It surprises me how often I am asked why the Paramedic Program at Fanshawe College (London, Ontario) began teaching evidence-based medicine and why so much focus on cultivating research literacy and skills within the paramedic students has been added to the curriculum. For me the answer to both is the same – research saves lives.
Traditionally the initial education of paramedics at most colleges or organizations in Canada has followed a common training structure. Textbooks are utilized as the primary reference source. Regional medical directives defined by physician Medical Directors serve as one of two primary curriculum foundations; provincial standards or legislation-defined processes serve as the other primary curriculum foundation.
Regional medical directives are skills and/or procedures that a paramedic can initiate as part of their patient care when defined patient conditions or symptoms are present. These medical directives are available to paramedics directly through telephone or video-conference based consultation with a physician or indirectly through formally written reference manuals from physicians. These medical directives generally cover those acts which are legislated to be practiced by licensed and regulated health care practitioners, e.g., the Ontario Regulated Health Professions Act (RHPA). An example of a medical directive is protecting a patient’s airway with the insertion of an endotracheal tube through direct laryngoscopy. In some provinces, for example, Alberta and Nova Scotia, paramedics are regulated professions under legislation and may not utilize these defined medical directives. Provincial standards, for example, the Ontario Emergency Health Services Branch, Ministry of Health and Long-Term Care Basic Life Support Patient Care Standards (BLSPCS), are published standards defining the procedures a paramedic must follow for common patient presentations. These standards do not include medical directives and generally include basic patient assessment and treatment standards, such as managing a patient with multiple systems involved trauma, as well as common special circumstance management such as mental health presentations and treatments.
These traditional approaches to education content delivery are not flexible enough to allow for constant and timely updates to training curriculum. Specifically, the standards require several organizations to approve of changes and as such can take a long period of time to revise. To be more responsive to the changes of medical practice as defined by current research the Paramedic Program at Fanshawe College shifted away from medical directive and defined standards-based education as foundations and established an evidence-based practice as the cornerstone of the curriculum.
The role of the paramedic in Canada continues to evolve. In 2006, the EMS Chiefs of
Evidence-based practice, also referred to as evidence-based medicine is defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett, 1998, p. 1085). In essence, a physician or healthcare practitioner who wishes to adapt their patient care practice could do so as research results are released as opposed to waiting for formal continuing medical education training or textbook releases. An example of the benefits of applying evidence-based medicine can be seen when looking at the treatment of a patient with chest pain from a myocardial infarction (commonly referred to as a heart attack). The BLSPCS states “administer high concentration oxygen to all patients with chest pain” (Emergency Health Services Branch, 2007, emphasis in original). Within this standard, the term all is bolded, placing emphasis that each patient experiencing this symptom must receive this treatment. In contrast, Wijesinghe, M., Perrin, K., Ranchord, A., Simmonds, M., Weatherall, M., & Beasley, R., (2009) stated, in reference to high-flow oxygen for the treatment of a myocardial infarction, “the routine use of oxygen in this situation may increase infarct size and possibly increase mortality” (page 201). This research from Wijesinghe and colleagues, and others including Cabello (2016) related to high flow oxygen for the treatment of a myocardial infarction have changed how these particular patient presentations are managed by health care practitioners who can adapt their practice to reflect the evidence.
This is only one example of the evidence-based changes in medicine that have led to decreased mortality. Improved patient outcomes and changing practice based on timely systemic review was the primary reason for us to push to change the way initial education was delivered to paramedic students at Fanshawe College. However, without understanding the process and value of research, health care practitioners are hesitant to adopt these clinical changes which could benefit the patient (Uysal, Temel, Ardahan, & Ozkahraman, 2010).
To encourage the adoption of evidence-based practice, research literacy education and skills have been integrated within the Paramedic Program at Fanshawe College. Components of this integration included critique and appraisal of research studies, education on research study designs, data collection and analysis through qualitative and /or quantitative research techniques and an understanding of research ethics. A mandatory research course led by paramedic researchers was created and implemented. Additionally, research and research results were integrated within all other courses in the program. This included the referencing of journal articles and research evidence when introducing or reinforcing patient care practices. It also included student-led primary or secondary research as part of the curriculum. This research involved all resources at the college including the Research and Ethics Board, and library services. Students complete research studies through quantitative, qualitative or mixed methods approaches and present their findings at an annual research conference hosted by the Paramedic Program, which is open to the community. It is our vision that this increase in research literacy and skills will make these paramedic graduates more effective practitioners when practicing in the field. Additional research is required related to this supposition and I hope to complete this research in the future.
Research has not only been integrated into the medical content taught, or the expectations of our student research studies, in addition, the methods by which we teach have been critically appraised by faculty, and adoptions made to our delivery models. Flipped classroom models, and significant curriculum enhancement through technological adoptions have been introduced. Currently, I am conducting research on these delivery models.
Paramedics in most regions of Canada must adhere to published standards and defined medical directives. In many cases, these standards and definitions do not meet the evidence-based practice established through extensive research and review. In order to address the shortfalls in these documents, paramedic students at Fanshawe College are taught evidence-based practice to increase their awareness of current patient care practices, with the expectation of improving patient care and decreasing mortality. Additionally, to improve research literacy and research skills, paramedic students within the Paramedic Program at Fanshawe College are taught several key elements of research including critical appraisal, research design, data collection and analysis which they then apply to a quantitative or qualitative research study. Faculty members within the Paramedic Program at Fanshawe College have integrated evidence-based teaching methodology in their curriculum design and delivery as well as integrated technology into the program. Initial results of ongoing research studies have shown positive results and continue to be investigated.
Emergency Health Services Branch, Ontario Ministry of Health of Health and Long Term Care. (2007). Basic life support patient care standards (version 2.0). Retrieved from http://www.health.gov.on.ca/english/public/program/ehs/edu/pdf/bls_patient.pdf
EMS Chiefs of Canada. (2006). The future of EMS in Canada: defining the new road ahead (Strategy Paper V5 7). Retrieved from https://semsa.org/ images/stories/committee/EMSCC-Primary_Health_Care.pdf
Cabello, J., Burls, A., Emparanza, J., Bayliss, S., & Quinn, T. (2016). Oxygen therapy for acute myocardial infarction. Cochrane Database of Systemic Reviews. https://doi.org/10.1002/14651858.CD007160.pub4
Donaghy, J. (2008). Higher education for paramedics — why ? Journal of Paramedic Practice, 31–35.
Jones, C., & Jones, P. (2013). Paramedic research methods: importance and implications. Journal of Paramedic Practice, 1(11), 465–469. Retrieved from http://web.b.ebscohost.com.ezproxy.royalroads.ca/ehost/pdfviewer/pdfviewer?vid=1&sid=c0e99471-615e-49b3-b0ac-ae4a86e51a91%40sessionmgr120.
Sackett, D. (1998). Evidence-based medicine. Spine, 23(10), 1085-1086.
Uysal, A., Temel, A. B., Ardahan, M., & Ozkahraman, S. (2010). Barriers to research utilisation among nurses in Turkey. Journal of Clinical Nursing, 19(23–24), 3443–3452. https://doi.org/10.1111/j.1365-2702.2010.03318.
Wijesinghe, M., Perrin, K., Ranchord, A., Simmonds, M., Weatherall, M., & Beasley, R. (2009). Routine use of oxygen in the treatment of myocardial infarction: systematic review. Heart, (95), 198–202. https://doi.org/10.1136/hrt.2008.148742