The tangled web of wisdom: A mixed methods exploration of ethics in paramedic education and practice.

Paramedicine in Australia has undergone significant change, with increasing scopes of practice and, most notably, the recognition of paramedicine as a profession and the introduction of paramedic registration. The education of paramedics has progressed concurrently, advancing from a post-employment vocational model to pre-employment higher education. With the evolution of the profession and the attendance of paramedics at cases involving high degrees of clinical, operational, and situational complexity, a need arises for paramedics to be prepared holistically, particularly regarding the application of reasoned ethical judgement in novel situations.

The motivation for this thesis arose from personal reflections on professional experiences and how we encourage student paramedics and those new to the profession to develop their practical wisdom without experience of the world. This research has been approached through a pragmatic lens, initially by considering the potential benefit and application of phronesis in paramedicine, as discussed in Chapter 3. Phronesis, or practical wisdom, is a form of wise and practical knowing and reasoning related to human action, ultimately formed the foundation for further studies in this thesis. However, the thesis topic leant itself to also using a variety of methodologies as well as phronesis to better understand the ethical dilemmas present-day paramedics face, the factors affecting paramedic ethical decision-making, and to explore how paramedics are taught about ethics in the Australian undergraduate paramedicine curriculum.

Despite previous international research in paramedicine and other areas of health and medicine, little is known about the ethical dilemmas faced specifically by Australian paramedics. A survey was utilised to gain evidence, with the findings from this research presented in Chapter 4, a published article entitled ‘Perceptions of ethical dilemmas in Australian paramedicine’. Sixteen paramedics were individually interviewed about a case that presented an ethical dilemma for them, to gain a deeper understanding of the factors affecting their ethical decision-making. These cases were explored using a consistent framework, with the findings contributing to two chapters in this thesis: Chapter 5, a published article entitled ‘Factors influencing the lived experience of paramedics facing ethical dilemmas: a case comparison’, and Chapter 6, a broader thematic analysis exploring the complexities of ethical decision-making in paramedic practice. Ethics education in undergraduate paramedicine programs in Australia was investigated through document analysis of course materials from university websites, supported by discussions with relevant paramedic academics. The findings from this investigation are presented in Chapter 7, a published article entitled ‘Undergraduate ethics education in paramedicine in Australia’.

Contemporary Australian paramedics' experience of ethical dilemmas is reasonably consistent with previous international findings. Notably, when asked the question of how they managed the ethical dilemmas they faced, 78% (n=31) of those who responded indicated they used their experience while 27% (n=11) indicated they relied on their education. Numerous factors influence a paramedic’s ethical decision-making, including communication and teamwork, clinical support, and education. Further in-depth thematic analysis revealed that culture, religion, and workplace support are additional factors impacting paramedic ethical decision-making. Regarding undergraduate paramedic ethics education, while similarities existed across universities, such as approaches to learning and teaching and the use of case-based learning, there were notable differences, including teaching staff profiles and content areas.

This thesis highlights that paramedics must engage in practices central to cultivating practical wisdom, such as reflective practice and mentoring others. Gaining consensus among paramedic educators and other key stakeholders regarding ethics education for paramedics would likely result in graduates possessing consistent knowledge and skills, setting them on the path to practical wisdom with the ability to engage and resolve the many challenges their profession presents. Findings also suggest that organisations employing paramedics have responsibilities regarding ethics, including clarity of organisational guidelines, an obligation to provide accessible, robust, and helpful support systems, and to ensure that any training provided is fit-for-purpose and contextually relevant.