Barriers to Paramedic Professionalisation: A Qualitative Enquiry Across the UK, Canada, Australia, USA and the Republic of Ireland.

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Fintan Feerick, Dr. Eoin Coughlan, Prof. Shane Knox, Prof. Adrian Murphy, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6732926/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Jul, 2025 Read the published version in BMC Health Services Research → Version 1 posted 13 You are reading this latest preprint version Abstract Background – Paramedicine is in the midst of a transformative shift, as paramedics move beyond traditional emergency roles toward recognition as healthcare professionals. Central to this evolution is the pursuit of professionalisation—seeking greater autonomy, expanded scope of practice, and formal integration into healthcare systems. However, significant barriers persist. Purpose – This study explores key barriers to paramedic professionalisation across five different developed healthcare systems, both domestically and internationally. Methods – A qualitative study using semi-structured interviews underpinned by a critical theory paradigm. Over five months (Dec 2022–Apr 2023), 15 stakeholders from paramedicine and pre-hospital emergency care across five countries participated. Their backgrounds spanned clinical practice, education, policy, and management. Interviews were conducted via Microsoft Teams, recorded, transcribed verbatim, and thematically analysed. Results – Analysis of fifteen semi-structured interviews revealed four main themes with overlapping but contextually distinct sub-themes: Theme 1: Current Barriers to Expansion – Included outdated legislation, limited funding, staffing challenges, and poor integration into healthcare. Theme 2: Elevating Professional Status – Focused on education, regulation, certification, and professional identity. Theme 3: Impact of COVID-19 – Highlighted lost momentum, shifting policy priorities, and redirected funding. Theme 4: Future Barriers to Change – Included structural/systemic issues, workforce development, collaboration, and entrenched mindsets. Conclusion – Multiple barriers hinder paramedic professional recognition, including fragmented regulation, inconsistent education standards, limited funding, and internal resistance. While COVID-19 briefly raised the profession’s profile, this momentum has since declined. Reinvigorating progress requires political commitment, regulatory reform, educational investment, and workforce development to fully embed paramedics within healthcare systems. Paramedicine Paramedic Professionalisation Professional Development Barriers Background The professionalisation of paramedicine is reshaping the healthcare landscape. Traditionally regarded as emergency responders providing critical pre-hospital care, paramedics are increasingly recognised as an essential healthcare profession with greater autonomy and an expanding scope of practice [1]. This shift highlights their vital role beyond emergency care, contributing to the broader healthcare system [2-3]. Achieving full professional recognition remains challenging due to outdated legislation, inconsistent regulatory frameworks, and a lack of formalised education, training pathways, and legal title protection. Internal barriers, such as resistance to change and concerns about professional identity, further complicate progress [4]. The COVID-19 pandemic underscored the indispensable role of paramedics, briefly accelerating efforts to elevate their professional standing [5]. However, as healthcare priorities shift, momentum has slowed [6]. Defining “professionalism” in paramedicine is complex, as the field lacks universally recognised standards, leading to fragmented regulations and varying scopes of practice worldwide [7-9]. This disparity hinders paramedics' ability to achieve the professional recognition enjoyed by other healthcare disciplines. Addressing these challenges requires a collective effort to establish and enforce unified professional standards, ensuring paramedicine's evolution into a fully integrated healthcare profession [10]. Legislation and Regulation Legislation and regulation are fundamental to the professionalisation of paramedicine, shaping its scope, responsibilities, and recognition within the healthcare system [11]. Strong legal frameworks safeguard public safety while providing paramedics with greater autonomy, standardised training, and clearer career pathways [12]. Paramedicine's regulatory landscape is often inconsistent, reflecting its historical development within emergency medical services (EMS) and varying regional priorities. Historically, paramedics were not legally recognised as distinct healthcare professionals, limiting their scope of practice to basic emergency response [13]. Over time, their role has expanded to include advanced clinical interventions and broader healthcare responsibilities [14]. Legislative and regulatory reforms have not always kept pace, leaving many regions with outdated or fragmented frameworks that fail to reflect modern paramedicine [15]. In some countries, paramedics are still perceived primarily as ambulance drivers or emergency technicians, restricting their ability to engage in advanced clinical roles. Establishing cohesive, modern regulations is essential to overcoming these challenges and ensuring professional recognition [16]. Different countries have adopted varied approaches to paramedic regulation, highlighting both progress and ongoing challenges: In the United Kingdom (UK), paramedics are regulated as "Allied Health Professionals" (AHP), under the Health and Care Professions Council (HCPC), granting them autonomy and access to advanced roles beyond emergency care [17]. A well-defined scope of practice and degree-level education as an entry requirement reflect the UK's commitment to professionalisation [18-19]. Variations persist across England, Scotland, Wales, and Northern Ireland, particularly in healthcare system integration, funding, and recognition of advanced practice roles [20-21]. In the United States of America, (USA), paramedic regulation is managed at the state level, leading to significant variability in training, certification, and scope of practice. Certification is generally overseen by state EMS offices, with voluntary national certification available through the National Registry of Emergency Medical Technicians (NREMT) [22]. Some states grant paramedics autonomy and advanced procedural authority, while others impose restrictive limitations [23-24]. The decentralised nature of U.S. healthcare further complicates efforts to standardise paramedic credentialing nationwide. Australia has made significant strides in paramedic regulation, particularly with the establishment of the Paramedicine Board of Australia under the Australian Health Practitioner Regulation Agency (AHPRA) in 2018 [25]. This national framework ensures uniform education and practice standards across states and territories, strengthening paramedics' professional standing [26-27]. Registration with AHPRA is mandatory, facilitating advanced roles and integration into multidisciplinary healthcare teams [28-29]. However, regional differences in autonomy and scope of practice persist, alongside challenges in workforce shortages, training access, and expanding community care roles [30-31]. Paramedic regulation in Canada varies by province and territory, resulting in inconsistent education, certification, and scope of practice [32-33]. While some provinces, such as Alberta and Ontario, have independent regulatory bodies, others rely on government departments for oversight. Efforts to establish a national registry and harmonise standards face obstacles due to Canada's decentralised healthcare system [34]. This lack of uniformity complicates interprovincial mobility for paramedics and limits the recognition of advanced practice roles such as critical care and community paramedics [35-36]. In the Republic of Ireland (ROI), paramedicine has undergone significant regulatory changes to align with modern healthcare demands [37]. Irish paramedics are overseen by the Pre-Hospital Emergency Care Council (PHECC) [38]. Established in 2000, PHECC sets educational, training, and practice standards for paramedics, advanced paramedics (APs), and emergency medical technicians (EMTs), maintaining a statutory register and professional development requirements [39]. Continuous Professional Development (CPD), requirements remain underdeveloped, and legislative support for ethics and fitness-to-practice issues is limited [40]. Efforts are underway to expand paramedics' roles beyond emergency response to include community care, critical care, mental health, and chronic disease management, but these changes require stronger legislative and regulatory backing [41-43]. Education and Training Education and training are fundamental to the professionalisation of paramedicine, shaping the competencies, clinical skills, and decision-making abilities of practitioners. The educational pathways and training requirements for paramedics vary significantly across jurisdictions, reflecting differing healthcare priorities, regulatory frameworks, and professional expectations [41]. In the UK, paramedic education has undergone substantial reform, transitioning from vocational training to degree-level qualifications. As of 2021, all paramedics must complete an HCPC-approved degree in paramedic science from a university to qualify for registration with the HCPC, [45]. The most common pathway is a three-year full-time undergraduate degree, which includes both academic study and clinical placements in pre-hospital and healthcare settings [46]. The curriculum emphasises a balance of theoretical knowledge and practical skills, covering areas such as anatomy, physiology, pharmacology, patient assessment, and emergency care. Opportunities for further education include postgraduate degrees including Masters and Doctoral degrees, and specialist training programs for roles such as advanced paramedics, critical care paramedics, and paramedic practitioners [47]. Registered paramedics are required to engage in CPD, to maintain their registration, ensuring that their skills remain current and aligned with best practices [48]. The UK’s emphasis on degree-level education reflects a broader effort to elevate paramedicine as a recognised healthcare profession, with a focus on clinical autonomy and multidisciplinary collaboration [49]. In the USA, paramedic education is more diverse, reflecting the decentralised nature of the country’s healthcare and regulatory systems. Training programs range from certificate-level courses to associate and bachelor's degrees, with significant variability in duration and content [50]. Most paramedics complete a certificate or associate degree program accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP). These programs typically take 1-2 years to complete. The curriculum includes foundational topics such as emergency medical services operations, patient assessment, trauma care, and advanced life support (ALS). Clinical rotations and internships are integral components and paramedics must pass the NREMT exam to obtain national certification. Bachelor's degree programs in paramedicine are available but are not universally required [51-52]. Advanced practice roles, such as critical care paramedics, often require additional certification and training. However, state-specific requirements vary, and some states do not mandate NREMT certification. The variability in educational standards and pathways reflects broader fragmentation within the U.S. healthcare system, posing challenges for professional consistency and mobility [53]. Australia has established a unified framework for paramedic education as part of its broader efforts to professionalise paramedicine. Degree-level qualifications are now the standard entry pathway for the profession [54-55]. Aspiring paramedics must complete a Bachelor of Paramedicine or a related degree from an accredited university, typically over three years of full-time study. The curriculum combines theoretical knowledge with extensive practical training. Key topics include advanced trauma care, pharmacology, ethics, patient communication, and clinical decision-making. Clinical placements with ambulance services and other healthcare providers are mandatory. Graduates must register with the AHPRA to practice as paramedics. Advanced practice roles, such as intensive care paramedics and extended care paramedics, require further postgraduate education and training, including bachelor’s degree, master’s degree and doctoral degree [56]. CPD is mandatory for registered paramedics to maintain their professional competence. Australia’s emphasis on degree-level education and national registration reflects its commitment to standardising paramedicine as a healthcare profession across its states and territories [57]. In Canada, paramedic education and training are regulated at the provincial and territorial levels, leading to significant variation in paramedic’s scope of practice and standards. There are three levels of paramedic certification: Primary Care Paramedic (PCP), Advanced Care Paramedic (ACP), and Critical Care Paramedic (CCP) [58]. Most paramedics begin their careers as PCPs, completing a college diploma program that typically takes 2 years. ACP training is an additional 1-2 years, while CCP certification requires further specialised education. Training programs focus on pre-hospital emergency care, pharmacology, patient assessment, and trauma management. Clinical placements and field internships are key components. Paramedics must pass provincial or territorial certification exams to practice. Some provinces also recognise national certification through the Canadian Organisation of Paramedic Regulators (COPR) [59]. Opportunities for further education include specialised training programs for ACP and CCP roles, as well as bachelor’s degrees master’s degrees and doctoral degrees in paramedicine in some provinces. Regulatory bodies require ongoing CPD to maintain licensure. Canada’s decentralised approach results in varying standards and training durations across provinces, creating challenges for interprovincial mobility and national standardisation [61]. In ROI, paramedic education is overseen by PHECC, which sets the standards for training and certification. Paramedics complete a PHECC approved paramedic program, which includes both academic coursework and clinical training. Advanced paramedics, and community paramedics require additional postgraduate training up to master’s degree level. Additional master’s degree and doctoral degree programmes are being developed including critical care and mental health paramedic, although in limited numbers [61] The curriculum includes patient assessment, advanced life support, pharmacology, and pre-hospital emergency care. Practical training involves clinical placements with ambulance services and other healthcare providers. Paramedics must pass a PHECC certification exam and register with the council to practice legally. PHECC mandates CPD for EMT’s, only [62]. In the ROI, paramedics certified by PHECC are designated as basic life support (BLS) providers, unlike their counterparts in neighbouring jurisdictions who operate at an advanced life support (ALS) level. Currently there is no requirement for paramedics to complete CPD other than mandatory recertification to remain competent and up to date with best practices. While the Republic of Ireland has made progress in standardising paramedic education, significant action is still needed to address issues such as the protection of the paramedic title, limitations in scope of practice, and the lack of clear career progression pathways — all of which require legislative and regulatory changes. This is limiting the number of advanced training opportunities and presents challenges for career development within the profession and greater healthcare system [38-40]. Paramedic Title Protection The protection of professional titles is a cornerstone of healthcare professions, ensuring that individuals who practice meet rigorous standards of education, training, and ethical accountability. In many parts of the world, the title "paramedic" lacks legal protection, creating challenges for the profession in achieving full recognition as a healthcare discipline [63]. In countries such as Australia, the UK, Canada, and some states within the U.S, the title "paramedic" is legally protected, requiring practitioners to be registered with a regulatory body and adhere to established standards of education and practice [64]. In contrast, in many jurisdictions, including the ROI, and some developing nations, the title is not protected. This means that individuals with varying levels of training—and in some cases, no formal training—can refer to themselves as paramedics [65]. The absence of uniform legislative protection of the paramedic title leads to significant variability in the qualifications and scope of practice associated with the title. In unregulated environments, this ambiguity undermines the professional standing of paramedics and creates disparities in the quality of care provided and erodes the public’s confidence and trust in the profession as a whole [66]. This inevitably will lead to dilution of the professional status, and present barriers for interprofessional collaboration, and limit career progression, and workforce mobility. Healthcare professions such as medicine, nursing, and physiotherapy have long benefited from title protection, which serves as a foundation for professional autonomy, public trust, and regulatory oversight. The absence of similar protections for paramedics reinforces perceptions that paramedicine is a technical trade rather than a legitimate healthcare profession. This has implications for funding, resources, and influencing policy. The lack of protection for the title "paramedic" has far-reaching implications, affecting public trust, professional identity, and recognition within the healthcare system [67]. While progress has been made in some countries, much work remains to establish paramedicine as a fully regulated and respected healthcare profession globally. Protecting the title "paramedic" is not merely a matter of professional pride—it is a vital step in ensuring consistent, high-quality care for patients and solidifying the role of paramedics as integral members of the healthcare team [68-16-70]. Methods Aim The aim of this study is to explore key barriers to paramedic professionalisation across five different developed healthcare systems, both domestically and internationally. Study Design This study employed a qualitative research design within the framework of the critical theory paradigm to examine and interpret key perspectives on the barriers to the professionalisation of paramedicine. Rooted in the principles of critical theory, the research sought to interrogate underlying power structures, systemic inequalities, and institutional challenges shaping the field of paramedicine [71]. This paradigm aligns with a transformative agenda, aiming to empower participants by uncovering structural barriers and exploring actionable solutions for change. Semi-structured interviews served as the primary data collection method, offering a flexible yet guided approach to elicit detailed insights. This method enabled participants to articulate their experiences and perspectives while addressing pre-defined themes central to the study’s objectives. This approach facilitated a nuanced exploration of the structural and relational factors affecting paramedicine, consistent with the emancipatory goals of critical theory [72]. Participants and Setting The selection of countries was guided by a snowball sampling approach, where each study participant, identified for their subject matter expertise, recommended additional participants with relevant knowledge and experience. This method ensured the inclusion of diverse perspectives from professionals deeply embedded in paramedic education, regulation, and practice across multiple healthcare systems. The countries chosen, the UK, Canada, Australia, USA, and the ROI represent a spectrum of paramedic professionalisation journeys, offering a rich comparative framework. The UK, Canada, and Australia exemplify structured, evolving paramedic frameworks, transitioning paramedics from emergency responders to autonomous, regulated healthcare professionals. The USA provides insight into decentralised, state-specific models of paramedic practice and regulation. The ROI offers a valuable case study of an emerging system still navigating legislative and regulatory barriers to professionalisation. The snowball sampling model further supported this cross-national approach by ensuring the inquiry remained rooted in expert knowledge, fostering a nuanced understanding of the barriers to paramedic professionalisation across these jurisdictions. Participants were initially recruited from a core group of experts identified for their extensive experience and leadership in paramedicine. Each participant was asked to recommend other professionals within their networks who possessed relevant expertise in areas such as clinical practice, education, policy development, and management. This approach facilitated the inclusion of a diverse, representative sample from both local and international paramedicine sectors, ensuring insights reflected a wide range of perspectives. Recruitment invitations were distributed via professional email networks within pre-hospital emergency medicine, accompanied by a formal letter detailing the study's objectives, confidentiality measures, and the voluntary nature of participation. The final cohort included 15 participants representing multiple jurisdictions and levels of expertise. Data collection continued until data saturation was reached, as defined by Braun and Clarke (2017) [74], where no new themes emerged during analysis. Data Collection Semi-structured interviews were conducted individually, via University College Cork, Microsoft Teams secure online platform. Each interview lasted approximately 45–60 minutes and was audio-recorded with the participants’ informed consent. The interview guide featured open-ended questions designed to explore participants’ views comprehensively while allowing them to introduce relevant, emergent topics [75]. Data Analysis Three transcripts were randomly selected by the senior authorship team and independently reviewed to generate initial codes, following step two of the six-stage thematic analysis process described by Braun and Clarke (2017). Reviewers worked in isolation to identify key patterns before collaboratively reaching a consensus on the preliminary codes. These codes were then applied to the remaining transcripts, ensuring a systematic approach to data collation. To refine the analysis further, transcripts were revisited multiple times, allowing the team to define and elaborate on the themes and subthemes. This iterative process ensured a comprehensive understanding and precise articulation of the core essence of each theme, enhancing the reliability and depth of the thematic analysis. Discrepancies in coding were resolved through discussion and consensus among the research team to ensure reliability and validity in the findings [74]. The study was reported in adherence to the Standards for Reporting Qualitative Research (SRQR), guidelines. Results Qualitative Evaluation of Semi-Structured Interviews Fifteen stakeholders with extensive expertise relevant to the research question participated in the interviews. The participants represented a diverse geographical distribution, encompassing perspectives from the ROI, UK, U.S.A, Australia, and Canada. This international scope facilitated a more comprehensive and holistic understanding of the issue under investigation. The professional backgrounds of the participants spanned clinical practice, education, policymaking, and management, ensuring a wide range of insights. The inclusion of stakeholders from multiple domains and jurisdictions enriched the data, highlighting shared challenges and contextual nuances associated with paramedicine's professionalisation. The four major themes identified from our analysis were, current barriers to expansion, elevating professional status, impact of COVID-19, and future barriers to change as outlined in Table 1 . Major themes were divided into a series of subthemes described below. Some subthemes overlapped but were discussed within a different context. Table 1 Summary of Qualitative Data in Major Themes and Subthemes Major Theme Subthemes 1.Current Barriers to Expansion I. Outdated legislation and regulations II. Funding and resource allocation III. Staffing and retention IV. Integration into the healthcare system 2.Elevating Professional Status I. Formal education and specialisation II. Regulation and certification III. Professional identity and recognition 3.Impact of COVID-19 I. Lost momentum II. Shifts in policymaker priorities III. Withdrawal or redirection of funding 4.Future Barriers to Change I. Structural and Systemic Barriers II. Workforce Development & Collaboration IV. Professional Mindsets 1. Current Barriers to Expansion This theme addresses the obstacles currently hindering the field of paramedicine from achieving its full potential and expanding its role in healthcare systems. Despite ongoing advancements, several key barriers persist, impeding growth and limiting the field's ability to transition into a broader, more integrated healthcare profession. i. Outdated Legislation and Regulation The absence of supportive legislation and policy frameworks is a significant barrier to the professional recognition of paramedics. It limits their ability to take on advanced roles such as prescribing medications, leading community health initiatives, or operating within multidisciplinary healthcare teams. This challenge underscores the need for robust regulatory and legislative structures that clearly define and support the expanded scope of paramedic practice. Disparities in legislation and regulation across jurisdictions—whether between states, territories, or countries—compound the issue further. The development of uniform policy frameworks and the legal protection of the paramedic title are critical steps toward professional recognition. These measures would enable paramedics to operate with greater autonomy, expand their scope of practice, and align their roles more closely with other healthcare professions. Addressing these regulatory disparities at both national and international levels would not only enhance the profession's credibility but also improve patient care outcomes by utilising paramedics' full potential. "The ability of the regulator to regulate the profession, I think, is very hamstrung in the paramedic sphere in comparison to medicine or nursing." P04 ii. Funding and Resource Allocation Securing adequate financial support and resources is a fundamental enabler for the evolution and professionalisation of paramedicine. The allocation of funding is essential for various aspects, including the development and implementation of advanced training programs, expanded roles for paramedics, and the introduction of innovative healthcare initiatives. These investments play a critical role in bridging the gap between traditional emergency medical services and the broader scope of healthcare delivery that modern paramedicine aspires to achieve. "The plan is that we're going to take in over 2000 new recruits in the next four years. Well, on the best day ever. We would never be able to take in more than 200 per year." P14. iii. Staffing and Retention The challenge of attracting and retaining qualified paramedics, particularly in specialised or advanced roles, is a significant concern within the field of paramedicine. This issue is compounded by competing demands, limited career progression opportunities, and the risk of burnout, all of which impact the sustainability of the workforce. High-pressure work environments, extended shifts, and exposure to traumatic incidents contribute significantly to professional exhaustion. Many paramedics report frustration with stagnant roles, limited leadership opportunities, and insufficient recognition within the healthcare system. Paramedics with advanced training often find more stable or lucrative roles in allied health professions, further depleting the workforce. “The dynamic has changed, the 12-hour shift is now becoming a 14 and a 16-hour shift. ... At the end of 14 hours your thinking processes may not be as optimal as you would wish."P08. I. Integration into the Healthcare System Integration into the healthcare system is a critical theme in advancing the professional recognition and utilisation of paramedics. This involves embedding paramedics within broader healthcare structures, expanding their roles beyond emergency response, and ensuring collaboration with other healthcare professionals. Paramedics are often perceived as emergency responders rather than integral members of the healthcare system. This perception limits their involvement in preventive care, chronic disease management, or community health initiatives. In many jurisdictions, paramedicine operates in parallel with, rather than integrated into, primary and secondary care systems. This fragmentation hampers seamless patient transitions and interprofessional collaboration. Variations in paramedic scope of practice, licensing requirements, and regulatory frameworks between regions create inconsistencies in integration efforts. "In the UK, paramedics are part of a service, but that service isn't always integrated with other services. I think this is also a reflection of the NHS itself." P07. 2. Elevating Professional Status This theme focused on the necessity to elevate the professional status of paramedicine, and this is central to achieving broader recognition as healthcare professionals. It requires concerted efforts across education, regulation, and societal awareness to redefine the role of paramedics as integral and indispensable within healthcare systems. "Some of the research that I've done has shown that the healthcare system has no idea what paramedics are." P01. i. Formal Education and Specialisation Establishing consistent educational standards is critical. Advanced qualifications, degree-level entry requirements, and opportunities for postgraduate specialisation create a foundation for professional credibility. Countries that have transitioned paramedic training into higher education, like Australia and the UK, have seen enhanced professional recognition. Formalised registration, licensing, and protection of the title "paramedic" are essential. These steps prevent misuse of the term, establish accountability, and uphold public trust. Regulatory bodies that define clear scopes of practice and ethical standards further solidify paramedics’ professional standing. "In Ontario, within a year, there will be a one-year, two-year, three-year and four-year way of becoming the exact same thing (a Paramedic) ...So straight away, that's madness." P01. II. Regulation and Certification Formalised registration, licensing, and the protection of the title "paramedic" are foundational to establishing the profession's integrity, enhancing public trust, and creating clear professional boundaries. Registration and licensing enforce professional accountability, allowing regulatory bodies to monitor compliance with established standards. Mechanisms for addressing misconduct ensure ethical practice and public trust. A formalised system reassures the public that paramedics are competent, qualified, and held to the same rigorous standards as other healthcare professionals. These elements contribute to the recognition of paramedics as accountable healthcare practitioners with well-defined roles and ethical responsibilities. "How do we strike someone off who’s a dodgy practitioner? How do we have competencies that someone can work privately? What’s our regulation around that?" P02. III. Professional Identity and Recognition Protection of the title ensures that only those who meet stringent educational, training, and ethical requirements can practice as paramedics. This prevents unqualified individuals from misrepresenting themselves, thereby safeguarding patient safety and the profession's reputation. Protected titles and licensing support the argument for role expansion into areas like community health and primary care by demonstrating the profession's capacity for safe and effective practice. Such measures support the profession’s evolution, ensuring paramedics are seen as integral and trustworthy members of the healthcare system. "I think globally, all Western healthcare paramedicine professions will mass move towards registration. Without registration, there is no ability to self-regulate, and you will always be at the whim of another profession. P03. 3. Impact of COVID-19 This theme delves into the profound challenges and opportunities presented by the COVID-19 pandemic, which significantly impacted the paramedic profession. It altered operational workflows, increased professional demands, and reshaped the perception of paramedics within healthcare systems. During the pandemic, paramedics often assumed expanded roles, such as administering vaccines, performing COVID-19 testing, and providing community-based care to alleviate the burden on hospital systems. This adaptability not only showcased their capacity but also illuminated their underutilised potential in broader public health and primary care roles. “The pandemic accelerated the pace of change and demonstrated the value of collaboration” P13. I. Lost Momentum The pandemic's heightened visibility of paramedics brought their contributions to the forefront of policymakers' agendas. This recognition underscored both the critical role of paramedics in emergency and non-emergency contexts and the structural barriers that limited their full integration into healthcare systems. By highlighting these issues, the COVID-19 crisis has acted as a catalyst for discussions around the professionalisation of paramedicine. It was seen as paving the way for potential reforms, including legislative changes, enhanced training opportunities, and better resource frameworks, which could have enabled the profession to leverage its full potential in future public health challenges. While the COVID-19 pandemic temporarily spotlighted the paramedic profession, highlighting its adaptability and critical role in healthcare, the post-pandemic period has seen a notable decline in momentum for systemic reforms. This lost momentum poses challenges to sustaining the progress made during the crisis. "COVID presented us with a threat and an opportunity."P05. II. Shifts In Policymaker Priorities This theme examines the shift in priorities by policymakers in the post-pandemic era. As emergency responses to the pandemic winded down, attention shifted to other healthcare priorities, such as addressing surgical backlogs and mental health crises. This redirection diluted the focus on advancing paramedic professionalisation and reforming regulatory frameworks. Post-pandemic economic pressures have limited funding for healthcare reforms, including the expansion of paramedic roles and the introduction of new training programs. "We're really bad at marketing ourselves." P01. III. Withdrawal Or Redirection of Funding Governments have prioritised stabilising economies over healthcare innovations, reducing opportunities for paramedic professional development. The expansive roles taken on by paramedics during the pandemic—such as vaccine administration and community care—have been scaled back in some regions. This has curtailed opportunities to embed these responsibilities into permanent scopes of practice. The pandemic exacerbated burnout, leading to retention issues and reduced capacity for advocacy within the profession. Many paramedics who pushed for systemic changes faced exhaustion or left the profession altogether, diminishing the advocacy force. 4. Future Barriers to Change The final theme examined the future barriers to change that remain within paramedicine. Though some of the subthemes are revisited they are discussed within different context. The ongoing evolution of paramedicine faces several barriers that could hinder further professionalisation and expansion of roles within the healthcare system. These challenges are influenced by regulatory frameworks, workforce dynamics, and systemic healthcare constraints. I. Structural and Systemic Barriers One of the primary barriers to advancing the paramedic profession is the lack of robust political support and sustained financial investment. This limitation undermines the potential for paramedics to assume expanded roles within healthcare systems and achieve greater professional recognition. Following the increased visibility of paramedics during the COVID-19 pandemic, attention and funding have often shifted to other areas, resulting in lost momentum for paramedic-focused reforms. Healthcare systems frequently prioritise established professions, leaving paramedicine at a disadvantage in the allocation of resources and decision-making roles. A lack of unified lobbying at the governmental level limits the profession's ability to push for necessary reforms or investments. In many jurisdictions, the absence of legislation protecting the title "paramedic" hinders the profession's ability to standardise practices and scopes of work. Political inertia in establishing advanced roles, such as paramedic prescribing or leading primary care initiatives, restricts opportunities for growth. The paramedic profession's fragmented representation across different jurisdictions weakens its advocacy efforts. A lack of unified lobbying at the governmental level limits the profession's ability to push for necessary reforms or investments. “There is no such thing as a Canadian paramedic… Healthcare is a provincial function here...And so there is no health system in Canada. There's 10 provinces and three territories who all do their own version of something."P01 Limited investment hampers paramedicine’s growth, affecting education, workforce development, technology adoption, and integration into healthcare. Inadequate funding restricts advanced training, leading to skill disparities and limited career progression. Financial constraints also contribute to staffing shortages, burnout, and difficulties in meeting healthcare demands. A lack of resources delays the adoption of modern technologies critical for patient care and efficiency. Funding disparities across regions create barriers to professional identity and role expansion, widening gaps between well-funded and underfunded areas and hindering global standardisation. "You've got to pay people for what they do and it's something I feel very passionately about our nurses for years were the victim of that." P03. II. Workforce Development and Collaboration The advancement of paramedicine as a recognised healthcare profession hinges on cultivating a highly skilled workforce and robust leadership. These elements are pivotal for ensuring that paramedics can meet evolving healthcare demands and advocate effectively for the profession's development. Expand access to higher education programs tailored to paramedicine, including bachelor’s, master’s, and doctoral degrees. Promote CPD to keep practitioners updated on best practices and emerging healthcare trends. Create specialised leadership training programs to equip paramedics with the skills to manage teams, influence policy, and advocate for systemic changes. Include paramedics in decision-making roles within healthcare organizations to ensure their perspectives shape policy and operational strategies. Promote research and knowledge exchange to support evidence-based practices and innovation in paramedicine. Interprofessional collaboration plays a vital role in the evolution of paramedicine, fostering seamless integration into healthcare systems and improving care delivery. By working closely with other healthcare professionals, paramedics contribute to enhanced patient outcomes through coordinated and comprehensive care, reducing errors and boosting patient satisfaction. This collaboration also clarifies the paramedic's scope of practice, ensuring their specialised skills are effectively utilised. Engaging across disciplines allows paramedics to build mutual respect and professional recognition, further embedding their role as integral contributors to the healthcare team. These collaborative practices not only elevate the standing of paramedics but also promote efficient resource utilisation and foster innovation within healthcare systems. "I think that the autonomy to decide not to convey someone, I think, is going to be really, really important for the health system in years to come."P04. III. Professional Mindsets Resistance to change within paramedicine, healthcare systems, and society hinders professionalisation. Internal resistance stems from attachment to traditional roles, leading to scepticism toward educational reform, technology, and new care models. Addressing this requires leadership that promotes dialogue and highlights the benefits of innovation. External resistance comes from healthcare professionals, policymakers, or institutions fearing competition, accountability concerns, or encroachment on their domains. Interprofessional education and advocacy can help overcome these barriers. Bureaucratic inertia further delays progress, reinforcing disparities in training and regulation. A multi-pronged approach—strong leadership, alliances with other healthcare professions, and gradual implementation—can help drive sustainable change. Internal professional mindsets significantly influence the growth of paramedicine. While external barriers like policy and funding are well-recognised, internal attitudes, beliefs, and self-perceptions also shape the profession’s evolution. A lack of confidence in role expansion can limit advocacy and progress, while resistance to change or preference for traditional emergency roles may hinder innovation and interdisciplinary collaboration. To advance, paramedics must embrace lifelong learning, evidence-based practices, and discussions about the profession’s future. Strong leadership is essential in challenging outdated mindsets and fostering adaptability. This cultural shift is crucial for strengthening paramedicine’s role within healthcare and ensuring its continued growth and integration. "I've had resistance from some pretty senior people around the direction that alternative care pathways are taking because they’re worried that we’re forgetting about our mantra, of dealing with emergencies." P03. Discussion This study explored key perspectives on the barriers to the professionalisation of paramedicine, uncovering themes that highlighted the challenges within the field. The findings underscore the significance of legislative and regulatory frameworks in shaping the paramedic profession’s trajectory. The lack of formal title protection and standardised regulations across jurisdictions emerged as a pervasive challenge, creating inconsistencies in practice and limiting professional recognition [ 64 ]. This issue resonates globally, as seen in previous studies that highlight the disparities in paramedic roles and recognition between countries such as Australia, UK, Canada, U.S.A and the ROI [ 38 , 39 , 60 , 68 ]. Moreover, financial constraints were identified as a critical barrier to advancing paramedicine. Limited funding not only restricts access to advanced education and training but also hampers efforts to expand paramedic roles into primary care and other specialised domains. This aligns with broader concerns in healthcare, where resource allocation often prioritises traditional medical professions over emerging disciplines. Addressing these financial barriers through advocacy, public-private partnerships, and targeted resource allocation will be pivotal in fostering growth within paramedicine [ 76 ]. Interprofessional collaboration was highlighted as a pathway for enhancing the paramedic profession’s status and integration into the healthcare system. The importance of fostering partnerships with other healthcare professionals to improve patient outcomes, reduce redundancies, and delineate professional roles cannot be overstated. The findings of this study align with current literature emphasising the need for interdisciplinary approaches in healthcare to enhance service delivery and professional recognition [ 77 ]. The study also delved into internal barriers, such as resistance to change and entrenched professional mindsets. These factors can slow progress by perpetuating traditional views of paramedicine as a technical rather than a professional field. Overcoming these internal challenges will require leadership within the profession to champion change and embrace innovation. Finally, the impact of the COVID-19 pandemic was a prominent theme. The pandemic highlighted the adaptability and potential of paramedics, as they took on expanded roles such as vaccine administration and community health initiatives. While this visibility brought temporary recognition, the post-pandemic environment risks losing momentum unless sustained efforts are made to institutionalise these expanded roles [ 5 , 78 ]. The findings from this study contribute to the growing body of literature advocating for a comprehensive strategy to address the multifaceted barriers facing paramedicine. By addressing legislative gaps, financial constraints, and internal resistance while leveraging opportunities for collaboration and innovation, paramedicine can secure its place as a vital and professional component of modern healthcare systems, [ 1 , 3 , 8 , 11 ]. Implications for Practice Title protection and uniform regulations are essential for paramedic recognition. Policymakers must prioritise legislative reforms to safeguard the "paramedic" title, ensure accountability, and standardise practice scopes [ 64 ]. Investing in advanced education and training will prepare paramedics for expanded roles, while workforce strategies should focus on retention to reduce burnout. Integrating paramedics into multidisciplinary teams through collaborative care and interprofessional education can enhance patient outcomes. Leadership development is key to driving systemic change, requiring training programs in educational institutions and professional associations [ 21 ]. Public awareness campaigns can build trust and support for role expansion. Evaluating innovations like paramedics in primary care and emergency preparedness can demonstrate their value and drive adoption [ 33 ]. International forums for best practices and global standards will help address regulatory disparities and elevate paramedicine’s standing worldwide. Addressing these areas will enhance recognition, integration, and patient outcomes [ 25 , 28 , 32 ]. Areas for Future Research Future research should focus on achieving global consistency in paramedic title protection by comparing jurisdictions with strong regulatory frameworks to identify effective models and their impact on professional identity. Studies on best practices for integrating paramedics into multidisciplinary teams and interprofessional education are essential to expanding their healthcare roles [ 35 ]. Research on the cost-effectiveness of expanded roles, such as community paramedicine and prescribing rights, could support policy reform. Investigating leadership pathways and strategies for developing strong professional leaders can drive systemic change [ 49 ]. Further studies should address recruitment, retention, and job satisfaction, particularly concerning burnout. Research into the impact of higher education (bachelor’s and master’s programs) on clinical practice and professional recognition is key to educational reform [ 11 , 25 , 27 ]. Comparative studies on paramedicine’s evolution across countries can highlight global trends, challenges, and opportunities for standardisation [ 1 ]. Understanding public perceptions of paramedics and trust in their expertise could inform awareness campaigns. Evaluating the long-term impact of COVID-19 on paramedicine, including lessons for role expansion and emergency preparedness, is vital [ 5 , 6 ]. Research on aligning paramedics with other healthcare disciplines in emergency, primary, and community care could strengthen their role in healthcare delivery [ 42 , 43 ]. These studies will support the advancement and integration of paramedicine worldwide. Limitations The study's limitations highlight areas that could impact the breadth and depth of its findings. While the inclusion of 15 stakeholders offered valuable insights, the relatively small sample size limits the generalisability of results across the paramedicine field. The use of snowball sampling, though efficient, may have introduced selection bias by drawing primarily from established professional networks, potentially excluding diverse or dissenting voices. Geographic and jurisdictional variations in paramedic practices and regulations might not be fully represented, restricting the global applicability of the outcomes. Additionally, the reliance on thematic analysis, inherently interpretative, may have introduced subjectivity. The study's emphasis on barriers might have overshadowed enabling factors, while the timing during the COVID-19 pandemic likely influenced responses, focusing on pandemic-related challenges and potentially neglecting broader systemic issues. Future research addressing these limitations could enhance the scope and applicability of findings. Conclusion This study highlights the significant barriers facing the professionalisation of paramedicine. Central to the challenges are the lack of formalised title protection, inconsistent legislative and regulatory frameworks, financial constraints, and internal resistance to change. These factors collectively hinder the recognition and integration of paramedics as essential healthcare professionals. Addressing these issues requires a multifaceted approach, combining advocacy for legislative reforms, strategic investment in education and training, and fostering interprofessional collaboration. The COVID-19 pandemic demonstrated the adaptability and potential of paramedics, offering a pivotal opportunity to redefine the profession’s scope and visibility within healthcare systems. Sustaining this momentum post-pandemic demands ongoing policy support and leadership within the field to drive innovation and embrace evolving healthcare needs. Future efforts must focus on establishing a unified professional identity and leveraging the contributions of paramedics to broader healthcare goals. By addressing these barriers and capitalising on opportunities for growth, paramedicine can continue to advance as a respected and indispensable healthcare profession, ultimately improving patient care and system efficiency on a global scale. Abbreviations ACP Advanced Care Paramedic ALS Advanced Life Support APs Advanced Paramedics AHP Allied Health Professionals AHPRA Australian Health Practitioner Regulation Agency BLS Basic Life Support COPR Canadian Organisation of Paramedic Regulators CAAHEP Commission on Accreditation of Allied Health Education Programs CPD Continuous Professional Development CCP Critical Care Paramedic EMS Emergency Medical Services EMT Emergency Medical Technicians HCPC Health and Care Professions Council NREMT National Registry of Emergency Medical Technicians PHECC Pre-Hospital Emergency Care Council PCP Primary Care Paramedic ROI Republic of Ireland UK United Kingdom USA United States of America Declarations Ethical Approval and Consent to Participate This study received ethical approval from the University College of Cork, Republic of Ireland, Social and Research Ethics Committee (SREC). All participants provided informed consent before their interviews and were assured of confidentiality and anonymity. The study was conducted in accordance with the ethical standards of the institutional research committee and the Declaration of Helsinki and its later amendments or comparable ethical standards. Consent for Publication Not applicable Availability of Data and Materials All data were securely stored and managed in accordance with ethical guidelines to protect participants’ identities. All data is available by contacting the primary author. Competing Interests The authors declare no conflict of interest in this publication. The research team would like to confirm that the manuscript is original work and that no part of the manuscript has been published or submitted elsewhere for publication. Funding No funding was made available for this study. Author’s Contribution Authors have contributed to the development of the ideas, writing and/or final review of the submitted manuscript, and all authors have read and approved this version of the manuscript and its submission to the journal. Acknowledgements The author’s wish to acknowledge the participants of this study for giving freely their time and expertise. References Reed B, Cowin L, O'Meara P, Wilson I. Professionalism and professionalisation in the discipline of paramedicine. Australasian Journal of Paramedicine. 2019 Jan; 16:1-0. Williams B, Onsman A, Brown T. From stretcher-bearer to paramedic: the Australian paramedics’ move towards professionalisation. Australasian Journal of Paramedicine. 2009 Jan; 7:1-2. First S, Tomlins L, Swinburn A. From trade to profession-the professionalisation of the paramedic workforce. Journal of Paramedic Practice. 2012 Jul 4;4(7):378-81. Williams B, Onsman A, Brown T. Is the Australian paramedic discipline a full profession? 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Introducing Advanced Paramedics into the rural general practice team in Ireland–general practitioners’ attitudes. BMC Primary Care. 2022 May 26;23(1):130. Brooks IA, Cooke M, Spencer C, Archer F. A review of key national reports to describe the development of paramedic education in England (1966–2014). Emergency Medicine Journal. 2016 Dec 1;33(12):876-81. Cooper S. Contemporary UK paramedical training and education. How do we train? How should we educate? Emergency Medicine Journal. 2005 May 1;22(5):375-9. Emms C, Armitage E. Paramedic training and higher education: a natural progression? Journal of Paramedic Practice. 2010 Nov 26;2(11):529-33. Avery P, Thompson C, Cowburn P. Training the trainers: improving the quality of education delivered to paramedics through a simulation-debrief model. British Paramedic Journal. 2023 Mar 1;7(4):51-6. Wheeler B, Dippenaar E. The use of simulation as a teaching modality for paramedic education: a scoping review. British Paramedic Journal. 2020 Dec 1;5(3):31-43. Givati A, Markham C, Street K. The bargaining of professionalism in emergency care practice: NHS paramedics and higher education. Advances in Health Sciences Education. 2018 May; 23:353-69. Ball MT, Powell JR, Collard L, York DK, Panchal AR. Administrative and educational characteristics of paramedic programs in the United States. Prehospital and Disaster Medicine. 2022 Apr;37(2):152-6. Cash RE, Clay CE, Leggio WJ, Camargo Jr CA. Geographic distribution of accredited paramedic education programs in the United States. Prehospital Emergency Care. 2022 Jan 2;26(1):93-101. Weber A, Devenish S, Lam L. Vocational and University Paramedicine Education: Implications for Professionalism. International Journal of Paramedicine. 2024 Jul 8(7):163-71. Ball M, Powell JR, Gage CB, Kapalo KA, Kurth JD, Collard L, Miller MG, Panchal AR. Paramedic educational program attrition accounts for significant loss of potential EMS workforce. Journal of the American College of Emergency Physicians Open. 2023 Apr;4(2): e12917. Brooks IA, Grantham H, Spencer C, Archer F. A review of the literature: the transition of entry-level paramedic education in Australia from vocational to higher education (1961–2017). Australasian Journal of Paramedicine. 2018 Jan; 15:1-1. O'Brien K, Moore A, Dawson D, Hartley P. An Australian story: paramedic education and practice in transition. Australasian Journal of Paramedicine. 2014 Jan; 11:1-3. Hou XY, Rego J, Service M. Paramedic education opportunities and challenges in Australia. Emergency Medicine Australasia. 2013 Apr;25(2):114-9. Bell A, Hammer S, Seymour-Walsh A. The role of educational theory in the future development of paramedicine as a profession: An integrative review. Australasian Journal of Paramedicine. 2021 Jan; 18:1-0. Bowles RR, van Beek C, Anderson GS. Four dimensions of paramedic practice in Canada: defining and describing the profession. Australasian Journal of Paramedicine. 2017 Jan; 14:1-2. O'Meara P, Ruest M, Stirling C. Community paramedicine: higher education as an enabling factor. Australasian Journal of Paramedicine. 2014 Jan; 11:1-9. Brydges M, Dunn JR, Agarwal G, Tavares W. At odds: How interprofessional conflict and stratification has stalled the Ontario paramedic professionalization project. Journal of Professions and Organization. 2022 Oct 1;9(3):333-47. Bury G, Egan M, Vallely J. The Advanced Paramedic Training Programme: challenges for an adult workforce entering the university sector. Knox S, Brand C, Sweeney C. Perceptions of paramedic educators on assessments used in the first year of a paramedic programme: a qualitative exploration. BMC Medical Education. 2023 Dec 12;23(1):952. Eburn M. Registered paramedics, insurance and first aid–looking for coherence in law. Australasian Journal of Paramedicine. 2019 Jan; 16:1-7. Eaton G, editor. Law and Ethics for Paramedics: An Essential Guide. 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Traditionally regarded as emergency responders providing critical pre-hospital care, paramedics are increasingly recognised as an essential healthcare profession with greater autonomy and an expanding scope of practice [1]. This shift highlights their vital role beyond emergency care, contributing to the broader healthcare system [2-3]. Achieving full professional recognition remains challenging due to outdated legislation, inconsistent regulatory frameworks, and a lack of formalised education, training pathways, and legal title protection. Internal barriers, such as resistance to change and concerns about professional identity, further complicate progress [4]. The COVID-19 pandemic underscored the indispensable role of paramedics, briefly accelerating efforts to elevate their professional standing [5]. However, as healthcare priorities shift, momentum has slowed [6]. Defining \u0026ldquo;professionalism\u0026rdquo; in paramedicine is complex, as the field lacks universally recognised standards, leading to fragmented regulations and varying scopes of practice worldwide [7-9]. This disparity hinders paramedics\u0026apos; ability to achieve the professional recognition enjoyed by other healthcare disciplines. Addressing these challenges requires a collective effort to establish and enforce unified professional standards, ensuring paramedicine\u0026apos;s evolution into a fully integrated healthcare profession [10].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegislation and Regulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLegislation and regulation are fundamental to the professionalisation of paramedicine, shaping its scope, responsibilities, and recognition within the healthcare system [11]. Strong legal frameworks safeguard public safety while providing paramedics with greater autonomy, standardised training, and clearer career pathways [12]. Paramedicine\u0026apos;s regulatory landscape is often inconsistent, reflecting its historical development within emergency medical services (EMS) and varying regional priorities. Historically, paramedics were not legally recognised as distinct healthcare professionals, limiting their scope of practice to basic emergency response [13]. Over time, their role has expanded to include advanced clinical interventions and broader healthcare responsibilities [14]. Legislative and regulatory reforms have not always kept pace, leaving many regions with outdated or fragmented frameworks that fail to reflect modern paramedicine [15]. In some countries, paramedics are still perceived primarily as ambulance drivers or emergency technicians, restricting their ability to engage in advanced clinical roles. Establishing cohesive, modern regulations is essential to overcoming these challenges and ensuring professional recognition [16]. Different countries have adopted varied approaches to paramedic regulation, highlighting both progress and ongoing challenges: In the United Kingdom (UK), paramedics are regulated as \u0026quot;Allied Health Professionals\u0026quot; (AHP), under the Health and Care Professions Council (HCPC), granting them autonomy and access to advanced roles beyond emergency care [17]. A well-defined scope of practice and degree-level education as an entry requirement reflect the UK\u0026apos;s commitment to professionalisation [18-19]. Variations persist across England, Scotland, Wales, and Northern Ireland, particularly in healthcare system integration, funding, and recognition of advanced practice roles [20-21].\u003c/p\u003e\n\u003cp\u003eIn the United States of America, (USA), paramedic regulation is managed at the state level, leading to significant variability in training, certification, and scope of practice. Certification is generally overseen by state EMS offices, with voluntary national certification available through the National Registry of Emergency Medical Technicians (NREMT) [22]. Some states grant paramedics autonomy and advanced procedural authority, while others impose restrictive limitations [23-24]. The decentralised nature of U.S. healthcare further complicates efforts to standardise paramedic credentialing nationwide. Australia has made significant strides in paramedic regulation, particularly with the establishment of the Paramedicine Board of Australia under the Australian Health Practitioner Regulation Agency (AHPRA) in 2018 [25]. This national framework ensures uniform education and practice standards across states and territories, strengthening paramedics\u0026apos; professional standing [26-27]. Registration with AHPRA is mandatory, facilitating advanced roles and integration into multidisciplinary healthcare teams [28-29]. However, regional differences in autonomy and scope of practice persist, alongside challenges in workforce shortages, training access, and expanding community care roles [30-31]. Paramedic regulation in Canada varies by province and territory, resulting in inconsistent education, certification, and scope of practice [32-33]. While some provinces, such as Alberta and Ontario, have independent regulatory bodies, others rely on government departments for oversight. Efforts to establish a national registry and harmonise standards face obstacles due to Canada\u0026apos;s decentralised healthcare system [34]. This lack of uniformity complicates interprovincial mobility for paramedics and limits the recognition of advanced practice roles such as critical care and community paramedics [35-36]. In the Republic of Ireland (ROI), paramedicine has undergone significant regulatory changes to align with modern healthcare demands [37]. Irish paramedics are overseen by the Pre-Hospital Emergency Care Council (PHECC) [38]. Established in 2000, PHECC sets educational, training, and practice standards for paramedics, advanced paramedics (APs), and emergency medical technicians (EMTs), maintaining a statutory register and professional development requirements [39]. \u0026nbsp;Continuous Professional Development (CPD), requirements remain underdeveloped, and legislative support for ethics and fitness-to-practice issues is limited [40]. Efforts are underway to expand paramedics\u0026apos; roles beyond emergency response to include community care, critical care, mental health, and chronic disease management, but these changes require stronger legislative and regulatory backing [41-43].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation and Training\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEducation and training are fundamental to the professionalisation of paramedicine, shaping the competencies, clinical skills, and decision-making abilities of practitioners. The educational pathways and training requirements for paramedics vary significantly across jurisdictions, reflecting differing healthcare priorities, regulatory frameworks, and professional expectations [41]. In the UK, paramedic education has undergone substantial reform, transitioning from vocational training to degree-level qualifications. As of 2021, all paramedics must complete an HCPC-approved degree in paramedic science from a university to qualify for registration with the HCPC, [45]. The most common pathway is a three-year full-time undergraduate degree, which includes both academic study and clinical placements in pre-hospital and healthcare settings [46]. The curriculum emphasises a balance of theoretical knowledge and practical skills, covering areas such as anatomy, physiology, pharmacology, patient assessment, and emergency care. Opportunities for further education include postgraduate degrees including Masters and Doctoral degrees, and specialist training programs for roles such as advanced paramedics, critical care paramedics, and paramedic practitioners [47]. Registered paramedics are required to engage in CPD, to maintain their registration, ensuring that their skills remain current and aligned with best practices [48]. The UK\u0026rsquo;s emphasis on degree-level education reflects a broader effort to elevate paramedicine as a recognised healthcare profession, with a focus on clinical autonomy and multidisciplinary collaboration [49].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the USA, paramedic education is more diverse, reflecting the decentralised nature of the country\u0026rsquo;s healthcare and regulatory systems. Training programs range from certificate-level courses to associate and bachelor\u0026apos;s degrees, with significant variability in duration and content [50]. Most paramedics complete a certificate or associate degree program accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP). These programs typically take 1-2 years to complete. The curriculum includes foundational topics such as emergency medical services operations, patient assessment, trauma care, and advanced life support (ALS). Clinical rotations and internships are integral components and paramedics must pass the NREMT exam to obtain national certification. Bachelor\u0026apos;s degree programs in paramedicine are available but are not universally required [51-52]. Advanced practice roles, such as critical care paramedics, often require additional certification and training. However, state-specific requirements vary, and some states do not mandate NREMT certification. The variability in educational standards and pathways reflects broader fragmentation within the U.S. healthcare system, posing challenges for professional consistency and mobility [53]. Australia has established a unified framework for paramedic education as part of its broader efforts to professionalise paramedicine. Degree-level qualifications are now the standard entry pathway for the profession [54-55]. Aspiring paramedics must complete a Bachelor of Paramedicine or a related degree from an accredited university, typically over three years of full-time study. The curriculum combines theoretical knowledge with extensive practical training. Key topics include advanced trauma care, pharmacology, ethics, patient communication, and clinical decision-making. Clinical placements with ambulance services and other healthcare providers are mandatory. Graduates must register with the AHPRA to practice as paramedics. Advanced practice roles, such as intensive care paramedics and extended care paramedics, require further postgraduate education and training, including bachelor\u0026rsquo;s degree, master\u0026rsquo;s degree and doctoral degree [56]. CPD is mandatory for registered paramedics to maintain their professional competence. Australia\u0026rsquo;s emphasis on degree-level education and national registration reflects its commitment to standardising paramedicine as a healthcare profession across its states and territories [57].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Canada, paramedic education and training are regulated at the provincial and territorial levels, leading to significant variation in paramedic\u0026rsquo;s scope of practice and standards. There are three levels of paramedic certification: Primary Care Paramedic (PCP), Advanced Care Paramedic (ACP), and Critical Care Paramedic (CCP) [58]. \u0026nbsp;Most paramedics begin their careers as PCPs, completing a college diploma program that typically takes 2 years. ACP training is an additional 1-2 years, while CCP certification requires further specialised education. Training programs focus on pre-hospital emergency care, pharmacology, patient assessment, and trauma management. Clinical placements and field internships are key components. Paramedics must pass provincial or territorial certification exams to practice. Some provinces also recognise national certification through the Canadian Organisation of Paramedic Regulators (COPR) [59]. Opportunities for further education include specialised training programs for ACP and CCP roles, as well as bachelor\u0026rsquo;s degrees master\u0026rsquo;s degrees and doctoral degrees in paramedicine in some provinces. Regulatory bodies require ongoing CPD to maintain licensure. Canada\u0026rsquo;s decentralised approach results in varying standards and training durations across provinces, creating challenges for interprovincial mobility and national standardisation [61].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn ROI, paramedic education is overseen by PHECC, which sets the standards for training and certification. Paramedics complete a PHECC approved paramedic program, which includes both academic coursework and clinical training. Advanced paramedics, and community paramedics require additional postgraduate training up to master\u0026rsquo;s degree level. Additional master\u0026rsquo;s degree and doctoral degree programmes are being developed including critical care and mental health paramedic, although in limited numbers [61] The curriculum includes patient assessment, advanced life support, pharmacology, and pre-hospital emergency care. Practical training involves clinical placements with ambulance services and other healthcare providers. Paramedics must pass a PHECC certification exam and register with the council to practice legally. PHECC mandates CPD for EMT\u0026rsquo;s, only [62]. In the ROI, paramedics certified by PHECC are designated as basic life support (BLS) providers, unlike their counterparts in neighbouring jurisdictions who operate at an advanced life support (ALS) level. Currently there is no requirement for paramedics to complete CPD other than mandatory recertification to remain competent and up to date with best practices. While the Republic of Ireland has made progress in standardising paramedic education, significant action is still needed to address issues such as the protection of the paramedic title, limitations in scope of practice, and the lack of clear career progression pathways \u0026mdash; all of which require legislative and regulatory changes. This is limiting the number of advanced training opportunities and presents challenges for career development within the profession and greater healthcare system [38-40].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParamedic Title Protection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protection of professional titles is a cornerstone of healthcare professions, ensuring that individuals who practice meet rigorous standards of education, training, and ethical accountability. In many parts of the world, the title \u0026quot;paramedic\u0026quot; lacks legal protection, creating challenges for the profession in achieving full recognition as a healthcare discipline [63]. In countries such as Australia, the UK, Canada, and some states within the U.S, the title \u0026quot;paramedic\u0026quot; is legally protected, requiring practitioners to be registered with a regulatory body and adhere to established standards of education and practice [64]. In contrast, in many jurisdictions, including the ROI, and some developing nations, the title is not protected. This means that individuals with varying levels of training\u0026mdash;and in some cases, no formal training\u0026mdash;can refer to themselves as paramedics [65]. The absence of uniform legislative protection of the paramedic title leads to significant variability in the qualifications and scope of practice associated with the title. In unregulated environments, this ambiguity undermines the professional standing of paramedics and creates disparities in the quality of care provided and erodes the public\u0026rsquo;s confidence and trust in the profession as a whole [66]. This inevitably will lead to dilution of the professional status, and present barriers for interprofessional collaboration, and limit career progression, and workforce mobility. Healthcare professions such as medicine, nursing, and physiotherapy have long benefited from title protection, which serves as a foundation for professional autonomy, public trust, and regulatory oversight. The absence of similar protections for paramedics reinforces perceptions that paramedicine is a technical trade rather than a legitimate healthcare profession. This has implications for funding, resources, and influencing policy. The lack of protection for the title \u0026quot;paramedic\u0026quot; has far-reaching implications, affecting public trust, professional identity, and recognition within the healthcare system [67]. While progress has been made in some countries, much work remains to establish paramedicine as a fully regulated and respected healthcare profession globally. Protecting the title \u0026quot;paramedic\u0026quot; is not merely a matter of professional pride\u0026mdash;it is a vital step in ensuring consistent, high-quality care for patients and solidifying the role of paramedics as integral members of the healthcare team [68-16-70].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of this study is to explore key barriers to paramedic professionalisation across five different developed healthcare systems, both domestically and internationally.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a qualitative research design within the framework of the critical theory paradigm to examine and interpret key perspectives on the barriers to the professionalisation of paramedicine. Rooted in the principles of critical theory, the research sought to interrogate underlying power structures, systemic inequalities, and institutional challenges shaping the field of paramedicine [71]. This paradigm aligns with a transformative agenda, aiming to empower participants by uncovering structural barriers and exploring actionable solutions for change. Semi-structured interviews served as the primary data collection method, offering a flexible yet guided approach to elicit detailed insights. This method enabled participants to articulate their experiences and perspectives while addressing pre-defined themes central to the study\u0026rsquo;s objectives. This approach facilitated a nuanced exploration of the structural and relational factors affecting paramedicine, consistent with the emancipatory goals of critical theory [72].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe selection of countries was guided by a snowball sampling approach, where each study participant, identified for their subject matter expertise, recommended additional participants with relevant knowledge and experience. This method ensured the inclusion of diverse perspectives from professionals deeply embedded in paramedic education, regulation, and practice across multiple healthcare systems. The countries chosen, the UK, Canada, Australia, USA, and the ROI represent a spectrum of paramedic professionalisation journeys, offering a rich comparative framework. The UK, Canada, and Australia exemplify structured, evolving paramedic frameworks, transitioning paramedics from emergency responders to autonomous, regulated healthcare professionals. The USA provides insight into decentralised, state-specific models of paramedic practice and regulation. The ROI offers a valuable case study of an emerging system still navigating legislative and regulatory barriers to professionalisation.\u003c/p\u003e\n\u003cp\u003eThe snowball sampling model further supported this cross-national approach by ensuring the inquiry remained rooted in expert knowledge, fostering a nuanced understanding of the barriers to paramedic professionalisation across these jurisdictions. Participants were initially recruited from a core group of experts identified for their extensive experience and leadership in paramedicine. Each participant was asked to recommend other professionals within their networks who possessed relevant expertise in areas such as clinical practice, education, policy development, and management. This approach facilitated the inclusion of a diverse, representative sample from both local and international paramedicine sectors, ensuring insights reflected a wide range of perspectives. Recruitment invitations were distributed via professional email networks within pre-hospital emergency medicine, accompanied by a formal letter detailing the study\u0026apos;s objectives, confidentiality measures, and the voluntary nature of participation. The final cohort included 15 participants representing multiple jurisdictions and levels of expertise. Data collection continued until data saturation was reached, as defined by Braun and Clarke (2017) [74], where no new themes emerged during analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSemi-structured interviews were conducted individually, via University College Cork, Microsoft Teams secure online platform. Each interview lasted approximately 45\u0026ndash;60 minutes and was audio-recorded with the participants\u0026rsquo; informed consent. The interview guide featured open-ended questions designed to explore participants\u0026rsquo; views comprehensively while allowing them to introduce relevant, emergent topics [75].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree transcripts were randomly selected by the senior authorship team and independently reviewed to generate initial codes, following step two of the six-stage thematic analysis process described by Braun and Clarke (2017). Reviewers worked in isolation to identify key patterns before collaboratively reaching a consensus on the preliminary codes. These codes were then applied to the remaining transcripts, ensuring a systematic approach to data collation. To refine the analysis further, transcripts were revisited multiple times, allowing the team to define and elaborate on the themes and subthemes. This iterative process ensured a comprehensive understanding and precise articulation of the core essence of each theme, enhancing the reliability and depth of the thematic analysis. Discrepancies in coding were resolved through discussion and consensus among the research team to ensure reliability and validity in the findings [74]. The study was reported in adherence to the Standards for Reporting Qualitative Research (SRQR), guidelines.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eQualitative Evaluation of Semi-Structured Interviews\u003c/h2\u003e\n \u003cp\u003eFifteen stakeholders with extensive expertise relevant to the research question participated in the interviews. The participants represented a diverse geographical distribution, encompassing perspectives from the ROI, UK, U.S.A, Australia, and Canada. This international scope facilitated a more comprehensive and holistic understanding of the issue under investigation. The professional backgrounds of the participants spanned clinical practice, education, policymaking, and management, ensuring a wide range of insights. The inclusion of stakeholders from multiple domains and jurisdictions enriched the data, highlighting shared challenges and contextual nuances associated with paramedicine\u0026apos;s professionalisation. The four major themes identified from our analysis were, current barriers to expansion, elevating professional status, impact of COVID-19, and future barriers to change as outlined in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Major themes were divided into a series of subthemes described below. Some subthemes overlapped but were discussed within a different context.\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSummary of Qualitative Data in Major Themes and Subthemes\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMajor Theme\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSubthemes\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.Current Barriers to Expansion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eI. Outdated legislation and regulations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eII. Funding and resource allocation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eIII. Staffing and retention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eIV. Integration into the healthcare system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.Elevating Professional Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eI. Formal education and specialisation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eII. Regulation and certification\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eIII. Professional identity and recognition\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.Impact of COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eI. Lost momentum\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eII. Shifts in policymaker priorities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eIII. Withdrawal or redirection of funding\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.Future Barriers to Change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eI. Structural and Systemic Barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eII. Workforce Development \u0026amp; Collaboration\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIV. Professional Mindsets\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e1. Current Barriers to Expansion\u003c/h2\u003e\n \u003cp\u003eThis theme addresses the obstacles currently hindering the field of paramedicine from achieving its full potential and expanding its role in healthcare systems. Despite ongoing advancements, several key barriers persist, impeding growth and limiting the field\u0026apos;s ability to transition into a broader, more integrated healthcare profession.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003ei. Outdated Legislation and Regulation\u003c/h2\u003e\n \u003cp\u003eThe absence of supportive legislation and policy frameworks is a significant barrier to the professional recognition of paramedics. It limits their ability to take on advanced roles such as prescribing medications, leading community health initiatives, or operating within multidisciplinary healthcare teams. This challenge underscores the need for robust regulatory and legislative structures that clearly define and support the expanded scope of paramedic practice. Disparities in legislation and regulation across jurisdictions\u0026mdash;whether between states, territories, or countries\u0026mdash;compound the issue further. The development of uniform policy frameworks and the legal protection of the paramedic title are critical steps toward professional recognition. These measures would enable paramedics to operate with greater autonomy, expand their scope of practice, and align their roles more closely with other healthcare professions. Addressing these regulatory disparities at both national and international levels would not only enhance the profession\u0026apos;s credibility but also improve patient care outcomes by utilising paramedics\u0026apos; full potential.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The ability of the regulator to regulate the profession, I think, is very hamstrung in the paramedic sphere in comparison to medicine or nursing.\u0026quot; P04\u003c/em\u003e\u003c/p\u003e\u003cspan\u003e\n \u003ch2\u003e\u003cstrong\u003eii. Funding and Resource Allocation\u003c/strong\u003e\u003c/h2\u003e\n \u003c/span\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eSecuring adequate financial support and resources is a fundamental enabler for the evolution and professionalisation of paramedicine. The allocation of funding is essential for various aspects, including the development and implementation of advanced training programs, expanded roles for paramedics, and the introduction of innovative healthcare initiatives. These investments play a critical role in bridging the gap between traditional emergency medical services and the broader scope of healthcare delivery that modern paramedicine aspires to achieve.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The plan is that we\u0026apos;re going to take in over 2000 new recruits in the next four years. Well, on the best day ever. We would never be able to take in more than 200 per year.\u0026quot; P14.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eiii. Staffing and Retention\u003c/h2\u003e\n \u003cp\u003eThe challenge of attracting and retaining qualified paramedics, particularly in specialised or advanced roles, is a significant concern within the field of paramedicine. This issue is compounded by competing demands, limited career progression opportunities, and the risk of burnout, all of which impact the sustainability of the workforce. High-pressure work environments, extended shifts, and exposure to traumatic incidents contribute significantly to professional exhaustion. Many paramedics report frustration with stagnant roles, limited leadership opportunities, and insufficient recognition within the healthcare system. Paramedics with advanced training often find more stable or lucrative roles in allied health professions, further depleting the workforce.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The dynamic has changed, the 12-hour shift is now becoming a 14 and a 16-hour shift. ... At the end of 14 hours your thinking processes may not be as optimal as you would wish.\u0026quot;P08.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eI. Integration into the Healthcare System\u003c/h2\u003e\n \u003cp\u003eIntegration into the healthcare system is a critical theme in advancing the professional recognition and utilisation of paramedics. This involves embedding paramedics within broader healthcare structures, expanding their roles beyond emergency response, and ensuring collaboration with other healthcare professionals. Paramedics are often perceived as emergency responders rather than integral members of the healthcare system. This perception limits their involvement in preventive care, chronic disease management, or community health initiatives. In many jurisdictions, paramedicine operates in parallel with, rather than integrated into, primary and secondary care systems. This fragmentation hampers seamless patient transitions and interprofessional collaboration. Variations in paramedic scope of practice, licensing requirements, and regulatory frameworks between regions create inconsistencies in integration efforts.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;In the UK, paramedics are part of a service, but that service isn\u0026apos;t always integrated with other services. I think this is also a reflection of the NHS itself.\u0026quot; P07.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003e2. Elevating Professional Status\u003c/h2\u003e\n \u003cp\u003eThis theme focused on the necessity to elevate the professional status of paramedicine, and this is central to achieving broader recognition as healthcare professionals. It requires concerted efforts across education, regulation, and societal awareness to redefine the role of paramedics as integral and indispensable within healthcare systems.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Some of the research that I\u0026apos;ve done has shown that the healthcare system has no idea what paramedics are.\u0026quot; P01.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003ei. Formal Education and Specialisation\u003c/h2\u003e\n \u003cp\u003eEstablishing consistent educational standards is critical. Advanced qualifications, degree-level entry requirements, and opportunities for postgraduate specialisation create a foundation for professional credibility. Countries that have transitioned paramedic training into higher education, like Australia and the UK, have seen enhanced professional recognition. Formalised registration, licensing, and protection of the title \u0026quot;paramedic\u0026quot; are essential. These steps prevent misuse of the term, establish accountability, and uphold public trust. Regulatory bodies that define clear scopes of practice and ethical standards further solidify paramedics\u0026rsquo; professional standing.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;In Ontario, within a year, there will be a one-year, two-year, three-year and four-year way of becoming the exact same thing (a Paramedic) ...So straight away, that\u0026apos;s madness.\u0026quot;\u003c/em\u003eP01.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eII. Regulation and Certification\u003c/h2\u003e\n \u003cp\u003eFormalised registration, licensing, and the protection of the title \u0026quot;paramedic\u0026quot; are foundational to establishing the profession\u0026apos;s integrity, enhancing public trust, and creating clear professional boundaries. Registration and licensing enforce professional accountability, allowing regulatory bodies to monitor compliance with established standards. Mechanisms for addressing misconduct ensure ethical practice and public trust. A formalised system reassures the public that paramedics are competent, qualified, and held to the same rigorous standards as other healthcare professionals. These elements contribute to the recognition of paramedics as accountable healthcare practitioners with well-defined roles and ethical responsibilities.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;How do we strike someone off who\u0026rsquo;s a dodgy practitioner? How do we have competencies that someone can work privately? What\u0026rsquo;s our regulation around that?\u0026quot; P02.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eIII. Professional Identity and Recognition\u003c/h2\u003e\n \u003cp\u003eProtection of the title ensures that only those who meet stringent educational, training, and ethical requirements can practice as paramedics. This prevents unqualified individuals from misrepresenting themselves, thereby safeguarding patient safety and the profession\u0026apos;s reputation. Protected titles and licensing support the argument for role expansion into areas like community health and primary care by demonstrating the profession\u0026apos;s capacity for safe and effective practice. Such measures support the profession\u0026rsquo;s evolution, ensuring paramedics are seen as integral and trustworthy members of the healthcare system.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I think globally, all Western healthcare paramedicine professions will mass move towards registration. Without registration, there is no ability to self-regulate, and you will always be at the whim of another profession. P03.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003e3. Impact of COVID-19\u003c/h2\u003e\n \u003cp\u003eThis theme delves into the profound challenges and opportunities presented by the COVID-19 pandemic, which significantly impacted the paramedic profession. It altered operational workflows, increased professional demands, and reshaped the perception of paramedics within healthcare systems. During the pandemic, paramedics often assumed expanded roles, such as administering vaccines, performing COVID-19 testing, and providing community-based care to alleviate the burden on hospital systems. This adaptability not only showcased their capacity but also illuminated their underutilised potential in broader public health and primary care roles.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The pandemic accelerated the pace of change and demonstrated the value of collaboration\u0026rdquo; P13.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\n \u003ch2\u003eI. Lost Momentum\u003c/h2\u003e\n \u003cp\u003eThe pandemic\u0026apos;s heightened visibility of paramedics brought their contributions to the forefront of policymakers\u0026apos; agendas. This recognition underscored both the critical role of paramedics in emergency and non-emergency contexts and the structural barriers that limited their full integration into healthcare systems. By highlighting these issues, the COVID-19 crisis has acted as a catalyst for discussions around the professionalisation of paramedicine. It was seen as paving the way for potential reforms, including legislative changes, enhanced training opportunities, and better resource frameworks, which could have enabled the profession to leverage its full potential in future public health challenges. While the COVID-19 pandemic temporarily spotlighted the paramedic profession, highlighting its adaptability and critical role in healthcare, the post-pandemic period has seen a notable decline in momentum for systemic reforms. This lost momentum poses challenges to sustaining the progress made during the crisis.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;COVID presented us with a threat and an opportunity.\u0026quot;P05.\u003c/em\u003e\u003c/p\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003eII. Shifts In Policymaker Priorities\u003c/h2\u003e\n \u003cp\u003eThis theme examines the shift in priorities by policymakers in the post-pandemic era. As emergency responses to the pandemic winded down, attention shifted to other healthcare priorities, such as addressing surgical backlogs and mental health crises. This redirection diluted the focus on advancing paramedic professionalisation and reforming regulatory frameworks. Post-pandemic economic pressures have limited funding for healthcare reforms, including the expansion of paramedic roles and the introduction of new training programs.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;We\u0026apos;re really bad at marketing ourselves.\u0026quot; P01.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n \u003ch2\u003eIII. Withdrawal Or Redirection of Funding\u003c/h2\u003e\n \u003cp\u003eGovernments have prioritised stabilising economies over healthcare innovations, reducing opportunities for paramedic professional development. The expansive roles taken on by paramedics during the pandemic\u0026mdash;such as vaccine administration and community care\u0026mdash;have been scaled back in some regions. This has curtailed opportunities to embed these responsibilities into permanent scopes of practice. The pandemic exacerbated burnout, leading to retention issues and reduced capacity for advocacy within the profession. Many paramedics who pushed for systemic changes faced exhaustion or left the profession altogether, diminishing the advocacy force.\u003c/p\u003e\n \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n \u003ch2\u003e4. Future Barriers to Change\u003c/h2\u003e\n \u003cp\u003eThe final theme examined the future barriers to change that remain within paramedicine. Though some of the subthemes are revisited they are discussed within different context. The ongoing evolution of paramedicine faces several barriers that could hinder further professionalisation and expansion of roles within the healthcare system. These challenges are influenced by regulatory frameworks, workforce dynamics, and systemic healthcare constraints.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\n \u003ch2\u003eI. Structural and Systemic Barriers\u003c/h2\u003e\n \u003cp\u003eOne of the primary barriers to advancing the paramedic profession is the lack of robust political support and sustained financial investment. This limitation undermines the potential for paramedics to assume expanded roles within healthcare systems and achieve greater professional recognition. Following the increased visibility of paramedics during the COVID-19 pandemic, attention and funding have often shifted to other areas, resulting in lost momentum for paramedic-focused reforms. Healthcare systems frequently prioritise established professions, leaving paramedicine at a disadvantage in the allocation of resources and decision-making roles. A lack of unified lobbying at the governmental level limits the profession\u0026apos;s ability to push for necessary reforms or investments. In many jurisdictions, the absence of legislation protecting the title \u0026quot;paramedic\u0026quot; hinders the profession\u0026apos;s ability to standardise practices and scopes of work. Political inertia in establishing advanced roles, such as paramedic prescribing or leading primary care initiatives, restricts opportunities for growth. The paramedic profession\u0026apos;s fragmented representation across different jurisdictions weakens its advocacy efforts. A lack of unified lobbying at the governmental level limits the profession\u0026apos;s ability to push for necessary reforms or investments.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There is no such thing as a Canadian paramedic\u0026hellip; Healthcare is a provincial function here...And so there is no health system in Canada. There\u0026apos;s 10 provinces and three territories who all do their own version of something.\u0026quot;P01\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eLimited investment hampers paramedicine\u0026rsquo;s growth, affecting education, workforce development, technology adoption, and integration into healthcare. Inadequate funding restricts advanced training, leading to skill disparities and limited career progression. Financial constraints also contribute to staffing shortages, burnout, and difficulties in meeting healthcare demands. A lack of resources delays the adoption of modern technologies critical for patient care and efficiency. Funding disparities across regions create barriers to professional identity and role expansion, widening gaps between well-funded and underfunded areas and hindering global standardisation.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;You\u0026apos;ve got to pay people for what they do and it\u0026apos;s something I feel very passionately about our nurses for years were the victim of that.\u0026quot; P03.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\n \u003ch2\u003eII. Workforce Development and Collaboration\u003c/h2\u003e\n \u003cp\u003eThe advancement of paramedicine as a recognised healthcare profession hinges on cultivating a highly skilled workforce and robust leadership. These elements are pivotal for ensuring that paramedics can meet evolving healthcare demands and advocate effectively for the profession\u0026apos;s development. Expand access to higher education programs tailored to paramedicine, including bachelor\u0026rsquo;s, master\u0026rsquo;s, and doctoral degrees. Promote CPD to keep practitioners updated on best practices and emerging healthcare trends. Create specialised leadership training programs to equip paramedics with the skills to manage teams, influence policy, and advocate for systemic changes. Include paramedics in decision-making roles within healthcare organizations to ensure their perspectives shape policy and operational strategies. Promote research and knowledge exchange to support evidence-based practices and innovation in paramedicine.\u003c/p\u003e\n \u003cp\u003eInterprofessional collaboration plays a vital role in the evolution of paramedicine, fostering seamless integration into healthcare systems and improving care delivery. By working closely with other healthcare professionals, paramedics contribute to enhanced patient outcomes through coordinated and comprehensive care, reducing errors and boosting patient satisfaction. This collaboration also clarifies the paramedic\u0026apos;s scope of practice, ensuring their specialised skills are effectively utilised. Engaging across disciplines allows paramedics to build mutual respect and professional recognition, further embedding their role as integral contributors to the healthcare team. These collaborative practices not only elevate the standing of paramedics but also promote efficient resource utilisation and foster innovation within healthcare systems.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I think that the autonomy to decide not to convey someone, I think, is going to be really, really important for the health system in years to come.\u0026quot;P04.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\n \u003ch2\u003eIII. Professional Mindsets\u003c/h2\u003e\n \u003cp\u003eResistance to change within paramedicine, healthcare systems, and society hinders professionalisation. Internal resistance stems from attachment to traditional roles, leading to scepticism toward educational reform, technology, and new care models. Addressing this requires leadership that promotes dialogue and highlights the benefits of innovation. External resistance comes from healthcare professionals, policymakers, or institutions fearing competition, accountability concerns, or encroachment on their domains. Interprofessional education and advocacy can help overcome these barriers. Bureaucratic inertia further delays progress, reinforcing disparities in training and regulation. A multi-pronged approach\u0026mdash;strong leadership, alliances with other healthcare professions, and gradual implementation\u0026mdash;can help drive sustainable change. Internal professional mindsets significantly influence the growth of paramedicine. While external barriers like policy and funding are well-recognised, internal attitudes, beliefs, and self-perceptions also shape the profession\u0026rsquo;s evolution. A lack of confidence in role expansion can limit advocacy and progress, while resistance to change or preference for traditional emergency roles may hinder innovation and interdisciplinary collaboration.\u003c/p\u003e\n \u003cp\u003eTo advance, paramedics must embrace lifelong learning, evidence-based practices, and discussions about the profession\u0026rsquo;s future. Strong leadership is essential in challenging outdated mindsets and fostering adaptability. This cultural shift is crucial for strengthening paramedicine\u0026rsquo;s role within healthcare and ensuring its continued growth and integration.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I\u0026apos;ve had resistance from some pretty senior people around the direction that alternative care pathways are taking because they\u0026rsquo;re worried that we\u0026rsquo;re forgetting about our mantra, of dealing with emergencies.\u0026quot; P03.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored key perspectives on the barriers to the professionalisation of paramedicine, uncovering themes that highlighted the challenges within the field. The findings underscore the significance of legislative and regulatory frameworks in shaping the paramedic profession\u0026rsquo;s trajectory. The lack of formal title protection and standardised regulations across jurisdictions emerged as a pervasive challenge, creating inconsistencies in practice and limiting professional recognition [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. This issue resonates globally, as seen in previous studies that highlight the disparities in paramedic roles and recognition between countries such as Australia, UK, Canada, U.S.A and the ROI [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Moreover, financial constraints were identified as a critical barrier to advancing paramedicine. Limited funding not only restricts access to advanced education and training but also hampers efforts to expand paramedic roles into primary care and other specialised domains. This aligns with broader concerns in healthcare, where resource allocation often prioritises traditional medical professions over emerging disciplines. Addressing these financial barriers through advocacy, public-private partnerships, and targeted resource allocation will be pivotal in fostering growth within paramedicine [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]. Interprofessional collaboration was highlighted as a pathway for enhancing the paramedic profession\u0026rsquo;s status and integration into the healthcare system. The importance of fostering partnerships with other healthcare professionals to improve patient outcomes, reduce redundancies, and delineate professional roles cannot be overstated.\u003c/p\u003e \u003cp\u003eThe findings of this study align with current literature emphasising the need for interdisciplinary approaches in healthcare to enhance service delivery and professional recognition [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. The study also delved into internal barriers, such as resistance to change and entrenched professional mindsets. These factors can slow progress by perpetuating traditional views of paramedicine as a technical rather than a professional field. Overcoming these internal challenges will require leadership within the profession to champion change and embrace innovation. Finally, the impact of the COVID-19 pandemic was a prominent theme. The pandemic highlighted the adaptability and potential of paramedics, as they took on expanded roles such as vaccine administration and community health initiatives. While this visibility brought temporary recognition, the post-pandemic environment risks losing momentum unless sustained efforts are made to institutionalise these expanded roles [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. The findings from this study contribute to the growing body of literature advocating for a comprehensive strategy to address the multifaceted barriers facing paramedicine. By addressing legislative gaps, financial constraints, and internal resistance while leveraging opportunities for collaboration and innovation, paramedicine can secure its place as a vital and professional component of modern healthcare systems, [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eImplications for Practice\u003c/h3\u003e\n\u003cp\u003eTitle protection and uniform regulations are essential for paramedic recognition. Policymakers must prioritise legislative reforms to safeguard the \"paramedic\" title, ensure accountability, and standardise practice scopes [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Investing in advanced education and training will prepare paramedics for expanded roles, while workforce strategies should focus on retention to reduce burnout. Integrating paramedics into multidisciplinary teams through collaborative care and interprofessional education can enhance patient outcomes. Leadership development is key to driving systemic change, requiring training programs in educational institutions and professional associations [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Public awareness campaigns can build trust and support for role expansion. Evaluating innovations like paramedics in primary care and emergency preparedness can demonstrate their value and drive adoption [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. International forums for best practices and global standards will help address regulatory disparities and elevate paramedicine\u0026rsquo;s standing worldwide. Addressing these areas will enhance recognition, integration, and patient outcomes [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eAreas for Future Research\u003c/h2\u003e \u003cp\u003eFuture research should focus on achieving global consistency in paramedic title protection by comparing jurisdictions with strong regulatory frameworks to identify effective models and their impact on professional identity. Studies on best practices for integrating paramedics into multidisciplinary teams and interprofessional education are essential to expanding their healthcare roles [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Research on the cost-effectiveness of expanded roles, such as community paramedicine and prescribing rights, could support policy reform. Investigating leadership pathways and strategies for developing strong professional leaders can drive systemic change [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Further studies should address recruitment, retention, and job satisfaction, particularly concerning burnout. Research into the impact of higher education (bachelor\u0026rsquo;s and master\u0026rsquo;s programs) on clinical practice and professional recognition is key to educational reform [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Comparative studies on paramedicine\u0026rsquo;s evolution across countries can highlight global trends, challenges, and opportunities for standardisation [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Understanding public perceptions of paramedics and trust in their expertise could inform awareness campaigns. Evaluating the long-term impact of COVID-19 on paramedicine, including lessons for role expansion and emergency preparedness, is vital [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Research on aligning paramedics with other healthcare disciplines in emergency, primary, and community care could strengthen their role in healthcare delivery [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. These studies will support the advancement and integration of paramedicine worldwide.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study's limitations highlight areas that could impact the breadth and depth of its findings. While the inclusion of 15 stakeholders offered valuable insights, the relatively small sample size limits the generalisability of results across the paramedicine field. The use of snowball sampling, though efficient, may have introduced selection bias by drawing primarily from established professional networks, potentially excluding diverse or dissenting voices. Geographic and jurisdictional variations in paramedic practices and regulations might not be fully represented, restricting the global applicability of the outcomes. Additionally, the reliance on thematic analysis, inherently interpretative, may have introduced subjectivity. The study's emphasis on barriers might have overshadowed enabling factors, while the timing during the COVID-19 pandemic likely influenced responses, focusing on pandemic-related challenges and potentially neglecting broader systemic issues. Future research addressing these limitations could enhance the scope and applicability of findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the significant barriers facing the professionalisation of paramedicine. Central to the challenges are the lack of formalised title protection, inconsistent legislative and regulatory frameworks, financial constraints, and internal resistance to change. These factors collectively hinder the recognition and integration of paramedics as essential healthcare professionals. Addressing these issues requires a multifaceted approach, combining advocacy for legislative reforms, strategic investment in education and training, and fostering interprofessional collaboration. The COVID-19 pandemic demonstrated the adaptability and potential of paramedics, offering a pivotal opportunity to redefine the profession\u0026rsquo;s scope and visibility within healthcare systems. Sustaining this momentum post-pandemic demands ongoing policy support and leadership within the field to drive innovation and embrace evolving healthcare needs. Future efforts must focus on establishing a unified professional identity and leveraging the contributions of paramedics to broader healthcare goals. By addressing these barriers and capitalising on opportunities for growth, paramedicine can continue to advance as a respected and indispensable healthcare profession, ultimately improving patient care and system efficiency on a global scale.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eACP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eAdvanced Care Paramedic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eALS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eAdvanced Life Support\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eAdvanced Paramedics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAHP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eAllied Health Professionals\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAHPRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eAustralian Health Practitioner Regulation Agency\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eBLS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eBasic Life Support\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eCOPR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eCanadian Organisation of Paramedic Regulators\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eCAAHEP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eCommission on Accreditation of Allied Health Education Programs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eCPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eContinuous Professional Development\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eCCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eCritical Care Paramedic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eEmergency Medical Services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eEmergency Medical Technicians\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eHCPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eHealth and Care Professions Council\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNREMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eNational Registry of Emergency Medical Technicians\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePHECC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003ePre-Hospital Emergency Care Council\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003ePrimary Care Paramedic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eROI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eRepublic of Ireland\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eUK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eUnited Kingdom\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 443px;\"\u003e\n \u003cp\u003eUnited States of America\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the University College of Cork, Republic of Ireland, Social and Research Ethics Committee (SREC). All participants provided informed consent before their interviews and were assured of confidentiality and anonymity. The study was conducted in accordance with the ethical standards of the institutional research committee and the Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data were securely stored and managed in accordance with ethical guidelines to protect participants\u0026rsquo; identities. All data is available by contacting the primary author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest in this publication. The research team would like to confirm that the manuscript is original work and that no part of the manuscript has been published or submitted elsewhere for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was made available for this study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors have contributed to the development of the ideas, writing and/or final review of the submitted manuscript, and all authors have read and approved this version of the manuscript and its submission to the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author\u0026rsquo;s wish to acknowledge the participants of this study for giving freely their time and expertise.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eReed B, Cowin L, O\u0026apos;Meara P, Wilson I. 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BMC Emergency Medicine. 2019 Dec; 19:1-7.\u003c/li\u003e\n \u003cli\u003eBarry T, Batt A, Agarwal G, Booker M, Casey M, McCombe G. Potential for Paramedic roles in Irish General Practice: A qualitative study of stakeholder\u0026rsquo;s perspectives. HRB Open Research. 2022;5.\u003c/li\u003e\n \u003cli\u003eFeerick FI, Connor CO, Hayes PE, Kelly DE. Introducing Advanced Paramedics into the rural general practice team in Ireland\u0026ndash;general practitioners\u0026rsquo; attitudes. BMC Primary Care. 2022 May 26;23(1):130.\u003c/li\u003e\n \u003cli\u003eBrooks IA, Cooke M, Spencer C, Archer F. A review of key national reports to describe the development of paramedic education in England (1966\u0026ndash;2014). Emergency Medicine Journal. 2016 Dec 1;33(12):876-81.\u003c/li\u003e\n \u003cli\u003eCooper S. Contemporary UK paramedical training and education. How do we train? How should we educate? 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A review of the literature: the transition of entry-level paramedic education in Australia from vocational to higher education (1961\u0026ndash;2017). Australasian Journal of Paramedicine. 2018 Jan; 15:1-1.\u003c/li\u003e\n \u003cli\u003eO\u0026apos;Brien K, Moore A, Dawson D, Hartley P. An Australian story: paramedic education and practice in transition. Australasian Journal of Paramedicine. 2014 Jan; 11:1-3.\u003c/li\u003e\n \u003cli\u003eHou XY, Rego J, Service M. Paramedic education opportunities and challenges in Australia. Emergency Medicine Australasia. 2013 Apr;25(2):114-9.\u003c/li\u003e\n \u003cli\u003eBell A, Hammer S, Seymour-Walsh A. The role of educational theory in the future development of paramedicine as a profession: An integrative review. Australasian Journal of Paramedicine. 2021 Jan; 18:1-0.\u003c/li\u003e\n \u003cli\u003eBowles RR, van Beek C, Anderson GS. Four dimensions of paramedic practice in Canada: defining and describing the profession. Australasian Journal of Paramedicine. 2017 Jan; 14:1-2.\u003c/li\u003e\n \u003cli\u003eO\u0026apos;Meara P, Ruest M, Stirling C. Community paramedicine: higher education as an enabling factor. Australasian Journal of Paramedicine. 2014 Jan; 11:1-9.\u003c/li\u003e\n \u003cli\u003eBrydges M, Dunn JR, Agarwal G, Tavares W. At odds: How interprofessional conflict and stratification has stalled the Ontario paramedic professionalization project. Journal of Professions and Organization. 2022 Oct 1;9(3):333-47.\u003c/li\u003e\n \u003cli\u003eBury G, Egan M, Vallely J. The Advanced Paramedic Training Programme: challenges for an adult workforce entering the university sector.\u003c/li\u003e\n \u003cli\u003eKnox S, Brand C, Sweeney C. Perceptions of paramedic educators on assessments used in the first year of a paramedic programme: a qualitative exploration. BMC Medical Education. 2023 Dec 12;23(1):952.\u003c/li\u003e\n \u003cli\u003eEburn M. Registered paramedics, insurance and first aid\u0026ndash;looking for coherence in law. Australasian Journal of Paramedicine. 2019 Jan; 16:1-7.\u003c/li\u003e\n \u003cli\u003eEaton G, editor. Law and Ethics for Paramedics: An Essential Guide. Class Professional Publishing; 2023 Dec 12.\u003c/li\u003e\n \u003cli\u003eAcker JJ, Johnston TJ, Lazarsfeld-Jensen A. Industrial paramedics, out on site but not out of mind. Rural and Remote health. 2014 Dec;14(4):141-57.\u003c/li\u003e\n \u003cli\u003eTownsend R. An introduction to the legal system and paramedic professionalism. Applied Paramedic Law, Ethics and Professionalism: Australia and New Zealand. 2019 Aug 1:54.\u003c/li\u003e\n \u003cli\u003eNowak-Zając K, Domagała A, Bielska IA, Kowalska-Bobko I. New paramedic scope of practice in Poland based on the 2022 reform. Health Policy. 2024 May 1; 143:105015.\u003c/li\u003e\n \u003cli\u003eFeerick, F., Coughlan, E., Knox, S., Murphy, A., Grady, I.O. and Deasy, C., 2024. Alternative Paramedic Roles: An International Perspective.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMorrison A, Reynolds L. Paramedicine and the Health Care System. Understanding the Australian Health Care System. 2023 Oct 1:292.\u003c/li\u003e\n \u003cli\u003eEaton G, Mahtani K, Catterall M. The evolving role of paramedics\u0026ndash;a NICE problem to have? Journal of Health Services Research \u0026amp; Policy. 2018 Jul;23(3):193-5.\u003c/li\u003e\n \u003cli\u003eNuryatno Ma. The Call For the Paradigm Shift in Qualitative Research from Positivism and Interpretive to Critical Theory. Jurnal Hermeneia\\Vol-2-No-1-2003. 2003 Jan 1.\u003c/li\u003e\n \u003cli\u003eKincheloe JL, McLaren P. Rethinking critical theory and qualitative research. In Key works in critical pedagogy 2011 Jan 1 (pp. 285-326). Brill.\u003c/li\u003e\n \u003cli\u003eNaderifar M, Goli H, Ghaljaie F. Snowball sampling: A purposeful method of sampling in qualitative research. Strides in development of medical education. 2017 Sep 30;14(3).\u003c/li\u003e\n \u003cli\u003eTerry G, Hayfield N, Clarke V, Braun V. Thematic analysis. The SAGE handbook of qualitative research in psychology. 2017 Jun 30;2(17-37):25.\u003c/li\u003e\n \u003cli\u003eKallio H, Pietil\u0026auml; AM, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi‐structured interview guide. Journal of advanced nursing. 2016 Dec;72(12):2954-65.\u003c/li\u003e\n \u003cli\u003eTakoutsing BD, Zolo Y. Developing a prehospital care service in a low‐resource setting: Barriers and solutions. Health Science Reports. 2023 Nov;6(11): e1719.\u003c/li\u003e\n \u003cli\u003eThurman WA, Moczygemba LR, Tormey K, Hudzik A, Welton-Arndt L, Okoh C. A scoping review of community paramedicine: evidence and implications for interprofessional practice. Journal of Interprofessional Care. 2021 Mar 4;35(2):229-39.\u003c/li\u003e\n \u003cli\u003eAlmutairi FG, Alsomali OH, Alsulami EH, Alshammari MA, Alonezi AD, Kabi AH, Almutairi AZ, Alotaibi HM, Alanazi AF, Alqadeeb HA, Baurasien BK. Paramedic and COVID-19 Pandemic. International journal of health sciences.;5(S1):1170-90.\u003c/li\u003e\n \u003cli\u003eO\u0026rsquo;Brien, Bridget C. PhD; Harris, Ilene B. PhD; Beckman, Thomas J. MD; Reed, Darcy A. MD, MPH; Cook, David A. MD, MHPE. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Academic Medicine 89(9): p 1245-1251, September 2014. DOI: 10.1097/ACM.0000000000000388.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Paramedicine, Paramedic, Professionalisation, Professional Development, Barriers","lastPublishedDoi":"10.21203/rs.3.rs-6732926/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6732926/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003e–\u003cstrong\u003e \u003c/strong\u003eParamedicine is in the midst of a transformative shift, as paramedics move beyond traditional emergency roles toward recognition as healthcare professionals. Central to this evolution is the pursuit of professionalisation—seeking greater autonomy, expanded scope of practice, and formal integration into healthcare systems. However, significant barriers persist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePurpose \u003c/strong\u003e– This study explores key barriers to paramedic professionalisation across five different developed healthcare systems, both domestically and internationally.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e – A qualitative study using semi-structured interviews underpinned by a critical theory paradigm. Over five months (Dec 2022–Apr 2023), 15 stakeholders from paramedicine and pre-hospital emergency care across five countries participated. Their backgrounds spanned clinical practice, education, policy, and management. Interviews were conducted via Microsoft Teams, recorded, transcribed verbatim, and thematically analysed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e – Analysis of fifteen semi-structured interviews revealed four main themes with overlapping but contextually distinct sub-themes: Theme 1: Current Barriers to Expansion – Included outdated legislation, limited funding, staffing challenges, and poor integration into healthcare. Theme 2: Elevating Professional Status – Focused on education, regulation, certification, and professional identity. Theme 3: Impact of COVID-19 – Highlighted lost momentum, shifting policy priorities, and redirected funding. Theme 4: Future Barriers to Change – Included structural/systemic issues, workforce development, collaboration, and entrenched mindsets.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e – Multiple barriers hinder paramedic professional recognition, including fragmented regulation, inconsistent education standards, limited funding, and internal resistance. While COVID-19 briefly raised the profession’s profile, this momentum has since declined. Reinvigorating progress requires political commitment, regulatory reform, educational investment, and workforce development to fully embed paramedics within healthcare systems.\u003c/p\u003e","manuscriptTitle":"Barriers to Paramedic Professionalisation: A Qualitative Enquiry Across the UK, Canada, Australia, USA and the Republic of Ireland.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-04 12:57:14","doi":"10.21203/rs.3.rs-6732926/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-17T07:46:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-17T03:59:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-05T11:32:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217871710934256938965367317170139056591","date":"2025-06-05T06:55:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-04T23:06:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147544938570348365148736126553397402378","date":"2025-06-04T02:16:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151820350102116443559862253295244707922","date":"2025-06-03T05:08:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54483100440172065454397741688776622059","date":"2025-06-02T20:47:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57271579491020777485290898876696108782","date":"2025-06-02T06:23:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-02T02:10:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-30T12:13:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-30T07:39:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-30T07:36:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e3f8cd93-e2a2-4d28-b1fe-04b53076603f","owner":[],"postedDate":"June 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-04T16:44:02+00:00","versionOfRecord":{"articleIdentity":"rs-6732926","link":"https://doi.org/10.1186/s12913-025-13196-5","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-07-29 16:13:27","publishedOnDateReadable":"July 29th, 2025"},"versionCreatedAt":"2025-06-04 12:57:14","video":"","vorDoi":"10.1186/s12913-025-13196-5","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13196-5","workflowStages":[]},"version":"v1","identity":"rs-6732926","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6732926","identity":"rs-6732926","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}