Volume 14 | Issue 3 | Article 3

Four dimensions of paramedic practice in Canada:
Defining and describing the profession
Ron R Bowles

Justice Institute of British Columbia, Canada

Catherina van Beek

Justice Institute of British Columbia, Canada

Gregory S Anderson

Justice Institute of British Columbia, Canada

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Research
Four dimensions of paramedic practice in Canada: Defining and
describing the profession
Ron R Bowles PhD, is Associate Dean, Centre for Applied Research1; Catherina van Beek RN, BSN, MHA, CHE, is
Research Strategist1; Gregory S Anderson PhD, is Dean, Office of Applied Research and Graduate Studies1
Affiliations:
1
Justice Institute of British Columbia, Canada

Abstract
Introduction
This article presents a framework for describing four dimensions of paramedic practice: Practitioners, Practice Setting, Care
and Patient Disposition. The framework emerged from a qualitative study conducted to identify potential research directions and
opportunities to advance paramedicine and paramedic education at Justice Institute of British Columbia in Canada.
Methods
Researchers conducted semi-structured interviews with 17 stakeholders in Canadian paramedicine to explore the current state
and emerging expectations of paramedic practice and paramedic education.
Results
The study found no consensus, and little agreement, on what term or terms best describe the profession. Participants agreed
that the core of paramedic practice involves an advanced medical provider responding by ambulance to the patient’s side in an
emergency to assess and treat urgent medical and traumatic conditions, then transport the patient to further medical care – most
often an emergency physician at an emergency department. However, participants also described paramedics as healthcare
providers who are increasingly taking on varied operational roles to improve patient care and address gaps in an evolving and
stressed healthcare system. Four dimensions emerged for describing key characteristics of paramedic practice: the Practitioners,
Practice Settings, Care and Patient Disposition.
Discussion
The framework described in this article may be useful for examining and better understanding both traditional and evolving
paramedic roles. This, in turn, informs the efforts of paramedic educators, regulators, employers, and professional associations
to support practitioners in the field. The article uses the framework to contrast two distinctly different community paramedic
programs.
Keywords:

paramedics; paramedic practice; paramedicine; EMS; profession; discipline boundaries
Corresponding Author: Ron Bowles, rbowles@jibc.ca

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Introduction
In 1971, the American Academy of Orthopedic Surgeons
published the first edition of Emergency Care and
Transportation of the Sick and Injured (1) as a national text
for emergency medical care. The title of this text serves as an
apt description of the role of ambulance services at that time.
By 2006, these services had evolved into complex emergency
medical systems (EMS) and a white paper published by the
Paramedic Chiefs of Canada (PCC) (2) posed a future vision
for EMS in Canada as ‘a community-based mobile healthcare
service’ (p. 18).
Healthcare in Canada is regulated at the provincial level
(3,4) and the professional boundaries of paramedic practice
are set through provincial legislation, such as the British
Columbia Emergency Health Services Act (5). This legislation
typically defines who paramedics are, their mandate, where
they may practice (both geographically and practice setting),
and establishes processes for licensure (in provinces such
as British Columbia) or self-regulation in other provinces
(such as New Brunswick) (6). In British Columbia, the actual
scope of practice is outlined in the Emergency Medical
Assistants Regulations (7), which lists the practices,
procedures and medications that may be used by paramedics
at various certification levels. Specific practices in the field
are established by ambulance operators through policy,
procedures, protocols and/or clinical practice guidelines.
Actual practice ‘on the street’ is influenced by a number of
factors that may include the paramedic’s background, training
and experience, operational role (eg. emergency response
ambulance, airevac, special teams), the call distribution within
the responding area and local practice.
The profession – variously called EMS, paramedicine and
paramedic practice – is rapidly evolving. In addition to
traditional roles in responding to, treating and transporting the
sick and injured, paramedics now participate in specialised
teams (8-10), practice at fixed locations ranging from mass
gatherings (11) to remote industrial sites (12), within hospitals
(13,14), long term care (15) and community settings (1618). While providing urgent care in emergency situations,
paramedics increasingly provide non-urgent care and
monitoring (17,18), primary care (19,20), preventive care
and health education (19,21,22). Traditionally, paramedics
transported patients to medical care, usually the closest
emergency department. However, patient disposition options
now include programs for critical care bypass of multiple
trauma, acute cardiac and stroke patients (23-32), treat and
release (22,15,17,33) and referral to other health and social
service providers (15,18,33).
The evolution of the profession raises questions about
how to define and describe paramedic practice, and what
its boundaries or limits are. For example, how does an

‘emergency health service’ differ from an ‘ambulance service’?
Does providing onsite management and monitoring of minor
injuries and illnesses at a remote industrial camp fit within
the scope of the practice and licensure of a paramedic?
Does paramedicine include high acuity interfacility transport
by interprofessional healthcare teams? Paramedics may be
members of police tactical response teams; but is a police
officer on the same team with emergency medical training
also practicing paramedicine? How are these varying roles,
practice settings, and types of care incorporated within
professional documents such as occupational profiles
and standards of practice? How do educational programs
approach and support these changes?
This article addresses questions such as these through the
lens of a research study at Justice Institute of British Columbia
in Canada (JIBC). The primary research goal was to identify
potential directions and opportunities for JIBC research
efforts to contribute to and advance paramedic practice and
education in Canada. The changing expectations, operational
roles and scope of practice in paramedicine have a direct
impact on both educational content and educational practice.
Thus, the study explored current conceptions of the terms,
roles, boundaries and future directions of Canadian paramedic
practice, and sought to identify key issues and problems
facing stakeholders in Canadian paramedic education.

Methods
The study employed semi-structured interviews of key
informants from selected stakeholder groups involved in
paramedicine in Canada generally, and British Columbia in
particular. Key informant interviews focused on identifying
trends, issues and challenges with an emphasis on
educational aspects of paramedic practice. An inductive
thematic analysis was conducted following the general
procedures of grounded theory (34,35). Results of this
analysis were interpreted through the lens of identifying
areas of research that would inform paramedic practice and
education within Canada.
Participants
Interview participants were recruited using purposeful and
convenience strategies, seeking key informants from diverse
stakeholder groups that could provide insight on the central
questions of this research (36). Selection characteristics
included membership in key stakeholder organisations,
operational role and regional/geographic focus. Potential
organisations and key individuals were identified by JIBC’s
Health Sciences Division leadership group. Potential
participants were initially contacted by email with telephone
follow up. Participants unavailable or unwilling to participate
were asked to identify other potential candidates with similar
characteristics.

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Procedures
Two researchers (RB and CVB) conducted 17 individual
hour-long semi-structured interviews, consisting of five openended questions, each with prompting questions (see Table
1). Participants were encouraged to use the questions as
starting points, not as boundaries. The researchers allowed
the conversations to emerge organically. All interviews were

audio-recorded then transcribed verbatim by both researchers
(RB and CVB) using Transana (37), with each researcher
reviewing the other’s work against the audio recordings to
ensure accuracy. Researchers also took field notes in the
interviews. Coding notes, memos, and interim writings on
emergent themes gathered throughout the study became
additional data.

Table 1. Semi-structured interview questions
1. Can you describe your background in EMS?
• When did you enter the service, where, and in what role?
• What has your career trajectory been?
• What aspects of EMS are you involved in and at what levels: operational role, organisational role, ‘systems’ role (local,
provincial, national, international)?
2. How would you describe the world of EMS?
• What is the best term to use to describe the field? Why?
• What is the primary role or function of EMS? What should it NOT be doing? Why?
• What’s in and what’s out? Where are the boundaries of EMS? (eg. community care, primary healthcare, industry,
in-hospital)
• Where do you see EMS going in the next 5 years?
3. How could research help you deal with issues and problems in EMS?
• What types of issues and problems do you deal with?
• How might research help you with those?
• What would you like to know that would help you solve problems, do things better, advance the profession?
• What are the issues and problems that we can’t even tackle right now?
4. What are the gaps and holes in the EMS knowledge base?
• What do we not know that we probably should?
• What information would you really like to have that you don’t have right now? (eg. # calls done across Canada on a daily
basis; how many paramedics are in Canada; how long the ‘average’ paramedic stays in the service)
• Note that this can be more than clinical: can prompt for political, operational, education, etc.
5. What are the puzzles and problems – what are you ‘curious’ about? What would you like to know?
• Meant as an open-ended question.
• Can use framework (political, operational, education) to prompt for areas that have not been addressed above.
• Focus on curiosity and needs – how can research make life better, solve problems.

Data analysis
Analysis and interpretation employed inductive thematic
analysis, consistent with procedures of grounded theory as
described by Chamaz (34) and Corbin and Strauss (35).
The researchers engaged in an ongoing cycle of interview,
transcription, analysis and discussion, allowing emergent
findings to help inform and focus subsequent data collection.
Initial analysis involved listening to the audio recordings
while concurrently reviewing the transcripts, followed by
line-by-line open coding. Core terms describing paramedicine
were extracted from the transcripts then mapped to

look for relationships, similarities and differences, with
particular attention to developing an understanding of how
terms describing paramedicine overlapped, informed and
contradicted each other. Data elements were coded using
a mix of in vivo and emergent codes. Conceptually similar
codes were brought together into coding categories. These
categories were then analysed axially and in relationship
to the main research questions to explore participants’
descriptions and understandings of paramedic practice, the
current and future roles of paramedicine, and the discipline’s
perceived boundaries.

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Chamaz (34) noted the purpose of grounded theory as
the development of middle-range theories that allow for
conceptualisation of key issues in a manner that allows
more complex analysis of the data. Chamaz (34) described
the process of looking at variation within categories and
for relationships between categories with the goal of
theory development. She identified four characteristics of
developing theory: a description, an empirical generalisation,
relationships between categories, and an abstract
understanding of relationships between the concepts in the
theory. This process informed the development of the ‘Four
Dimensions of Paramedic Practice’ discussed below.

Ethics
The study received ethical approval and oversight from the
Justice Institute of British Columbia Research Ethics Board.
Note that the initial study design employed semi-structured
interviews, allowing for adaptation of the interview questions
to explore emergent findings. The study received no external
funding. Both researchers conducted the study in their roles
at JIBC.

Results
Participant characteristics
Seventeen participants engaged in semi-structured
interviews. Almost half (n=7) were current or former
paramedics, with the remaining participants from nursing,
medicine, and other health professions. Many held primary
roles within their operational organisation (eg. a provincial
regulator) while also holding a leadership role within a
provincial or national organisation. Several participants held
both operational/clinical roles and academic appointments.
Seven participants held primarily operational or clinical
positions, with five holding leadership positions within
provincial agencies or organisations. Five participants also
held leadership positions within national organisations such
as the Paramedic Association of Canada, Paramedic Chiefs
of Canada, Canadian Organization of Paramedic Regulators,
and the Society for Prehospital Educators in Canada. While
the majority of participants were from British Columbia (n=11),
participants were recruited from five provinces representing
British Columbia, the Prairies, Central Canada and Atlantic
Canada. Note that there were no participants from Quebec or
the northern territories.
Findings
Several of the questions in this study explored how
participants understood and described paramedic practice –
for example, what operational roles or functions paramedics
assume, what distinguishes paramedicine from other health
disciplines, and what participants perceived as the boundaries

of the profession. Participants’ general descriptions of
paramedicine coalesced around two holistic conceptions:
a ‘traditional’ view of paramedicine as ambulance-based
emergency response, treatment and transport and an
emerging view of paramedicine as a healthcare discipline
that is evolving to support a stressed healthcare system.
Multiple codes emerged as describing different aspects of
paramedicine and these, in turn, led to the development of
four conceptual dimensions. Further analysis of the codes
within each dimension in relationship to the two emerging
holistic conceptions led to the identification and organisation
of elements within each dimension. What emerged was a
framework for describing key dimensions and attributes of
paramedic practice. The two conceptions of paramedicine
and the resulting framework are described in the following
sections.
What’s in a name? Terms describing the discipline
There was no consensus (and little agreement) on what
term or terms best describe the profession. The discussion
on this topic was wide ranging, and participants tended to
spend more time explaining why they did not like specific
terms than in justifying the terms they preferred. Three
general sets of terms emerged (see Table 2). Terms such as
‘EMS’ (emergency medical services) and ‘EHS’ (emergency
health services) were seen as emphasising the traditional
emergency aspect of ground ambulance-based services
and not acknowledging emerging functions of paramedics
in less urgent, continuing and preventive care. A second set
of terms focused on the practitioners themselves such as
‘paramedicine’ or ‘paramedic practice’. Some participants
noted that these were ‘boundary’ terms that excluded other
types of health providers and emergency responders from
the profession. Finally, terms such as ‘pre-hospital’ and
‘out-of-hospital care’ were situated in the place of practice
but were seen as not inclusive of emerging or non-traditional
uses of paramedics in broader health and community
settings. The tension between these terms highlights
conflicting conceptions or dimensions that may define the
profession, including who the practitioners are (paramedics
and other health providers), where they practise (ambulance,
community- or location-based and/or in-hospital), and what
their role is (emergency care, definitive care, preventive care).
The researchers propose two terms for describing paramedic
practice in the remainder of this article. ‘Paramedicine’ is used
as an umbrella term for paramedic practice in its broadest
sense, regardless of who the practitioners are, their practice
setting, the type of care provided and patient disposition. The
term ‘EMS’ is used to refer to traditional paramedic staffed
land- and air-based ambulance services or systems. In this
conception, EMS can be thought of as one of the practice
settings that makes up the broader discipline or profession of
paramedicine.

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Table 2. Terms used to describe the discipline
‘Emergency’ terms

Practitioner terms

Context of practice
terms

• EMS
• Emergency medical services

• Paramedicine
• Paramedic care

• Pre-hospital
• Pre-hospital care

• EHS
• Emergency health services
• Health services

• Paramedic practice
• Paramedics
• Paramedic service

• Pre-hospital medicine
• Out-of-hospital
• Ambulance
• Ambulance medicine

The core of paramedicine
The challenge of naming the profession extended to
participants’ efforts to define its central role or purpose.
Participants identified two conceptions of paramedicine –
one based in the historical roots of EMS and the other in the
expanding role of paramedicine in an evolving healthcare
system. All participants saw the traditional view of EMS as the
core role of paramedicine, but differed in the degree to which
they saw evolving roles as ‘within the discipline’.
At its core, paramedicine involves a practitioner trained
in advanced medical care driving an ambulance to the
patient’s side in an emergency to assess and treat urgent
medical conditions and traumatic injuries, then transport the
patient to further medical care in a hospital – most often to
an emergency physician at an emergency department. All
participants agreed with this conception of EMS.
‘I think it’s essentially the system responsible for providing
timely access to a healthcare professional when an acute
emergency arises… and to make a decision about whether
or not care can be provided in that setting or in an alternate
setting or if transportation to an acute care facility is required’.
(Participant I03)
‘I think the premier role should be rapid intervention in critical
situations that are time sensitive where the interval from
event to hospital is too long for satisfactory outcomes a high
percentage of the time’. (Participant I06)
However, participants differed in the degree to which they
saw emerging roles as part of paramedicine. Contrasting
views situated paramedics as healthcare providers who are
increasingly taking on varied roles to improve patient care and
address gaps in a stressed and evolving healthcare system.
‘We’re not just emergency care. We’re certainly well beyond
that with some of the systems that exist that allow for things
like treat and release and for community based practice’.
(Participant I04)
‘It’s an extension of any health authority or government health
service, whether it’s the state, whether it’s federal, provincial…
I think that… EMS is one of the initial phases of delivery

Other terms
• First responders
• Bastard child of medicine

healthcare’. (Participant I09)
‘EMS has to start looking at themselves as part of the first
layer of healthcare’. (Participant I08)
‘Really I think in the broadest of terms I think we are the safety
net for the healthcare system’. (Participant I06)
The participants’ comments mirror discussion in the
literature that contrasts EMS as an emergency service and
paramedicine as an evolving healthcare profession (2,38-43).
However, the participants’ language and examples did not
frame these as ‘either/or’ conceptions; rather, all participants
saw the traditional definition as the core of EMS, but differed
on the degree to which they saw aspects of changing practice
as ‘in’ or ‘out’ of their conceptions of paramedic practice.
Dimensions describing paramedic practice
Participants provided a wealth of terms, phrases and
concepts for defining and describing aspects of paramedic
practice. These included terms used to name the discipline,
descriptions of the purpose or role of paramedicine, examples
of existing and emerging practice they considered within
or outside the bounds of the profession, and features that
distinguished paramedicine from other health disciplines.
Participants identified a wide range of emerging roles and
capabilities for paramedics:
•
•
•
•
•
•
•
•

Community paramedic
Expanded practice
Moving towards diploma/degree
Code response (managing cardiac arrest) and urgent
response within the hospital
Community or even in-hospital care
Access to care; providing community care and preventative
healthcare
Trying to lessen or eliminate where possible people that
are chronically sick from having to access the healthcare
system in its traditional form
Specialty teams such as tactical response, mass
gatherings, HAZMAT.

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Table 3. Dimensions of paramedic practice
Practitioner
Paramedic:
• Critical care
• Advanced care
• Primary care
Specialty Responders:
• Tactical EMS
• CBRNE/HAZMAT
• Special events
• Industrial
First responders:
• Emergency medical responders
• Fire/other first responder
Community resources:
• Lifeguard
• Search and rescue tech
• Dual role: EMS/fire
Healthcare providers:
• Nurse, nurse practitioner
• Physician, physician assistant
• Other health disciplines

Practice settings
Uncontrolled:
• At the patient’s side
• Out-of-hospital (eg. home
visit)
Location-based:
• Events (eg. sports, concerts, mass gatherings)
• Industrial sites
• In community (eg. ‘store
front’)
Community-based:
• Home visits
• BP/diabetes clinics
Facility-based:
• In-hospital (eg. ED, triage,
code team)
• In-facility (eg. extended
care)
• Rural ED (eg. night coverage)

Analysis of these data led to the emergence of four
conceptual categories or dimensions: who the practitioners
are, where they practice, what type of care they provide, and
who/where they transition care of the patient to (referred to
in this article as ‘patient disposition’). Further analysis of the
codes within each category led to the development of a series
of attributes or elements within each dimension (see Table 3).
Paramedicine is a relatively young discipline that is rapid
evolving and the lack of agreement in terminology reflects
the role confusion expressed by many participants. While
most participants recognised that emerging roles and the
changing scope of paramedic practice required different ways
of describing the field, there was still a strong attachment to
the concept of an advanced care paramedic in an ambulance
responding to the patient’s side, intervening to manage a
medical or trauma-related crisis, and then transporting the
patient to hospital. Thus, the final categorisation of the data
was to hierarchically organise the elements in each dimension

Care
Emergency:
• Emergency responses
• Urgent responses
• Non-emergency/ routine
responses
• In-hospital code/cardiac
arrest responses
Urgent/ongoing care:
• Interfacility monitoring and
intervention
• Triage or monitor (in-hospital/ED)
Definitive:
• Treat and bypass (eg.
trauma, stroke, STEMI)
• Treat and release (eg.
diabetic)
• Treat and refer (eg. BP
clinic, home visit)
• Interprofessional/team
based care (eg. IPP team
in ED; paramedic/nurse
staffing rural ED)
Primary and preventative
healthcare:
• Health surveillance
• Primary healthcare monitoring
• Public health education

Patient disposition
Transport to care:
• Ambulance calls
• Airevac
Transport between care:
• Interfacility transfers
• Critical care transfers
Care in place (no transport):
• Treat and release
• Treat at point of care (eg.
in-facility, ED)
• Treat and refer

in relationship to its conceptual ‘closeness’ to the ‘core’ or
traditional view of paramedicine.
Four dimensions of paramedic practice
Figure 1 presents a graphic representation of four dimensions
emanating from a core concept of paramedic practice. The
elements in each dimension are ordered from those most
closely associated with the core definition to those that
have the least in common or are conceptually ‘farthest’ from
traditional descriptions of paramedic practice.
There was general agreement among the participants on the
elements that form the core of paramedic practice. However,
changing any of the elements in that description elicited
considerable disagreement on whether or not the resulting
description was still within the bounds of paramedic practice.
The greater the degree of change, the less agreement there
was among participants.

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Figure 1. Four dimensions of paramedic practice
Practitioners
There was general agreement among the participants that
paramedics form the core of the profession. However, there
was less agreement on whether or not being a paramedic
is what defines the profession. One participant saw only
advanced life support providers as paramedics (in line with
the traditional division between paramedics and emergency
medical technicians or assistants). Most participants
included critical care, advanced care and primary care
paramedics (which are the current certification levels found
in many Canadian provinces) as being within the profession.
Several participants explicitly excluded emergency medical
responders and/or other providers of emergency care (such
as specialty teams, lifeguards, search and rescue technicians
or industrial medics) from being part of the profession. Other
participants saw membership in paramedicine much more
inclusively, noting that ambulance services, and in particular
high acuity transport and airevac teams in many jurisdictions
– including some areas of Canada – are routinely staffed by
nurses, physicians, and other healthcare providers.

Practice settings
One of the defining characteristics of ambulance-based care
was described as its uncontrolled and unpredictable setting
– while most healthcare requires the patient to come to a
hospital or practitioner’s clinic, paramedics respond to where
the patient is. However, participants noted that paramedics
are increasingly taking on new roles in industry, locationbased settings (eg. concerts, sporting events and other
mass gatherings), and in-facility settings such as emergency
departments, health clinics and extended care facilities.
There was no agreement on whether these alternate settings
were within or outside the profession. Several distinguished
between EMS, which included traditional land- and air-based
ambulance services, and a broader view of paramedicine
comprised of multiple practice settings. This conception
focused on the practitioners as defining the profession (of
paramedicine), with EMS, community-care, and in-facility
roles all as subsets or practice settings in which paramedics
could function.

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Care
All participants agreed that emergency care is core to
paramedicine. Several participants limited the boundaries
of paramedicine solely to emergency care, seeing nonemergency care, interfacility transport or community-based
care as being non-paramedic duties. Other participants
easily accepted paramedicine as including the provision of
definitive care (examples included treat and release programs
for diabetics or paramedics in multi-disciplinary teams in
emergency departments). Several participants described
paramedics performing primary healthcare monitoring and
preventive care as part of providing mobile community-based
health services.
Transport/disposition
Again, all participants noted that transport and transfer of
care to emergency physicians in the emergency department
is a core element of paramedic practice. However, most
participants noted that this is a dimension whose elements
are rapidly changing. Several participants mentioned treat and
release programs and bypass protocols for specific categories
of trauma, cardiac and stroke patients. In addition, participants
described emerging and potential programs allowing
paramedics to treat in place, treat and refer and monitor
patients in their homes.

Discussion
The participants in this study characterised paramedic
practice as transitioning from its roots as an emergency
service towards a broader conception as a diverse healthcare
discipline or profession. There was no common term
for the discipline, nor did the participants agree upon its
boundaries. There was, however, a strong consensus on
paramedicine’s core function as responding to the patient’s
side in an emergency to provide urgent care and transport
to hospital. Further, there was agreement that paramedics
are increasingly providing a wide range of care to patients
in a growing set of practice contexts, involving alternative
disposition and transfer of care. These characteristics form
the four dimensions of paramedicine practice presented in this
article.
This framework is useful for examining and contrasting
evolving roles within paramedic practice. This, in turn, informs
the efforts of paramedic educators to develop effective
programs to support practitioners, regulators to explore
the scope and contexts of paramedic practice, and service
operators to identify and meet patient and community needs.
Case study: Community paramedic programs
Community paramedic programs are increasingly common
throughout Canada and internationally (40,44–47). Yet

there is substantial variation among these programs, both
operationally and in the education required to support them.
Some programs leverage ‘down-time’ between calls of landbased ambulance paramedics to complete home visits and
monitor ‘frequent flyers’ – patients who frequently attend local
emergency departments (24,27). Programs such as these
can be mapped onto the Four Dimensions framework as
illustrated in Figure 2. Other community paramedic programs
create new roles and employ paramedics to set up clinics in
remote locations and conduct primary healthcare monitoring
and education (15,48,49). Figure 3 illustrates how these types
of programs can be represented using the Four Dimensions
framework. The first example stays ‘close’ to the core of
paramedic practice and practitioners. Little has changed in
terms of location of practice, care, or decisions around patient
disposition. In contrast, paramedics responding to remote
communities employ similar skills, but make very different
decisions, including monitoring health trends over time
and referring patients to other health providers rather than
transport to hospital. While both are ‘community paramedic’
programs, they have distinct differences in the ‘distance’ from
traditional practice (and education), and require different types
of educational support.
A distinguishing aspect of this model, and the descriptions
of paramedic practice from which it emerged, is the focus
on the overall context and outcome of practice, rather than
on skills and knowledge of the practitioner. Traditional
paramedic occupational descriptions, regulatory frameworks
and educational models (49) have focused on differentiating
types of paramedic practice by skill- and procedurebased taxonomies (eg. routes of drug administration, use
of advanced or invasive procedures, types of injuries or
conditions with medical directives or protocols) – features
rarely mentioned by the participants in this study when
describing current and future paramedic practice. Rather,
the participants’ discussion, and the resulting dimensions
of practice framework, looked more at the capabilities and
attributes required of paramedics within varying practice
contexts, and in particular their ability to adapt to changing
settings and new roles.
This finding has interesting implications for the development
of professional documents describing practice. Occupational
profiles in several health and medical disciplines, such as
the CANMeds (50) and the Canadian physiotherapy profile
(51), have adopted role-based descriptions that focus on the
functional roles of practitioners, and the capabilities required
to assume those roles (52). This, then, highlights the need for
paramedic education programs to explore how foundational
skills, knowledge and decision-making change when
practitioners provide expanded forms of patient care involving
alternative patient dispositions in varied practice settings.

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Figure 2. Land-based ambulance with home visit roles

The four dimensions presented in this article provide
educational programs a framework with which to analyse and
incorporate the complexity of emerging paramedic practice
into learning environments such as simulations and practicum
experiences.

Limitations
This study was set in the context of developing a program
of research to advance practice and inform paramedic
education in the Canadian, and more specifically, within the
British Columbian context. While participants were selected
with the goal of broad diversity in professional background,
operational perspective, and geography, the data obtained
in this study cannot be considered representative of all
stakeholders in Canadian paramedicine. Rather, the intention
of the study was to explore and better understand the range
of perspectives and understanding participants had of
paramedic practice, not to examine the prevalence of those
views among, or between, stakeholder groups.
The emergence of the four dimensions of paramedic
practice, and the ordering of elements within those domains
were influenced by the backgrounds and experience of the
researchers as a paramedic (RB) and a nurse (CVB), and
as educators and researchers. Other researchers may have
developed different categories or seen different relationships
within those categories. We acknowledge these limitations

Figure 3. Paramedics stationed in rural communities with
primary and preventative care roles
and offer the framework as a starting point for discussion and
an invitation for further study.

Conclusion
As paramedics take on new roles they push at the ‘traditional’
boundaries of the profession. Paramedic educators seeking
to prepare practitioners for these roles face an intriguing set
of challenges. Some of these new roles bring paramedics’
existing scope of practice to new environments. Other roles
are opportunities for paramedics with expanded scopes
of practice to provide alternative forms of care within their
existing context of practice. Changes in patient disposition
and treatment options radically change the types of decisions
paramedics will make, and the educational foundation
needed to function effectively.
The four dimensions proposed in this article provide
a framework for exploring, comparing and contrasting
attributes of various forms of paramedic practice. The
examples provided show that different paramedic roles may
share attributes along some dimensions and vary among
others. Further study is required to better understand the
relationships between these dimensions, and to explore
how different ‘maps’ may relate to the underlying skills,
knowledge, and decision-making, and perhaps more
importantly, their integration and adaptation within specific
contexts or roles, required to support practitioners.

09

Bowles: Four dimensions of paramedic practice in Canada
Australasian Journal of Paramedicine: 2017;14(3)

Conflict of interest

The authors declare they have no competing interests. Each
author of this paper has completed the ICMJE conflict of
interest statement.

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