Whilst there is evidence of competence and CPD programmes within ambulance services internationally (e.g., Norway , Australia , UK , Canada ), the evidence of any consultation with practitioners prior to the introduction of such programmes is scarce.
EMTs must embrace the multitude of activities that contribute to a professional’s development and the outcome of good CPD should be practitioners with increased competence and improved patient care . This is the first study of attitudes towards professional competence among EMTs in Ireland and indicates that there appears to be a genuine enthusiasm for the introduction of CPC and a positive link to professionalism, similar to other healthcare professions [9, 11, 12, 23–26]. This enthusiasm towards CPC is reinforced further as a significant number of EMTs are already maintaining a learning portfolio and participating in CPC activities, as the vast majority of participants agreed that CPC should be a requirement for PHECC registration and as 95% believed that registration with PHECC is of personal importance to them. This view of CPD being a requirement for registration is supported by legislation for some professions [27–29] or shown in previous studies to be shared by practitioners themselves [26, 30].
E-learning is the use of internet technologies to enhance knowledge and performance . There are many formats in which e-learning is delivered and many terms synonymous with e-learning, such as web-based (WBL) or on-line learning. One of the advantages of e-learning is that it can be synchronous or asynchronous and, therefore, can be flexible and particularly attractive for pre-hospital practitioners. In Ireland, PHECC has progressed the use of on-line examinations and learning modules since its formation. Indeed, Irish EMT examinations are delivered partially via an electronic software programme. Most Health Professions regulators tend to accredit and set standards in training rather than develop training [32, 33] and, so, the e-learning approach (albeit blended with practical instruction provided by the training institutions) utilised most recently by PHECC to allow paramedics and APs complete on-line learning modules is unusual. Furthermore, this training methodology had not been in place for the initial training of EMTs surveyed and, taking cognisance of the survey results, it would appear that EMTs might use e-learning followed by practical reinforcement, but would appear less eager to use e-learning alone as a means to maintain competence.
Our survey included 22 potential CPC activities (see Table 4) and asked which activities did EMTs believe were relevant/irrelevant. The results showed that practical, hands-on activities were preferred over theoretical/non-practice type activities. Also, there were less negative responses regarding activities related to practical skills than to theoretical skills. This further substantiates the case for practical, hands-on activities, whether as a standalone activity or coupled with the e-learning approach. The EMTs surveyed in this study seemed to share the view of Ruiz et al in that perhaps they did not value e-learning as a replacement for traditional instructor-led training but rather as a complement to it, forming part of a blended-learning strategy . EMTs function in environments that require lateral thinking . Arguably, variation in learning methodologies could be encouraged so to facilitate the variations in personal learning styles while also taking cognisance of nuances in practice.
Previous studies with Irish advanced paramedics and paramedics reinforce the concept of practical-type learning as a preferred methodology and as an effective way of maintaining skills [7, 35] and that skills practice is an integral part of maintaining competence . Indeed, our results, in part, reinforce the focus of older/traditional basic training curricula for ambulance staff in the United Kingdom and Ireland, which for the most part, was skills-based . This is quite different to results seen for other professions who tend to prefer attending conferences, lectures and reading of relevant journals [9, 12], even though there is little evidence to suggest that attending conferences had any direct impact on improving professional practice .
CPC annual hours
Internationally, there are similarities in the way in which CPC hours are recorded, most being based on an hours-related credit system, in which one hour of educational activity equates to one credit and the number of credit/hours required vary from between 50–100 per year . Irish doctors now, under the Medical Practitioners Act  must meet professional competence requirements  and this currently is 50 hours per year. In that context, the respondents in this survey believe that it would not be unreasonable to expect EMTs to complete 20–40 hours annually.
The study had a number of strengths and weaknesses. The majority of respondents were male 70% (n = 272) in what is predominantly a male dominated profession in Ireland. At the time of the survey, there were 634 males registered with PHECC representing 69% of all EMTs registered (n = 925). Thus, the sample of participants in this study was similar to the proportion of male EMTs registered with PHECC.
The response to this survey was quite favourable, with a response rate of over 40%. This too is perhaps not surprising and may be due to the fact that the EMTs surveyed, for the most part, were affiliated with the voluntary organisations and, by association, are enthusiastic volunteers who self-nominated to progress to EMT programmes and subsequent examinations.
Notably, one group of EMTs may not have participated. These are EMTs not affiliated to any organisation and who most likely completed the EMT training programme independently.
While the response to the survey was quite favourable, we acknowledge some methodological considerations may limit generalisability. For instance, while we report data from 399 responses, this represented 43% of all registered EMTs. Our study was limited to those with valid email addresses on the PHECC register and clearly those for whom the subject area was a priority. Therefore, it is possible that our sample may not be representative of EMTs in general. Furthermore, the fact that a significant number of respondents represented a younger population (with over 27% under the age of thirty years, and a further 30% under the age of forty years) may have influenced the results. Arguably, a younger population may prefer a blended learning approach with an active participation and e-learning combination given the possibility that they may be more familiar with on-line/e-learning experiences. Indeed, the length of the survey may have been perceived as too long or complex, thereby reducing the return rate. Further research following the introduction of CPC for EMTs may expand upon these findings.