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The roles of the rural paramedic practitioner

The roles of the rural paramedic practitioner: case study of Australia
The sight of an ambulance attending to emergency cases is familiar to all people. In itself, it demonstrates the work of a paramedic practitioner who attends to the injured or the acutely ill. However, in recent times, the scope of the paramedic’s work is expanding. In particular, the duties of the rural paramedic are expanding, which is evident from their active engagement in primary health care and the wider community focus. From the paramedic’s scope of practice, like it is defined  by the CAA (Australian Council of Ambulance Authorities), the role of the rural paramedic covers different areas. These areas include emergency care, rural community engagement, primary health care and practice extension. The definition specifies that the rural paramedics will work together with ambulance volunteers, but they are not necessarilya member of the primary response team, like the volunteers.In many cases, the rural paramedic will work together with the volunteer staffs, like a member of the primary response crew.
Background and Rationale
Due to the changing focus of the job of the rural paramedic, the focus of work is changing from that of an emergency practitioner, to that of a community-based healthcare personnel; the paramedic is working, more closely with the practitioners from other disciplines.The expanding role of the paramedic is similar in other countries, including the USA and UK. The expansion in the duties of the paramedic has led to the development of an information base, used as a guide for the postgraduate qualification of Australian practitioners at the James Cook University (Andersson, Lennox & Petersen, 2003).The development of courses of that type is a step ahead, towards the future of the practice of the rural paramedics in Australian. Following the light of this discussion, this paper will explore, whether the role of the rural paramedic is different from that of the urban paramedic practitioner. This paper will explore the practice of a paramedic from a rural perspective, towards determining whether their practice is different, and whether specific rural-based education may be required.
Summary of Literature
The available literature gives little information on the differences between the role of the rural and the urban paramedic. Some sources give a comparison of urban and rural practice in terms of the practical skills featured in their work (Brown et al., 1996). These skills include intubation, and the focus is channeled towards, exploring whether rural paramedics are able to perform their duties, to similar standards as their urban counterparts (Jemmett et al., 2003).The inexperience of rural paramedics, with different types of patients has also been discussed through past literature (Burton, 2003). One case discussed is their inexperience with pediatric patients (Stevens & Alexander, 2005). Other studies discussed the differences of rural and urban practice, which is evident from different trauma levels, citing the longer transport distances; more trauma cases were exposed among rural paramedic practice, than from the case of urban practitioners (Huang et al., 2001).
The different sources show that focus of past literature is on the differences in the cases attended to, or the practical skills held by the different groups of practitioners.The available literature shows that, there is little literature exposing the differences between urban and rural practice, in the area of the interactions of the practitioner, with the community (Burton, 2003).There is also little information covering the differences in the interactions between paramedics and other health personnel,with whom they often work together. For these reasons, there is little information on the skills and the roles that may be unique to the working of the rural paramedic practitioner (McAllister et al., 1998). Towards developing this information, the differences in the practice of the rural and the urban paramedic, will be explored from the perspective of the paramedic, through asking a set of questions. These questions include, how the differences in paramedic roles give insights into the roles of rural paramedics and how these differences enrich the training and the education of paramedics.
A comparative case study model and a qualitative approach were employed during this study of the differences between urban and rural paramedic roles. Different data sets were gathered, using different tools. The first tool was semi-structured interviews with the paramedics working in intensive care settings, across two Australian states. The second tool was thereview of available literature on ambulance services, job descriptions, union websites, universities and local media; archival information and case dispatch information. Other tools for the study included the observation of the practitioners within the areas of study and key events and processes. The collection of data took place betweenJan 2012 and Feb 2013.
The design of the case study was administered according to the model suggested by Yin, where the different cases are developed based on analysis units – in the current study, these included the localities of paramedics, which were compared and contrasted for the two areas (Yin, 2003).For instance, one given rural case featured two analysis units, where the two were independent rural centers. The analysis of the different localities took account of the different datasources, and the formation of the caseinvolved comparing the different units of analysis, noting differences and similarities.
The total number of localities, two urban and five rural, contributed towards one urban and two rural cases, from two states: Victoria and Tasmania. In the case of the urban side, the guidelines of comparison were that the paramedic centers had to show some comparison, in the area of the accessibility to populations, medical facilities, and paramedic crewing. Two cities of relatively similar sizes from Victoria and Tasmania were chosen. Using remoteness / accessibility levelsin Australia, the two cities had an index of highly accessible, from a wide range of social interactions and services (Huang et al., 2001).
The guidelines used for the two rural centers were that they fitted either of the two models identified for rural paramedics in Australia. The two cases include 1) the model, where ambulance locations were determined before, in response to political and community pressure (O’Meara, 2002) and 2) the recently determined model for rural emergency care, community engagement, primary health care andthe scope of practice extension (O’Meara et al., 2006). Three of the rural centers were identified as moderately accessible, which means that there was limited access to social interactions, opportunities and goods and services. Two rural centers were grouped as remote, meaning that they were considerably restricted from access to social interactions, opportunities and goods and services. Two locations were grouped under model (1) and three were classified under the model (2). Through the creation of two rural cases, the differences in the practice in the rural areas, among the two models will be determined.
So as to sustain consistency, interviews were administered to the practitioners at the performance level of ICU paramedics. The interview questions were aimed at determining the types of work executed by the paramedics, their interactions with other health practitioners and that with the members of the community as well as their thoughts on their training and education. The intensive care paramedics communicated with the researcher directly, in expression of their interest to participate in the study (Andersson, Lennox & Petersen, 2003). Ten paramedics showed interest initially – the ten included three from group 2, four from the volunteer group and three from the urban paramedics groups. One urban and one rural paramedic pulled out of the study, prior to the interviews. The interview conversations were taped and later transcribed by theresearcher.
The documents gathered for the study include job descriptions, dispatch data,ambulance and union service memoranda, and the local media reports aligned to the different analysis units.Ambulance facility educational curricula and university educational models showed the types of subjects administered to the practitioners. The interviews were conducted in the local areas, which allowed for the observation of the workplace of the paramedics, in terms of service delivery and the local environment.Two interviews were administered over the phone, and in the two cases, the paramedics described their work environments (Huang et al., 2001). The cross referencing of different data forms enhanced the process of triangulation, which helped in eliminating any biases made during the individual interview sessions.
The analysis of data was done inductive, using the NVivi 7 statistical package; the analysis fostered comparison between the different urban and rural cases, and enhanced the identification of consistent themes.Ethics approval was acquired from the HRECN (Human Research Ethics Committee Network) of the University of Tasmania.
The study did a comparative study of the rural and the urban practice. Despite the fact that some similarities were evident, there were four main differences between urban and rural paramedic practice from the data. The differences included that 1) the rural paramedic employs a community-wide approach during practice, rather than a case dispatch outlook 2) the rural paramedic is a multi-disciplinary player, rather than an ambulance team member 3) the rural paramedic plays extra roles as a manager and teacher for volunteer staffs 4) the rural paramedic is a highly respected and visible community member (Yin, 2003).
Similarities were apparent, between the cases dispatched to urban and rural paramedics. The paramedics from the different regions were often required to attend to cases like cardiac problems, breathing problems, abdominal conditions, falls, fainting or unconscious patients and the victims of road accidents. The main difference evident from the dispatch data, except that on the number of cases, depicted a large proportion of transfers from rural to urban areas, following the need to transfer patients to better equipped medical facilities.
Rather than positioning themselves as a response team for the management of emergency cases only, the rural paramedic works like an active member of the community. The works they do – differently from urban paramedics – include school visits, public education, and general first aid education. Their approach towards their roles is innovative, which is evident from their use of public media like newsprint and radio to pass messages related to the health of the community to groups (Andersson, Lennox & Petersen, 2003).The primary health careduty broadens to cover community health centers, rural health care groups and drug rehabilitation classes to other emergency services groups like the state emergency and the fire service centers. This case was evident from the involvement of one paramedic, who has taken a central role in the development of a community health center, in a locality that did not have allied health support services like occupational therapy, physiotherapy and drug and alcohol education (Huang et al., 2001).
The role of the rural paramedic, within the community, is highly proactive, and that was evident from the formulation of plans for future health needs, among the practitioners. One example from one rural paramedic was the proposal for the development of a casualty treatment center, at a locality that did not have emergency department outlets and public hospitals. Many of the paramedics were members of the hospital committees of local hospitals.
Although  urban, like rural paramedics, extend their duties beyond pre-hospital care, to work with emergency staff and hospital accident staffs when there is a need for the rural paramedics to depict a more multidisciplinary practice. In all the cases checked, rural practitioners are engaged, as members of other community organizations related to health, apart from the ambulance services (McAllister et al., 1998). Others are members of community health councils, together with occupational therapists, psychotherapists and district nursing staffs, apart from participating in educational initiatives and community health promotion. The programs where rural paramedics are participants include those to do with drug and alcohol awareness and prenatal classes.
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