Journal of Emergency Primary Health Care (JEPHC), Vol. 7, Issue 4, 2009 – Article 990392

ISSN 1447-4999

PROFESSIONALISM
From learning activities to the meaning of life:
Fostering professionalism in Canadian paramedic education
Ronald R. Bowles B. Ed., MET, PhD (candidate)
School of Health Sciences
Justice Institute of British Columbia
New Westminster, BC, Canada

Abstract
This article explores the development of professionalism in paramedic programs of the Justice
Institute of British Columbia (JIBC), Canada. Professionalism is currently defined as a set of
competencies that are embedded as a set of skills and knowledge to be mastered, then applied in
simulations and a field practicum. In the second part of the article, professionalism is examined as a
broader concept and suggestions are presented for fostering the development of professionalism in the
current redevelopment of the JIBC’s Advanced Care Paramedic program.

Keywords: competencies; curriculum; EMS; paramedic education; professionalism

The article explores professionalism in the context of paramedic education in British Columbia,
Canada. The first section examines current approaches to teaching professionalism competencies in
the Justice Institute of British Columbia (JIBC)`s Primary Care Paramedic curriculum. A broader
definition of professionalism and its development is then presented. The article concludes with a
discussion on how the JIBC will foster the development of professionalism through the current
revision of the Advanced Care Paramedic program.
Context for the Discussion
In the Canadian context, professionalism is defined as a set competencies or observable behaviours
that are identified in a national competency profile. These competencies are embedded as a set of
skills and knowledge to be mastered then applied in increasingly complex patient encounters before
being assessed in a field practicum. The final assessment in the practicum involves a preceptor
observing and documenting at least two instances of the student exhibiting the observable behaviours
specified in the national competency profile.
Health care in Canada, including paramedic practice, is in the jurisdiction of the provinces. Each
province has, over time, developed its own unique set of standards, scope of practice, and forms of
regulation to meet local and regional needs. In 2001, the Paramedic Association of Canada released a
National Occupational Competency Profile (NOCP) for Paramedics in Canada 1. The NOCP
established a common framework and terminology for standardization of paramedic programs across
the country. The NOCP specified competencies for four levels of practitioner: Emergency Medical
Responders (EMR), Primary Care Paramedics (PCP), Advanced Care Paramedics (ACP) and Critical
Care Paramedics (CCP). While each province has retained its own standards and scope of practice,
many adopted the NOCP as the basis of their licensure levels. In addition, the NOCP has helped to
bring many non-patient care topics, such as professionalism, into the formal paramedic curriculum.
The first of the NOCP’s seven competency areas covers “Professionalism Responsibilities.” This
section specifies seven general competencies, which, in turn, contain sub competencies and associated

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criteria which must be demonstrated by paramedic students (Table 1). Moreover, the NOCP identifies
specific “performance domains” in which practitioners must demonstrate each competency. For
example, EMRs must “acknowledge patient privacy” and “demonstrate empathy” in a simulation
setting, while PCP, ACP, and CCP practitioners are required to demonstrate these competencies in the
practicum environment. Thus, the NOCP provides a list of professionalism-related content “bits” and
evaluation requirements that must be incorporated within a paramedic curriculum.
Table 1: Sample Professionalism Competencies from Canadian National Occupational Competency Profile
Competency Area 1
GENERAL COMPETENCY 1.1 Function as a professional.
GENERAL COMPETENCY 1.2 Participate in continuing education.
GENERAL COMPETENCY 1.3 Possess an understanding of the medicolegal aspects of the profession.
GENERAL COMPETENCY 1.4 Recognize and comply with relevant provincial and federal legislation.
GENERAL COMPETENCY 1.5 Function effectively in a team environment.
GENERAL COMPETENCY 1.6 Make decisions effectively.
Expansion of General Competence 1.1
SPECIFIC COMPETENCY
1.1.a Maintain patient dignity.
1.1.b Reflect professionalism through use of appropriate language.
1.1.c Dress appropriately and maintain personal hygiene.
1.1.d Maintain appropriate personal interaction with patients.
1.1.e Maintain patient confidentiality.
1.1.f Participate in quality assurance and enhancement programs.
1.1.g Utilize community support agencies as appropriate.
1.1.h Promote awareness of emergency medical system and profession.
1.1.i Participate in professional association.
Expansion of Specific Competency 1.1.a
Practice Level:
EMR
PCP
ACP
CCP
Performance Simulation
Practicum
Practicum
Practicum
Domain:
1.1.a Maintain
Define "dignity".
Discuss "dignity".
Discuss "dignity".
Discuss "dignity".
patient dignity.
Identify cultural
Identify cultural
Identify cultural
characteristics that
characteristics that
characteristics that
impact patient
impact patient
impact patient
dignity.
dignity.
dignity.
Acknowledge
Acknowledge
Acknowledge
Acknowledge
cultural
cultural
cultural
cultural
differences.
differences.
differences.
differences.
Acknowledge
Acknowledge
Acknowledge
Acknowledge
personal
personal
personal
personal
privacy.
privacy.
privacy.
privacy.
Demonstrate
Demonstrate
Demonstrate
Demonstrate
empathy.
empathy.
empathy.
empathy.
Demonstrate care
Integrate care
Integrate care
Integrate care
appropriate to
appropriate
appropriate
appropriate
situation.
to situation.
to situation.
to situation.
Demonstrate care
Adapt care
Adapt care
Adapt care
appropriate to the
appropriate to
appropriate to
appropriate to
needs
the needs of special the needs of special the needs of special
of special
populations.
populations.
populations.
populations.
Source: Adapted from the Paramedic Association of Canada’s National Occupational Competency Profile for Paramedics in Canada.1

The JIBC conducted a comprehensive task analysis of paramedic practice in the late 1990s. The
analysis broke medical and trauma calls into approximately 18 call types and over 200 specific injuries
and conditions. Further analysis of the assessment, decision-making, and management of these
conditions led to a comprehensive list of knowledge, skills, judgment, and attitude “bits” that
constituted paramedic practice. The JIBC’ simple-to-complex curriculum model emerged from this

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Journal of Emergency Primary Health Care (JEPHC), Vol. 7, Issue 4, 2009 – Article 990392

process (Figure 1). In this model, learners establish a foundation of generally held concepts and
principles (e.g. anatomy, physiology, and pathophysiology), then master the core skills and procedures
of prehospital care (e.g. airway management, drug administration). Next, learners integrate their skills
and knowledge to manage classic presentations of common injuries and conditions. In complex cases,
learners adapt to meet the unique challenges presented by special situations (e.g. patients with multiple
conditions) or special populations (such as the elderly). Finally, learners move to the field setting
where they begin the journey of developing their own personal style of practice.

Figure 1: Justice Institute of British Columbia Paramedic Curriculum Model

A parallel process analyzed paramedic practice from a functional perspective. Ambulance calls consist
of several components (e.g. Patient Assessment, History Taking). These components incorporate
procedures which, in turn, are comprised of simpler procedural chains and individual skills. The
pedagogic reconstruction of these “performance” elements moves from simple to complex – from
mastery of basic skills and simple procedural chains to their application in exemplar situations (classic
presentations of common conditions), and adaptation through increasingly complex scenarios (Figure
2). Each type of learning activity focuses on a different aspect of performing an ambulance call and
lends itself to a particular type of learning goal. In essence, learners move up a “Practice Ladder” that
rests alongside the curriculum model (Figure 3).

Figure 2: JIBC Practice Ladder

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Figure 3: JIBC Curriculum Model and Practice Ladder

Both the NOCP and the JIBC curriculum are based on a classic instructional design process. Thus,
embedding professionalism competencies in a paramedic curriculum becomes a relatively
straightforward task of identifying which curricular components each competency is best covered in.
The Practice Ladder is used to target each learning outcome (competency) with an appropriate practice
learning activity (e.g. case study, role play, drill, simulation). Professionalism “criteria” from the
NOCP become checklist elements in formal assessment tools.
In the JIBC’s PCP curriculum, most professionalism competencies are studied early in the program.
These competencies are further reinforced in subsequent simulations and the practicum. This ensures
that essential competencies are mastered and applied in a variety of contexts and become part of the
graduates’ overall practice. Demonstration of competence consists of consistent, independent, timely,
accurate performance in accordance with established standards and protocols.2
The Challenges of a Competency-based Approach
But is professionalism simply a set of competencies to be mastered?
A competency-based approach is grounded in a particular, albeit tried and tested, paradigm of learning
that focuses on building technical competence as evidenced by a learner’s observable performance
against a pre-determined external standard. The goal is to develop consistent performance by all
practitioners in all situations.
Yet, a closer examination of the professionalism “competencies” reveals that professionalism does not
necessarily seek consistent, context-free performance. Rather, several professionalism outcomes and
competencies refer to adaptation, modification, and the exercise of judgment to meet unique needs of
specific patients. They imply a sense of adaptability and prudence to meet the requirements of a
particular situation rather than the application of a common principle in any situation.
How Do We Get Good at What We Do?
The classic medical education framework, which sits under Canadian approaches to paramedic
education, calls on staged models of learning. In the 1980’s Benner3 described the nurse’s journey
from novice to expert. Her work called on Dreyfus and Dreyfus4 who posed that the development of
expertise follows a fairly predictable pattern. Learners initially master concepts in a contextindependent fashion, and then apply them through the use of concrete rules and principles. As they
move from “advanced beginners” to “competent performers” they employ analytic problem solving
strategies. Proficiency and expertise, however, require both practice and experience. While learners in

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the initial stages use analytic devices to reduce the complexity of problems, more experienced learners
develop a repertoire of experiential knowledge that become short cuts used to generate spontaneous
solutions to common problems. Expertise, in the Dreyfus and Dreyfus model, involves an intuitive,
holistic approach which calls upon both analytic and experiential knowledge.
What is particularly intriguing in this model is the assertion that proficiency and expertise are based on
adaptation and holistic judgment. Expertise, in this model, is not the consistent application of rules of
principles (mastery of competencies) in a context-independent fashion. That, in Dreyfus’ view, is the
mark of a competent practitioner. Rather, expertise involves the development of judgment and the
ability to react to the specifics of the situation at hand.
And this seems to speak to the challenge faced by a competency-based approach to professionalism.
Perhaps professionalism is about more than competency – perhaps, in Dreyfus and Dreyfus’ terms,
professionalism involves the development of expertise.
So, what, then, is Professionalism?
Cruess, Johnson, & Cruess5 examined changing concepts of professionalism in medical education and
identified several defining characteristics:
Mastery of a complex body of knowledge and skill
Service and accountability to those served
A code of ethics, with a commitment to “competence, integrity and morality,
altruism, and the promotion of public good” 5, p.75
Autonomy of practice and self-regulation
Based on these criteria, Canadian EMS is maturing, but does not meet the requirements for
professional status. Canadian EMS is not yet self-regulating. Paramedicine in many Canadian
jurisdictions is licensed by an external provincial regulating body, its scope of practice is established
by legislation and defined by regulation, and its members are more likely to belong to a union than a
professional association. At a national level, there is no common scope of practice, no code of ethics,
no mandated entry-to-practice examination or registry.
However, Canadian paramedics are making progress on several fronts. Several national organizations
represent operators6 and educators,7 and an umbrella organization for practitioners has membership
from over half the provinces.8 There are ongoing discussions on the development of a national
certification examination. As noted above, the NOCP, while not a national scope of practice, provides
a description of paramedic practice in Canada. In addition to the NOCP, there are at least two
textbooks that explicitly address EMS in the Canadian context.9, 10
Professionalism requires far more than ensuring that individual practitioners cover competencies and
demonstrate observable behaviours. Fostering professionalism, as defined by Cruess, Johnson, &
Cruess5 calls for a broader approach.

Learning Activities and the Meaning of Life
I have had several spirited discussions over the years with a colleague in our Centre for Conflict
Resolution. One of our ongoing debates is whether conflict resolution is a set of skills that we should
embed in our curriculum (competencies) or an overarching philosophy that should guide ethical
behaviour. I have been known to assert that conflict resolution is not the “meaning of life” and lean
more towards the skills-based position. However, in the context of professionalism, I am tempted to
argue differently.
Traditional instructional systems design is often portrayed as a circular model that, as noted above,

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seeks to match learning activities to desired outcomes. The process, however, is often mute on how
achieve this match. It is assumed that the structure of the learning objectives and the choice of verb
will imply an appropriate teaching and learning strategy. In practice, curriculum designers make
several important choices in between specifying the verb and outlining the learning activity.
Curriculum development occurs on several levels or layers. For the sake of this article, I will pose that
design strategies can include:
broad-based approaches to curriculum development;
organizing paradigms for entire programs including curriculum structure;
concepts for putting together lessons on specific topics using learning strategies;
and
individual learning activities that focus on specific learning outcomes or
objectives.
The following section will examine how professionalism, conceived as more than a set of
competencies, might be effectively embedded at several levels of a curriculum.

Professionalism as Competencies and the Meaning of Life
The JIBC is currently re-imagining and rebuilding its Advanced Care Paramedic (ACP) program. The
program is set within the School’s overall vision of a potential career path for paramedics. The
mission of the JIBC’s School of Health Sciences is to advance the role of paramedicine in an evolving
health care system. Part of that vision involves gaining recognition of paramedicine as a health
discipline. To that end, the JIBC is increasingly engaged in interdisciplinary initiatives with other
health education bodies and health authorities. The JIBC has articulated an overall blueprint for
paramedic education that includes both a technical and academic stream. Primary Care Paramedics
may take additional academic foundation and health science courses to complete a two-year Diploma
in Health Sciences with a focus on EMS. Graduates of the diploma and the Advanced Care Paramedic
program will receive a three-year advanced diploma. Post-graduate studies will focus on Critical Care
paramedicine, community-based paramedic practice and other specializations. The goal is to advance
paramedicine as a profession by developing an integrated set of programs and academic credentials
that build a solid foundation for practitioners and allows future growth in clinical practice or towards
leadership positions.
At the program level, professionalism is explicitly recognized as one of the five central themes of the
new ACP program. The other themes include health and wellness, interprofessional practice,
paramedic practice, and clinical (field) practice. These will serve as the central integrative concepts for
each course in the program.
Professionalism is embedded in both in the strategies and learning activities of each course.
Developing the content for these lessons is essentially an exercise in sifting and sorting. The NOCP
lists specific competencies related to professionalism. Similarly, the BC Academic Health Council has
developed a set of interprofessional practice competencies. Other sources of content include program
texts, lessons and modules from previous programs, instructors, and content experts. All of these
components are metaphorically thrown into a blender, then sorted into topics and sifted into an
integrated form for study and practice.
An additional layer of strategies link these individual learning activities to the central themes of the
program. The JIBC curriculum structure moves from simple to complex, but is also iterative and
integrative. Many of the essential professionalism competencies are covered in specific modules, then
revisited and reinforced in subsequent lessons and practice activities. Learners repeatedly encounter
these competencies as they progress from mastering core skills in drills to their application in

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increasingly complex patient presentations through simulation. The professionalism competencies are
encountered, enacted, and assessed through knowledge evaluations, checklist criteria, specific role
plays and simulations, as elements of other simulations, and as practicum evaluation elements.
In addition, the ACP program includes the concept of “planned serendipity.” Professionalism and
interprofessional dilemmas and issues are embedded throughout the curriculum. For example, a
simulation that focuses on the management of paediatric asthma in the respiratory disorders course
may involve a child who has evidence of physical abuse. The subsequent debrief focuses on the
assessment and management of the underlying condition. But the simulation also allows for “aha!”s
and learning moments that review, reinforce, and integrate broader issues.
The program reaches beyond its boundaries by planting seeds of service and lifelong learning. The
program encourages learners to explore both formal and informal roles of paramedics within their
communities and the health care system at large. Learners study principles of adult learning and are
given opportunities to act as peer tutors to their colleagues and mentors to junior cohorts. They are
encouraged to seek roles as preceptors and educators in their future practice.
A final strategy capitalizes on the informal socialization by which new practitioners are brought into a
discipline’s ways of thinking and acting. Instructors and preceptors serve as models for their students
through their everyday language and behaviour. This is a powerful form of learning that is often left
untouched. We can tap into this strategy by surfacing our intentions with both our instructors and our
learners and working towards consensus on the need to foster professionalism within our practice.

Summary
In this article, professionalism is presented as more than a series of competencies – more than a set of
outward behaviours. Certainly, professionalism includes these competencies, and traditional methods
of teaching and learning are effective ways of developing those behaviours. But professionalism
extends past patient care and beyond initial education to foster a particular mindset and approach to
one’s work. Efforts to foster professionalism must similarly extend past individual learning activities
and observations to include broader learning strategies, the acceptance of professionalism as a core
organizing element of a curriculum, and an integrative goal throughout a practitioner’s career.

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References
1. Paramedic Association of Canada. National Occupational Competency Profile for Paramedics
in Canada. 2001. Available from:
http://www.paramedic.ca/Content.aspx?ContentID=4&ContentTypeID=2
2. CMA Conjoint Accreditation Services. Guidelines for paramedic programs on the use of the
Paramedic Association of Canada’s national occupational competency profiles in the CMA
conjoint accreditation process. 2008. Available from:
http://www.cma.ca/multimedia/CMA/Content_images/Inside_cma/Accreditation/pdf/2008_gu
idelines_NOCP_e.pdf
3. Benner P. From novice to expert. Excellence and power in clinical nursing practice
(Commemorative edition). Upper Saddle River (NJ): Prentice Hall; 2001.
4. Dreyfus HL, Dreyfus SE. Mind over machine: The power of human intuition and expertise in
the era of the computer. New York: Free Press; 1986.
5. Cruess SR, Johnston S, Cruess RL. “Profession”: A working definition for medical educators.
Teaching and Learning in Medicine. 2004;16(1):74-76.
6. EMS Chiefs of Canada. Homepage. Available from: http://www.emscc.ca/
7. Society for Prehospital Educators in Canada. Available from:
http://prehospitaleducators.org/default.htm
8. Paramedic Association of Canada. Chapters. Available from:
http://www.paramedic.ca/Content.aspx?ContentID=29&ContentTypeID=1
9. Bledsoe BE, Porter RS, Cherry RA, Clayden DE. Essentials of paramedic care. Canadian
Edition. Toronto (ON): Pearson Prentice Hall; 2005.
10. Paramedic Association of Canada, Burgess RJ, MacDonald R. Nancy Caroline’s Emergency
Care in the Street. Canadian Edition. Canada: Jones and Barlett Publishers, Inc.; 2009.

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