 3

Current paramedic roles

Fig. 4

Future paramedic roles

Fig. 5

Aspirational future paramedic roles

Fig. 6

Practitioner title

Fig. 7

Ambulance care model

Fig. 8

Ambulance care model

Fig. 9

Paramedic regulation

Paramedic regulation model

This question asked respondents to describe the level of regulation pertaining to their practice within their organisation and/or jurisdiction with (n = 9), models provided. Of these responses, 52% (n = 82) reported an independent regulatory body with 31% (n = 49), reporting state regulation. National registration with national regulation was described by (n = 12), 8%, of respondents with (n = 6), 4%, describing to have regional regulation. A small cohort of respondents reported the question not applicable to current role, (n = 2), 1.3%. The remaining responses consisting of less than 1% (n = 1), described regulation provided by medical director, national registration, provincial regulation, state and federal regulation.

“Germany has 16 state EMS regulations and about 400 ambulance service areas with their own organisation and governing rules, there is no state-wide data collection and scientific research has been under development since the professionalization of the paramedic profession in 2014 but is still insufficient to a large extent…. the emergency medicine specialty is still being prevented. Overall, many structural and political barriers to professionalising out-of-hospital emergency care—with increasing demand, as well as increasing cost pressures and staffing shortages”P51.

Discussion

Paramedicine is an evolving profession shaped by diverse healthcare systems, regulatory frameworks, and educational models worldwide. The findings of this study highlight significant variation in professional roles, educational standards, and governance structures, reflecting the complexity of paramedic practice in different regions. These variations, while indicative of the adaptability of paramedicine, also present challenges for workforce mobility, standardisation, and professional recognition.

Global healthcare landscape

The global healthcare landscape is undergoing rapid transformation, influenced by demographic shifts, epidemiological changes, and increasing healthcare demands. As a frontline profession, paramedicine plays a crucial role in responding to these evolving needs, from emergency and disaster response to chronic disease management and community-based care [30]. The expansion of paramedic roles into areas such as critical care, mental health, and community paramedicine reflects the profession’s capacity to adapt to emerging healthcare priorities [31, 32].

Societal needs and evolving roles

Paramedicine is increasingly recognised as an integral component of healthcare systems, bridging the gap between emergency medicine and primary care [33, 34]. Collaborative models such as community paramedicine, which involve paramedics working alongside primary care providers, public health agencies, and social services, have demonstrated potential in improving healthcare access and patient outcomes. These models illustrate the profession’s ability to extend beyond traditional emergency response roles, addressing gaps in healthcare provision, particularly in underserved communities [35, 36].

Healthcare priorities and resource constraints

Resource allocation and healthcare priorities vary across regions, affecting paramedic practice and professional development. In some countries, paramedics face challenges such as limited training opportunities, equipment shortages, and fragmented regulatory frameworks. Addressing these disparities requires a comprehensive approach that considers both immediate clinical needs and broader healthcare system reforms to support professional growth and enhance service delivery [37,38,39].

Technological innovation

Technological advancements are reshaping paramedic practice, offering opportunities to enhance patient care and operational efficiency [40, 41]. Mobile health technologies, telemedicine, and advanced prehospital diagnostics enable paramedics to deliver more precise and timely interventions. These innovations are not only improving patient outcomes but also redefining the paramedic’s role within integrated healthcare systems. However, the integration of new technologies requires appropriate training, infrastructure, and regulatory support to ensure their effective use in diverse healthcare settings [42,43,44].

Heterogeneity in education, regulation, and practice

Despite global advancements in paramedicine, significant variations persist in education, regulation, and professional recognition. Different countries follow distinct prehospital care models, such as the Anglo-American and Franco-German systems, each with its advantages and challenges [45,46,47,48]. Even within regions with national regulation, such as Australia, the UK, and the ROI, discrepancies in educational pathways, clinical governance, and registration requirements affect the standardisation of practice [2, 49, 50]. For example, in ROI, constraints within the national registration system limit paramedics’ ability to work independently or across different healthcare sectors, unlike in neighbouring regions like Northern Ireland and the UK [51]. These regulatory differences impact career progression, cross-border mobility, and the overall professional development of paramedics [52,53,54,55].

Balancing homogeneity and diversity

While efforts to standardise paramedic education and practice globally could enhance workforce mobility and quality assurance, achieving complete homogeneity presents challenges. Standardisation must be balanced with the need for local adaptation, recognising the diverse healthcare environments in which paramedics operate. Rather than imposing a rigid global framework, fostering collaboration and sharing best practices across regions may offer a more effective approach to advancing the profession while maintaining flexibility to address region-specific needs [56,57,58,59,60,61,62,63,64,65].

Conclusion

The evolution of paramedicine is influenced by global healthcare trends, technological advancements, and regional healthcare priorities. The profession’s ability to adapt to emerging challenges, expand its scope of practice, and integrate into broader healthcare systems is crucial for its continued development. Rather than striving for absolute standardisation, recognising paramedicine as a dynamic and flexible profession allows for innovation and responsiveness to local healthcare needs. This study underscores the need for ongoing dialogue between regulators, educators, and policymakers to support the professionalisation of paramedicine while respecting the diversity of global healthcare systems. By investing in education, strengthening interdisciplinary collaboration, and embracing technological advancements, paramedicine can continue to evolve as a vital component of modern healthcare, delivering high-quality, patient-centered care across diverse settings.

Limitations

This study offers a snapshot of global paramedicine challenges but has limitations. The sample size and recruitment methods may limit generalisability, as participation was voluntary and not fully representative of all regions. Anonymised responses prevented linking data to specific jurisdictions, restricting subgroup analysis. Additionally, variations in paramedic roles and titles across regions posed challenges in interpretation. Further research with targeted sampling is needed to explore these complexities in greater depth.

Recommendations for further research

Future research should focus on addressing the limitations identified in this study by incorporating subgroup analyses to explore variations in paramedic roles across different jurisdictions, regulatory frameworks, and models of medical oversight. A longitudinal approach could provide insights into how the profession evolves over time, particularly in response to regulatory changes and advancements in education and scope of practice. Additionally, qualitative studies involving in-depth interviews or focus groups with paramedics, educators, and policymakers could offer a more comprehensive understanding of professional identity, challenges in standardisation, and the impact of emerging healthcare demands. Comparative studies between paramedicine and other regulated healthcare professions may also help identify strategies for achieving greater global consistency. Finally, further research into the integration of paramedics into non-traditional healthcare settings, such as community-based care and mental health services, could provide valuable insights into the future direction of the profession.