Peer Evaluation of Paramedic Professional behaviors in State of Kuwait

Master's Thesis, 2009

106 Pages, Grade: Master Degree


Table of Contents




List of Tables

List of Figures

List of Appendices

Operational Definitions


Chapter One: Introduction
1.1 Background
1.2 Statement of the problem
1.3 Research question
1.4 Objective of the study

Chapter Two: Review of the Literature
2.1 Professionalism definition
2.2 Principles of professionalism
2.2.1 Excellence
2.2.2 Humanism
2.2.3 Accountability
2.2.4 Altruism
2.2.5 Communication skills
2.2.6 Communication with patient and families
2.2.7 Ethics and law
2.3 Measuring Professionalism
2.4 Measuring professionalism across the continuum of health-professional career
2.5 Methods used for assessing professional behavior
2.5.1 Peer assessment
2.5.2 Faculty observations on student's professional behavior
2.5.3 Written examination
2.6 Summary

Chapter Three: Research Methods
3.1 Study design
3.2 Methodology
3.3 Data collection
3.4 Statistical analysis
3.5 Ethical considerations

Chapter Four: Study Results
4.1 A. Focus group findings
4.2 B. Survey results
4.2.1 Demographic data
4.2.2 Variables
4.2.3 The professional behaviour survey overall results
4.3 Effect of variables on professional behavior 45
4.3.1 Nationality 45
4.3.2 Marital status 47
4.3.3 Educational level 49
4.3.4 Years of experience 51
4.3.5 Ambulance districts 52

Chapter Five: Discussion & Limitations
5.1 Discussion
5.2 Study Limitations

Chapter Six: Conclusions & Recommandations
6.1 Conclusions
6.2 Recommendation



Appendices :


Arabic Section:

Arabic Abstract


To all my great family, specially my wife who supported me throughout this work.

Special appreciation to my supervisor

Professor Reginald P. Sequeira

who did not save any effort to help me and guide me in this journey.

Great thanks to Doctor Mohammed Al Sharhan,

Director of EMS Dept.

Dr. Abdelreda Abbas, Assistant Director EMS Dept.


all EMS Employees who participated in this study.


As I reflect back over this journey, I want to reflect on the positive effect of this experience on me; that I have developed not only professionally but also personally.

I want to acknowledge my thanks to my wife; in my darkest hours, she was there.

My Words can not express my gratitude to my supervisor, Professor Reginald P. Sequeira for all of his effort and time he spent to guide me on this project.

Thanks also to all AGU Faculty and Administrative staff who helped me.

I will not forget Professor Usha Nayar and Professor Hossam Hamdi, who supported and encouraged me from the beginning of the programme. Special thanks to program secretary Ms. Ina Carmelita D’Souza, and to Mr. Mohammed Obidat for his assistance in statistical consultations.


Background: Professionalism is the backbone of effective delivery of emergency medical services (EMS) practice, and is a component of the national standard curricula for advanced level of EMS education. The professional behavior of paramedics in Kuwait has never been evaluated. In this study peer evaluation has been used to assess these affective competencies of paramedics in Kuwait.

Methods: Focus group discussions were carried out at each of the six ambulance centers to get an insight into professionalism issues of paramedics. A professional behavior evaluation instrument developed by Brown et al (2005) was used to rate peers by paramedics of six Ambulance Districts in Kuwait. Paramedics with at least a diploma and one year field experience were asked to rate their paramedic partner with whom they have worked together in the past year on 11 categories of professional behavior using Likert scale. Variables such as nationality, educational qualifications, years of experience, marital status and ambulance centers were analysed.

Results: It emerged from the focus group discussion that there were instances of complaints from the public and other healthcare professionals about delay in providing pre-hospital care, misbehavior with fellow-paramedics, and failure to check equipments resulting in incidents. It was also perceived that there is a deficit in teaching and learning of professional behaviors in EMS curriculum for paramedic training in Kuwait.

In a sample of 240 paramedics who fulfilled the inclusion criteria, 171 participated in the study. Of these, 151 (63%) returned the completed questionnaires, and these were analyzed. The overall mean score for professional behaviors was 2.94 on a scale of 1–4 (excellent = 4; poor = 1). Behaviors rated as excellent were integrity, empathy, patient advocacy and appearance. However, the behaviors rated as good (in descending order) were: time management, respect, teamwork, careful delivery of service, confidence, communication skills and self-motivation. Variables such as the nationality, marital status and educational level of paramedics had a significant effect upon several professional behaviors. The years of job experience did not have a significant effect. There were considerable variations in paramedic ratings at different ambulance centers.

Conclusions: Overall, paramedics were rated as “good” on professional behaviors. The reasons for deficiencies in specific behaviors identified and measures to overcome these deficiencies should be addressed. There is a need for on-the-job training to enhance professional behaviors of paramedics to improve the quality of pre-hospital care rendered by EMS department in the State of Kuwait. The deficiencies in teaching and learning of professional behavior in paramedic diploma curriculum also need to be addressed.

List of Tables

Table 1 Categories of professional behavior

Table 2 Demographic data of participants : nationality, marital status, educational level and years of experience

Table 3 Professional behavior evaluation scores

Table 4 Comparison of professional behavior scores according to the nationality

Table 5 Comparison of professional behavior scores according to the marital status

Table 6 Comparison of professional behavior scores according to the level of education.

Table 7 Comparison of professional behavior scores according to the years in service

Table 8 Comparison of professional behavior scores of paramedics at various ambulance districts

Table 9 Comparison of the current study with findings of Brown et al (2005)

List of Figures

Figure 1 Conceptual framework of professionalism

Figure 2 Ethical conflict nodes in prehospital emergency care

Figure 3 Miller’s model (application for professionalism assessment)

Figure 4 Number and proportion of participants from the six ambulance districts

Figure 5 Maslow's hierarchy of needs

List of Appendices

Appendix 1. Organogram of Emergency Medical Services (EMS) Department in Kuwait

Appendix 2. Professional Behavior Questionnaire Form

Appendix 3. Letter of Approval

Appendix 4. Professional Behavior Questionnaire Form(Arabic Version)

Operational Definitions

Emergency Medical Services (EMS): An Emergency Medical Service system (abbreviated to initialism "EMS" in many countries) is a service providing out-of-hospital acute care and transport to definitive care, to patients with illnesses and injuries which the patient believes constitutes a medical emergency. The most common and recognized EMS type is an ambulance organization ( Free encyclopedia).

Emergency Medical Technicians (EMT): An emergency responder trained to provide emergency medical services to the critically ill and injured. In an advanced life support (ALS) service the EMT plays a largely supportive role assisting a paramedic like a nurse assists a doctor in the hospital. In basic life support (BLS) services EMTs are solely responsible for the care and emergency treatment of their patients (Free encyclopedia).

Paramedic: A medical professional, usually a member of the emergency medical service, who responds to medical and trauma emergencies in the pre-hospital environment, provides emergency treatment and when appropriate, transports a patient to definitive care, such as a hospital, for further assessment or follow-up care (Free encyclopedia).

Profession: An occupation whose core element is work based upon mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society (Cruess et al 2004).

Professionalism: A set of values, behaviors, and relationships that underpins the trust of the public has in doctors (The Royal College of Medicine 2005).

Professional behaviors: Domains, elements, or attributes of professionalism (Academy of Medical Royal Colleges 2004).


Abbildung in dieser Leseprobe nicht enthalten.

Chapter 1 Introduction

1.1 Background

Medicine bridges the gap between science and society (Working Party of the Royal College of Physician, 2005). The professional behavior of health care providers is becoming a global issue.

Recently, the concept of professionalism has received much attention from all health-care sectors and is widely considered to be a vital competency that all health profession schools should teach and make sure that all students acquired satisfactorily. The trend to teach and measure the professionalism competency has developed to include all health-care professions. There have been many attempts to define professionalism and to identify the values or attributes that underpin professionalism. The Royal College of Physicians of London, which published a report of the working party titled "Doctors in society: medical professionalism in changing world". In this report the group of the working party comprising different health professionals defined and described professionalism. In addition there were some recommendations for health-care professionals regarding practicing, teaching, and assessment of student's professionalism (Royal College of Physicians of London 2005).

Along with this work, different health-care regulatory bodies including the General Medical Council (GMC) (Academy of Medical Royal Colleges 2004), Health Professionals Council (Health Professions Council 2003), and the Nursing and Midwifery Council (Nursing and Midwifery Council 2004) have set standards of professional training, performance and code of conduct for health professionals. It is evident that different health care professionals are sharing the generic values, which are expected from all health professionals regardless of their working environment. Those values have been summarized by the GMC as attributes of professional competence are good clinical care, maintaining good medical practice, and professional relationship with patients and colleagues, applying self to teaching and training, honesty, being aware of health needs and responsibilities and having high standards of probity (Academy of Medical Royal Colleges 2004).

Professionalism and emergency health-care professionals

In emergency care context there is a special relationship between patient and health-care provider. Such patient has specific characteristics-ailing, dependent, incapacitated, vulnerable, uninformed, reliant, and disadvantaged (Adam et al 1998). Adam et al (1998) emphasize that the specialty of emergency medicine can preserve the trust of patients and society only with a commitment to professionalism. This commitment must be backed by action. It must be evident in clinical training, and demonstrated in behaviors of the practitioners and leaders of the specialty. He continues saying "we must build upon the already substantial strengths of the specialty of emergency medicine by articulating and consistently demonstrating a commitment to the highest ideals".

The emergency care providers need to be conscious about demonstrating highest level of professional behavior. Emergency physician has enhanced ethical duties, moral requirements, and social contracts (Adams et al 1998). Similarly, paramedics who work in prehospital setting face stressful environment and often provide emergency care to critically injured patients; they have added responsibility to make best clinical interventions to patient's benefit. They must show humanism and appropriate attitude toward victims and their families, as well as maintain good relation with their colleagues and other health-care personnel. Also, as paramedics work in prehospital setting they are subject to public scrutiny; they need to reflect positively on profession they represent. In contrast, any deficiency not only may harm patients but also leads to public criticism of both paramedics and the profession. Cruess et al (1997) view that clinicians are judged as healers and as professionals, and they have to fulfill these two roles: failing to do so will cause them and the profession to suffer. Adam et al (1998) conclude that the specialty of emergency medicine must recognize the importance of defining its professional responsibilities, values, and commitments. In addition, trainees must be taught and emergency clinicians must practice the following:

- Making clinical decisions according to the best interests of the patient.
- Behaving in a manner that enhances patient trust.
- Delivering high-quality emergency medical care, maintaining the highest level of knowledge and skills.
- Listening attentively, maintain confidentiality, and communicate truthfully, respectfully, openly and honestly.
- Being an advocate for the health care needs of emergency patients and the community.
- Placing the interest and well-being of the patient above self-interest.
- Working for justice.
- Serving as a role model for health care professionals in training.
- Working collegially with others, helping to create a productive and effective work environment.

1.2 Statement of the problem

Many believe that the two year paramedics diploma program in Kuwait does not adequately address professionalism in the curriculum. The traditional program has not undergone any major curricular changes since inception. The program has no specific educational objectives that are classified under knowledge, skill, and attitude domains (personal observation). The program is structured into four phases: the first three are held in the training center school whereas the last phase involves practical training. It is an on the job training wherein trainee paramedics join an ambulance center to practice what they learn. The program has one course that is expected to address communication skills. This course on public relation is a feature of business programs but seldom that of health-care programs, such as paramedics. Furthermore, the subject is taught on a lecture-based instructional method without integration with paramedic needs or job description.

The paramedic diploma curriculum does not adequately address professionalism. There is no specific subject in the curriculum that is designed for teaching professionalism in prehospital environment, and that includes specific objectives which enable the graduates to appreciate the importance of professional behaviors and how it is best practiced in a prehospital care setting. The graduates have at best superficial knowledge regarding professional behaviors. Introducing a tool to measure the professional behavior of the prehospital care providers may help in providing better patient care and allow for better measurement of professionalism of the paramedics in health science school. Also, it is hoped that the result of this study would create greater awareness of professionalism among the paramedics, which in turn would improve the quality of health care given to the patients in prehospital setting.

1.3 Research question

To what extent the prehospital care providers demonstrate professional behavior in Kuwait?

1.4 Objectives of the study

1.4.1 Ultimate goal

To improve health-care provided by paramedics

1.4.2 Intermediate goal

To improve the professionalism of the paramedics

1.4.3 Immediate goal

To determine the professional behavior of paramedics in Kuwait .

Chapter 2 Literature Review

2.1 Professionalism definition

The concept of professionalism is circumscribed with specific elements. Definitions, empirically and prospectively derived, abound. It is obvious that the elements of professionalism have been set differently from one institute to other and from one professional organization to other, even though there is analogy in these elements among professional organizations. For instance, the American Board of Internal Medicine (ABIM 1994), the Society of American Emergency Medicine (Adams et al 1998), and the Accreditation Council on Graduate Medical Education (ACGME 1999) have defined professionalism prospectively and have semi-consensus on the elements that encircle professionalism (Arnold 2002). These elements are: altruism; respect for other people; additional humanistic qualities: honor, integrity, ethical and moral standards; accountability; excellence; and duty/advocacy (ABIM 1994, Adams et al 1998, and ACGME 1999).

Stern (2006) suggests that one approach to develop a definition of professionalism is to look for universal values among physicians:

“Core values of professionalism derived from the universality of disease and begin with caring or compassion. Caring over time create the value of responsibility. The shared responsibilities result in trust and respect between both physician and patient. The maintenance of trust demands integrity and confidentiality. The humanistic values considered core to practice of medicine are thus biologically grounded in the nature of disease and the natural emotional connections between individuals".

Beside these humanistic core values, other values develop over time such as service, maintenance of competence, autonomy, and self–regulation. Stern (2006) states that the efforts made by physicians and medical educators along with social scientists and ethicists suggest the following definition for assessment of professionalism.

"Professionalism is demonstrated through a foundation of clinical competence, communication skills, and ethical and legal understanding, upon which is built the aspiration to and wise application of the principles of professionalism: excellence, humanism, accountability, and altruism" (Figure 1).

Abbildung in dieser Leseprobe nicht enthalten

Figure1. Conceptual framework of professionalism

This definition points to several fundamental elements of knowledge and skills that are necessary but not sufficient for professionalism-clinical competence, ethical understanding, and communication skills.

2.2 Principles of professionalism

While technical knowledge, skills, ethics, and communication are foundational to professionalism, principles, as statements of values are central to the definition of professionalism and distinguish professionalism from clinical competence (Stern 2006). ABIM Project Professionalism identified key principles of excellence, accountability, duty, altruism, respect, and other humanistic qualities such as compassion and empathy, as well as honor and integrity (ABIM 1994). Stern (2006) suggests that these elements can be is categorized under four domains:

"Excellence begins with commitment to competence, understanding of ethical principles and values, and knowledge of legal boundaries. However its unique element involves a commitment to exceed ordinary standards. Accountability entails fulfilling the implied contract governing the patient-physician relationship as well as the profession's relationship to society. It includes self-regulation, standard setting, management of conflicts of interest, duty or the free acceptance of service, and responsibility. Altruism demands that the best interest of patients, not self-interest guide physicians. Respect, compassion, and empathy, plus honor and integrity, comprise humanism".

Arnold (2002) adds that although most organizations agree on these elements they may disagree on details. Some organizations or authors would add here or there, vary the emphasis given to particular principle, or define a principle some-what differently. For instance, self-regulation appears on the list of only some authors’ criteria (Cruess and Cruess; 1997, Cruess et al 1999, 2000a, 200b). Responsibility figures in the definition of professionalism applied to medical students (Gibson et al 2000; Phelan et al 1993; Papadakis et al 1999) is implied in the definitions for graduate medical education and practicing physicians. Altruism is the salient principle for ABIM (1994). Hafferty (2001) considers empathy as part of humanism, whereas, autonomy is critical to others (Cruess et al 1997, 2000b). These divergent definitions incorporating elements of professionalism have lead to overlaps between them. Stern (2006) for instance, maintains that humanism involves integrity in an early ABIM formulation, but in Project Professionalism integrity is separate from humanistic qualities. Moreover, altruism, compassion, empathy are sometimes used interchangeably (McGaghie 2002). Boundary between ethics and professionalism itself can be unclear (Brody 2003). Although none of these definitions from different organizations and experts is superior to one another, there is a sufficient agreement about the principles of professionalism to serve as organizing concept for the measurement of dimensions deemed important for all health professions.

2.2.1 Excellence

The concept of excellence begins with a commitment to competence in technical knowledge and skills, ethical and legal understanding, and communication skills. However, commitment to meeting minimal standards is not adequate for the fundamental nature of excellence is a continual conscientious effort to exceed ordinary expectations (ABIM 1994). Another expression for excellence is dedication to the continuous improvement of the quality of care by reducing medical errors, increasing patient safety, minimizing overuse of health care resources, and maximizing health outcomes. In order to improve quality of care, physicians in collaboration with other health professionals must generate better measures of quality of care and use these measures in routine evaluation of the performance of all participants, organizations, and systems responsible for health care delivery. Another aspect of excellence involves the promotion of scientific knowledge and technology. According to the ABIM charter (2002), physicians must uphold scientific standards, promote research, and produce new knowledge based on scientific evidence and experience. Also, doctors have the duty to protect and maintain the integrity of their medical knowledge and technology and to assure the integrity of the use of that knowledge and technology (Stern 2006).

2.2.2 Humanism

Stern (2006) states that humanism indicates a sincere concern for and interest in humanity, a vital principle to guide a profession rooted in the interaction between people in need of assistance and people offering it. Peabody (1927) explained the rationale for this principle:

"The practice of medicine is that it is an intensely personal matter. The treatment of a disease may be entirely impersonal. The treatment of patient must be personal. The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it… one of the essential qualities of the clinicians is interest in humanity, for the secret of the care of the patient is in caring for the patient".

Humanism has been articulated to include respect, compassion, and empathy as well as honor and integrity (ABIM 1992). In fact, Arnold (2002) emphasizes that humanism has been defined in terms of these components that are to guide physician's relationships within the professional setting. Respect in medicine is "personal commitment to honor other [people], choices and rights regarding themselves and their medical care" (ABIM 1992). Respect also includes the sensitivity and responsiveness to person's culture, age, gender, and disabilities (Accreditation Council for Graduate Medical Education, 1999). Respect presents clinicians with a special challenge since signs of respect may vary across cultures (Stern 2006). Yet, it has been called the essence of humanism (ABIM 1994), since it signals recognition of the worth of the individual human being (Abbot 1983).

Respect is due for patients and requires confidentiality, privacy, and informed consent. It also is accorded to colleagues in medical as well as other health care professions, learners, institutions, systems, and processes (Association of Medical Colleges and the National Board of Medical Examiners 2002).

Empathy and compassion have been defined in different ways. Empathy is the ability to understand another person's perspectives, inner experiences, and feelings without intensive emotional involvement (Hojat et al 2003a; Marcus 1999). It is a basic human need and backbone of patient-physician relationships. Stern (2006) suggests that empathy is not just an ability to understand another person and viewing the world from the patient's perspective. Empathy is more than understanding. It is multidimensional and includes the capacity to communicate that understanding (Hojat et al 2002; Feighny et al 1998). Some authors add an emotional dimension to empathy that points to the capacity to enter into or join the experience and feelings of another person (Hojat et al 2002; Halpen 2003). But that capacity is conceptually more relevant to sympathy, which in turn may affect necessary objectivity in medical care (Hojat et al 2002). Close with empathy is compassion, which is the feeling or emotion when a person is moved by the suffering or distress of another and the desire to relieve it (Oxford English Dictionary 1989). It also refers to an individual's inner recourses- his or her affective assets, awareness of others, and accumulated wisdom derived from life experiences (McGaghie et al 2002). In medical science, it involves an appreciation that illness engenders special needs for comfort and help but without excessive emotional involvement that could undermine professional responsibility for the patient (ABIM 1992); in addition, the expression of appreciation through appropriate sensitive communication and actions. Compassion also extends to peers, co-workers, and self (Association of American Medical Colleges and the National Board of Medical Examiners 2002).

Other essential components of humanism are honor and integrity. Honor and integrity means to be "fair and truthful, keeping one’s word, and being straightforward" (ABIM 1994). These qualities pertain to relationship with patients, colleagues, other health care professionals, and learners. They can be noted through a variety of activities such as patient care, academic assignments, scholarly work, and research. Admitting of errors, addressing errors of others, and crediting the work of others appropriately are some positive behavioral examples of respect and integrity. In contrast, negative behavioral examples for these principles are stealing, cheating on examinations, misrepresenting data, falsifying documents, and impersonating others (Association of American Medical Colleges and the National Board of Medical Examiners 2002).

2.2.3 Accountability

According to Emmanuel and Emmanuel (1996) accountability refers to "procedures and processes which one justifies and takes responsibility for its activities". It can involve several different parties that could be held accountable or hold others accountable (Emmanuel and Emmanuel 1996).The accountability has different levels including responsibility to patient for fulfilling the implied contract governing the patient-physician relationship, to colleagues, to the profession for adhering to medicine's time-honored precepts, and to society for addressing the health needs of the public (Stern 2006). Furthermore, "responsibility represents the most personal behavioral application of accountability". He adds that in a conservative definition, one is responsible "to" [patients, families, society] and accountable "for" [quality of care, upholding principles, reporting conflicts on interest]" (Stern 2006). Responsibility involves availability when "on call", acceptance of inconvenience to meet patient's needs and endurance of unavoidable risks to oneself when a patient's welfare is at stake. It also means advocacy for individual patients so they may receive the best possible care. It involves an obligation to collaborate with other health professionals, to provide leadership when appropriate, and to defer to the leadership of others when indicated (Medical School Objectives Writing Group 1999).

A core aspect to this definition of accountability includes self-regulating activities, for which clinicians can be held accountable, and range from their professional competence and legal and ethical conduct to financial performance (ABIM 1994; ABIM 2002; Medical School Objectives Project Writing Group 1999; Emmanuel and Emmanuel 1996) . Other related activities of accountability are setting standards for current and future members of the profession, engagement in internal scrutiny and acceptance of external scrutiny, and remediation and disciplining of members who fail to meet those standards (ABIM 2002).

2.2.4 Altruism

Altruism has been included in most definitions of professionalism, yet it is challenging to categorize. It could be included in the domain of excellence (demanding the best for patients), accountability (avoiding self-interest), or humanism (selfless behavior). In medical context, altruism demands that patient's best interests, rather than the interest of the physicians, guide behavior (ABIM 1999). According to the Medical School Objectives Projects Writing Group (1999) there are potential threats to altruism inherent in various financial and organizational arrangements for practice of medicine and calls for physicians" to advocate patients interest instead of one’s self interest".

2.2.5 Communication skills

Communication is a very essential skill for all health-care professionals. The most important skill a prehospital care provider can have is the ability to communicate effectively (Dernocoeur 1996). It includes taking histories, educating patients, developing alliances, and managing illness. Core professional values of compassion, responsibility, and integrity are all demonstrated through communication (Stern 2006). With effective communication, the ability to assist the physical and psychological needs of people will increase. Further, good communication is essential for prehospital safety. It is also vital to scene control, when chaos and confusion are managed with effective communication (Dernocoeur 1996).

2.2.6 Communication with patient and families

Many authors have described the general routines used by clinicians to communicate with patients. These routines are organized around the purpose of each element of the routine. Billings and Stoeckle (1999) discuss six broad tasks that characterize clinical encounters with patients:

1. Beginning the interview and establishing a relationship with the patient.
2. Eliciting from the patient information needed for diagnosis and management,
3. Consultation with the student's preceptor (oral case presentation)
4. Assessment and plan formulated in conjunction with the preceptor
5. Providing information and counseling the patient (including the negotiation of a mutually agreeable plan and saying goodbye to the patient), and
6. The recording of the interview and discussion with the preceptor in written form.

The Kalamazoo Consensus Statement (2001) identifies seven essential elements of communication in medical encounters:

1. Building the patient-physician relationship,
2. Opening discussion,
3. Gathering information,
4. Understanding the patients’ perspective,
5. Sharing information,
6. Reaching agreement on problems and plans
7. Providing closure.

Makoul (2001) developed a widely used framework to teach and evaluate communication skills entitled SEGUE, an acronym for:

S et the stage;

E licit information;

G ive information;

U nderstand the patients’ perspective, and

E nd this visit.

2.2.7 Ethics and law

The prehospital care providers are confronted with a variety of emergency situations where they have to take appropriate decisions that benefit the patient. Unfortunately, legal guidance does not provide the answer to every dilemma that may arise. Furthermore, current training does not equip even the most advanced prehospital care provider to deal readily with every potential situation. Many learn by experience, and some are guided by clear policy (Adam et al 1999). Actually, there are many situations in the prehospital setting that have not been addressed by statute or case law. Ethical conflicts are present in the daily practice of prehospital care. These conflicts are related to issues of resuscitation, futile therapy, consent, and refusal of care, duty, and confidentiality (Sandman & Nordmark 2006). These are illustrated in figure 2.

Abbildung in dieser Leseprobe nicht enthalten.

Figure 2: Ethical conflict nodes in pre-hospital emergency care

(Adapted from Sandman and Nordmark 2006)

2.3 Measuring Professionalism

Assessment is an essential component in the educational process. It is well-known that assessment drives learning (Thistlethwaite 2004).

Without a valid and reliable assessment no one can judge that the student has acquired the required knowledge, skills, or behaviors. In other word students who complete the course/program can not be a declared competent unless they pass the examinations that prove that learning has taken place. Almost 50% of medical schools have written criteria and specific assessment methods to assess professional behavior (Miller et al 1989; Swick et al 1999). According to (Stern 2006) the ability to measure professionalism will help to detect and dismiss those students or clinicians with inappropriate behavior. At the same time it can be used to reward those clinicians who show high level of altruism, humanism, and compassion. Measuring professionalism will allow educators to detect changes in professionalism as a result of educational interventions. Stern (2006) adds that while educators have achieved great strides over the past 50 years in assessing knowledge, and over at least 20 years in assessing skills, the assessment of behaviors and professionalism has lagged.

2.4 Measuring Professionalism across the Continuum of Health-professional Career

According to Stern (2006) measuring the principles of professionalism are stage specific and are dependent upon context; in contrast, an alternative view suggests that these principles apply throughout the career. Many studies documented the context dependency of professional behavior (Hartshorne and May 1928,1930; Carlo et al 1991; Rezler et al 1992; Marcus 1999; Simmons et al 1992; Wolf et al 1989; Testerman et al 1996 Satterwhite et al 1998; Garfinkel 1997), the perspective of health care professionals educator (Novack et al. 1999; Feghny et al 1998; Swick et al 1999; Kao et al 2003; Gibson et al 2000; Phelan et al 1993; Papadakis et al 1999), and the views of learners (Charistakis and Feudtner 1993; Ginsburg et al 2002; Arnold et al 1998). Brownell et al (2001) adds that health professional needs to know and do, and what therefore should be assessed, depend on career stage. An example, resident physicians would recommend that because principles of professionalism related to societal issues are not intimately germane to their patient care tasks while principles related to caring for individual patient are; assessment of their professionalism should be directed to their commitment to excellence and their respect and compassion for patient. Also, evidence does exist for the alternative proposition that the principles of professionalism apply throughout the health professional career. Research on the development of moral behavior as well as studies of learners in medical education (Burton 1963; Nelsen et al 1969; Clark et al 1987; Rushton 1980; Rogers and Coutts 2000; Stewart 1999; Papadakis et al 2004) suggest that the specificity of professional behavior according to context is an overstatement. In addition, professional organizations have delineated a comprehensive set of principles that apply equally to medical students, residents, and/or physicians in practice (Medical School Objectives Writing Group 1999, Accreditation Council for Graduate Medical Education 2004; ABIM 1994; Arnold 2002). Furthermore, effective pedagogy that enables learners to anticipate and practice their future in safe surrounding also supports the idea that the principles of professionalism are relevant to all stages of health professionals’ career. The developmental relationships among the principles of professionalism (Clark et al 1987; Damon 2001; Eisenberg et al 1991; Christakis and Feudtner 1993; Arnold 2002; Castellani and Wear 2000; Ginsburg et al 2000; Shaffer 1993; Rushton 1980) argue for an assessment approach that examines learners’ progress toward acquiring, embracing, and demonstrating the principles of professionalism throughout their career. Stern (2006) suggests to tailor the principles of professionalism to the role of students, residents, and practitioner using Miller's pyramid of learning- known as "know, can, do" schema (Miller 1990; see figure 3). He adds that:

"The pyramid provides for teaching and assessing knowledge, then competence or the capacity to apply, and finally actual performance in practice. By adapting the pyramid to professionalism, learners would be expected to reach-stage specific achievement in knowledge, competence, and performance depending upon the principles at hand".

Abbildung in dieser Leseprobe nicht enthalten

Figure 3. Miller's model (application for professionalism assessment).

Previous studies have adopted this approach for assessing ethical development of medical students (Roberts et al 1997) and residents (Larkin 1999). In the initial stages only ethical knowledge of students was tested. The following year their knowledge of ethics and competence in applying ethical principles to simulated scenarios were examined. In the final year, students’ ethical knowledge, competence, and performance in actual setting were assessed (Stern 2006). Such progressive approach to assessing professionalism of health professionals has a sound educational basis.

According to Stern (2002) this approach can be used by all health care professions to promote and assess professionalism. Depending upon the principles of professionalism at hand and health professionals’ career stage, assessment of professionalism would be progressively and cumulatively directed toward the subsequent developmental stages. He suggests that the initial stages are awareness or the ability to identify the principles of professionalism in clinical and professional situations and the ability to prioritize these principles relative to other values, and possession of the character and skills to act, based on these principles.

Stern (2006) summarized the steps that should guide the assessment of professionalism, as below:

1. The development of an institutional plan for assessing professionalism.
2. Discussion and agreement upon the meaning of professionalism as applied to the organization using wide range of participants.
3. Selection of a set of behaviors on which to focus.
4. Deciding the purpose of the evaluation whether it is formative or summative.
5. Identification of a set of instruments to measure behaviors.
6. Training evaluators to improve both their connoisseurship and their criticism of professional behaviors.


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Peer Evaluation of Paramedic Professional behaviors in State of Kuwait
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Ahmad Al Harbi (Author), 2009, Peer Evaluation of Paramedic Professional behaviors in State of Kuwait, Munich, GRIN Verlag,


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Title: Peer Evaluation of Paramedic Professional behaviors in State of Kuwait

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