Enhancing Paramedic Job Performance: A Diagnostic And Literature-Based Approach

Enhancing Paramedic Job Performance: A Diagnostic and Literature-Based Approach

Lotfi Anuar, Nomahaza Mahadi

Universiti Teknologi Malaysia, Malaysia

DOI: https://dx.doi.org/10.47772/IJRISS.2025.909000440

Received: 07 September 2025; Accepted: 14 September 2025; Published: 14 October 2025

ABSTRACT

Paramedics are essential providers of emergency and non-emergency healthcare services. However, the evolving demands of the healthcare sector are increasingly constraining their job performance. This article investigates the factors influencing paramedic performance through diagnostic tools such as SWOT analysis, fishbone diagram and risk matrix assessments. A critical review of the existing literature was undertaken to frame the research context, identify prevailing gaps and guide the selection of diagnostic methodologies and interventions. Problem diagnosis indicated that outdated training modules and limited career development or opportunities were key impediments to optimal job performance. Further analysis through a research model matrix led to the identification of two targeted interventions: the development of updated training modules and the incorporation of promotion board assessments within a structured career development framework. By integrating systematic problem diagnosis with evidence-based insights from the literature, this study provides a foundation for future research aimed at evaluating the effectiveness of these interventions in strengthening paramedic job performance.

Keywords: Job performance; Healthcare; Paramedics; Research tools

INTRODUCTION

The latest global healthcare landscape is undergoing significant transformations driven by technological advancements and a focus on improving patient experience, enhancing healthcare delivery and addressing workforce challenges. Key developments include the integration of emerging technologies such as artificial intelligence (AI) (Mundinger & Mundinger, 2024), healthcare robotics (Kumar & Ali, 2024), telehealth systems (Iqbal et al., 2024) and digital therapeutics (Xiong et al., 2023), mainly aimed to improve patient care and streamline healthcare workflows. The global healthcare industry is also focusing on addressing staffing shortages, clinical burnout, and employee retention through innovative recruitment and retention strategies, as well as leveraging cloud technology (Putzier et al., 2024) to optimize patient care and access historical and recent clinical results.

As the healthcare landscape continues to evolve, the Malaysian public healthcare industry has started to face the challenge of job performance issues due to several converging factors such as the COVID-19 pandemic, high patient load, clinical burnout, and the inability to cope with the rapid advancement of medical technology. These challenges also occurred in the Armed Forces Health Services (AFHS), which has a special focus on the Armed Forces Health Training Institute (INSAN) as the leading institute to train paramedics in the Malaysian Armed Forces (MAF). However, continuous learning and training were essential for them to stay updated with the emergence of new medical devices and treatment protocols. These would be adding to their existing workload and stress. Furthermore, integrating new technology into daily practice requires time and effort, and any technical malfunctions could complicate emergencies. These challenges would necessitate adequate training, support, and resources to enhance their job performance and maintain high standards of patient care.

In action research, various diagnostic tools are employed to identify problems, analyze their causes, and guide effective interventions. A SWOT Analysis helps evaluate internal strengths and weaknesses alongside external opportunities and threats to identify areas needing improvement (Namugenyi et al., 2019). The TOWS Matrix extends this by aligning internal and external factors to create strategic responses (Weihrich, 1982). The Fishbone Diagram visually maps out potential root causes of a specific issue (Sakdiyah et al., 2022), and Root Cause Analysis further explores these causes systematically (Soares et al., 2022). Risk Matrix Analysis prioritizes risks based on their likelihood and impact to support decision-making in planning (Prasetyo & Arvitriada, 2025). The LR Matrix facilitates the synthesis of literature to form a theoretical framework that supports the research process (Chen et al., 2018), while the Research Model Matrix identifies themes that encourage continuous cycles of action and reflection to refine interventions (Mallory, 2024). Collectively, these tools enhance the rigor, depth, and clarity of action research by enabling systematic diagnosis and informed planning of interventions.

Problem Statement

Armed Forces Health Training Institute (INSAN) is responsible for providing training for paramedics in Armed Forces Health Services since 1980. Early observations from interviews with eight stakeholders revealed that outdated training modules (Training and Development) and insufficient career progression (Career Development) were identified as the primary factors contributing to their declined job performance.

Problem Diagnosis

Early observations revealed that outdated training modules (Training and Development) and insufficient career progression (Career Development) were identified as the primary factors contributing to the decline in job performance among paramedics trained by INSAN. In order to further diagnose the problems, SWOT analysis, TOWS analysis, fishbone diagram, root cause analysis and risk matrix assessment table were also used.

SWOT Analysis

SWOT (acronym for Strengths, Weaknesses, Opportunities and Threats) analysis is a straightforward instrument that does not require complex knowledge or abilities. It used four fundamental categories to assess and organize information, making the process of diagnosis and analysis more intuitive and straightforward to comprehend (Helms & Nixon, 2010). A SWOT analysis of INSAN could provide insight into the situation faced and offer helpful information for problem diagnosis and formulation. Table 1 shows the SWOT analysis of INSAN.

Table 1: The SWOT Analysis of INSAN

By using SWOT analysis, INSAN’s strengths were identified in its expertise in military medicine and status as the sole training center for Malaysian Armed Forces paramedics. Opportunities emerged from Education 4.0 and stakeholder support for modernization. However, weaknesses included outdated curricula, lack of standardized management, and inconsistent program delivery, all of which reduced graduate competency. Threats such as obsolete infrastructure and global economic uncertainty further jeopardized performance. This analysis revealed that outdated training and poor career progression are critical issues, directly guiding the problem diagnosis and prioritizing interventions to modernize training and strengthen career development frameworks.

TOWS Analysis

Further TOWS analysis outlined the strategic actions by directly linking INSAN’s internal and external factors. For SO strategies, S2O1 recommends integrating high-tech simulation with stakeholder-driven digital transformation to strengthen training, while S1O3 leverages INSAN’s unique national role to secure stakeholder and military budget support. In WO strategies, W2O3 calls for collaboration with stakeholders to redesign transparent promotion and salary systems, and W2O2 focuses on reforming HR policies with external best practices. Under ST strategies, S1T1 highlights INSAN’s national uniqueness to secure funding during economic downturns, and S2T1 emphasizes tech-enhanced curricula as cost-effective investments. Lastly, WT strategies such as W4T2 prioritize infrastructure upgrades to overcome rural challenges, while W2T1 proposes contingency budgets to safeguard salaries.

Table 2: The TOWS analysis of INSAN

Fishbone Analysis

Ishikawa (1990), a Japanese quality control statistician, developed a fishbone diagram to illustrate the complex interrelationships and interactions between certain phenomena or causes (Coccia, 2018). It would facilitate a thorough root cause analysis, leading to a diagnosis of the probable root cause of the problem and assisting organizations in identifying the underlying causes of the issue (Groot, 2021). The fishbone diagram of a paramedic’s job performance is shown in Figure 1.

Figure 1: Fishbone diagram of a paramedic’s job performance

Figure 1 shows the problem diagnosis of declined job performance, which was divided into six categories: training, teaching infrastructure, compensation, human resource policies, curriculum and budget. It was determined that all these factors were significant influencers, and therefore, further root cause analysis is required.

Root Cause Analysis

The root cause analysis identified six key factors contributing to the decline in job performance among paramedics trained by INSAN. These include a lack of training due to an outdated training system, inadequate teaching infrastructure stemming from old facilities, an uncompetitive and outdated compensation scheme, unclear career progression linked to repetitive promotion tests, curriculum issues such as outdated modules and overlapping content, and limited training opportunities resulting from budget restrictions. All six categories showed clear issues with no area reported as problem-free. These findings suggest that systemic weaknesses in organizational support, resource allocation and curriculum development are collectively impacting the effectiveness and motivation of paramedics, leading to declined job performance. The summary of root cause analysis is shown in Table 3.

Table 3: Summary of possible root causes for declined job performance

Risk Matrix Assessment

The identified issues are further categorized and examined. By prioritizing the individual problem entries for risk assessment, a clearer view of the priority level of INSAN’s problem diagnosis is gathered. The 5X5 risk matrix is a standard risk assessment instrument with the horizontal axis represented by an integer from 1 to 5 indicating the probability of the risk occurring and the vertical axis represented by an integer from 1 to 5 indicating the severity of the risk. The product of the intersections of the horizontal and vertical axes is the criterion for evaluating the likelihood of the risk’s occurrence, with higher values indicating a greater risk priority (Kovačević et al., 2019). Table 4 indicates that “curriculum ” and “training ” are the top two priorities based on the risk assessment of INSAN. Therefore, these two issues are the most perilous and must be addressed immediately.

Table 4: The Risk Matrix Assessment of INSAN

LITERATURE REVIEW

Prior studies confirm that training, career development, and organizational commitment are significant predictors of job performance (Hosen et al., 2024; Gatotrianto & Nadirah, 2024). Furthermore, few scholars have specifically addressed the challenges of outdated training modules and limited career progression within paramedic education. For instance, Dagnew and Elantheraiyan (2023) emphasize the need for training assessments, while Aung et al. (2023) highlight unclear promotion criteria as detrimental to performance. This gap directly aligns with the issues identified at INSAN, where outdated curricula and rigid promotion systems hinder workforce effectiveness. However, existing studies seldom integrate diagnostic tools with targeted interventions, leaving a gap that this article addresses by proposing updated training modules and structured promotion board assessments tailored to the needs of paramedics

Social Exchange Theory

The theory by Emerson (1976) posits that social interactions and relationships are based on the idea of maximizing benefits and minimizing costs. The concept of social exchange theory can be applied to training and job performance by understanding how individuals assess the value of their interactions and make decisions based on the expected outcomes. In the context of training, this theory suggests that individuals will be motivated to engage in training programs if they perceive the benefits, such as acquiring new skills or advancing their careers, to outweigh the costs, including time and effort. Employers can utilize this understanding to design training programs that emphasize the rewards and benefits for employees, thereby increasing their motivation to participate in and engage with the training process.

Job Embeddedness Theory

Job Embeddedness Theory explains why employees stay in their jobs rather than why they leave. It was introduced by Mitchell et al. (2001) as a more comprehensive approach to understanding employee retention beyond traditional turnover theories. The theory posits that employees become “embedded” in their jobs through three key dimensions: links, fit and sacrifice. Job embeddedness is a strong predictor of job retention and performance (Probosari et al., 2024). It is particularly relevant in healthcare settings, where strong professional relationships, alignment with organizational values, and the cost of leaving (e.g., losing tenure, patient relationships, or professional development opportunities) contribute to enhancing job performance.

Synthesis Of the Problem’s Solution (Interventions)

Based on the risk assessment analysis, we identified curriculum and training as the top two priorities. To further solve the problem, the Literature Review (LR) Matrix and the Research Model Matrix were utilized.

Literature Matrix

A Literature Matrix is a tool used to systematically organize and compare key findings from various studies on a specific topic. It typically includes columns for study details, research methods, findings, and relevance to the research question. The Literature Matrix will facilitate the researcher’s ability to quickly compare articles and determine the scope of research across time. It will make the task of spotting differences and similarities between journal articles about a research topic easier (The Matrix Method for Literature Reviews, 2020). It will also identify trends, gaps, and the effectiveness of different approaches. It aids in evaluating which solutions or methodologies have been most effective based on evidence, making it easier to pinpoint the best solutions for the problem being studied. In this study, the LR Matrix was used to identify possible antecedents (interventions) that could address the main issues, specifically reducing paramedics’ job performance trained by INSAN. A part of the Literature Matrix and the summary are shown in Tables 5 and 6.

Table 5: Summary of Past Studies

Table 6: Summary of Literature Matrix

Research Model Matrix

Based on the Literature Matrix, studies with possible similar interventions were grouped and finalized, as shown in Table 7.

Table 7: Research Model Matrix

DISCUSSION

This study investigated declining job performance among paramedics trained at INSAN and identified two key issues: outdated training modules and limited career progression pathways. Both factors are widely recognized in literature as central to employee performance and motivation, particularly in healthcare, where continuous learning is essential. To address these challenges, two interventions were proposed: updating training modules to align with modern medical technologies and integrating promotion board assessments into a structured career development framework. Guided by Social Exchange Theory and Job Embeddedness Theory, these measures aim to enhance competence, recognition, and motivation, fostering stronger engagement and improved job performance.

The significance of this work extends beyond military healthcare setting. The framework developed here has potential relevance for civilian healthcare training institutions. While military paramedics operate under rigid structures, frequent deployments and resource constraints, civilian paramedics, on the other hand, face challenges such as high patient loads, administrative burdens and diverse patient populations, both sectors, however, struggle with training gaps, burnout and unclear career pathways. Beyond Malaysia, the findings are relevant to ASEAN countries and other global contexts where healthcare sectors share similar concerns of outdated curriculum, limited promotion opportunities and rising demands for digital competencies, making these proposed interventions widely applicable and scalable.

As a conceptual paper, the interventions have not yet been tested in practice. The findings, therefore, serve as a foundation rather than a final answer. Future research should focus on conducting pilot studies to test the feasibility and effectiveness of the proposed interventions. A small cohort of paramedics can be selected to undergo the revised training and structured career development framework. Effectiveness will be measured through job performance scores, competency-based assessments and promotion success rates, alongside qualitative feedback from trainees on relevance and practicality. These pilot findings will provide valuable evidence to refine interventions and guide larger-scale implementation across healthcare training institutions.

CONCLUSION

This study demonstrates how the integration of research tools and literature review can effectively diagnose organizational problems and guide evidence-based interventions. The use of SWOT, TOWS, Fishbone, Root Cause, and Risk Matrix analyses were able to identified underlying critical issues. The literature review further validated these findings by linking them to established theories and prior studies, while highlighting gaps that were not previously addressed. Together, these approaches enabled the development of targeted interventions. By combining diagnostic rigor with theoretical insights, this study contributes a practical framework for enhancing paramedic job performance and offers a replicable model for other healthcare institutions.

REFERENCES

1. Aung, Z. M., San Santoso, D., & Dodanwala, T. C. (2023). Effects of demotivational managerial practices on job satisfaction and job performance: Empirical evidence from Myanmar’s construction industry. Journal of Engineering and Technology Management, 67, 101730. https://doi.org/10.1016/j.jengtecman.2022.101730.
2. Bishop, J. (1992, December). The impact of academic competencies on wages, unemployment, and job performance. In Carnegie-Rochester Conference Series on Public Policy (Vol. 37, pp. 127-194). https://doi.org/10.1016/0167-2231(92)90006-5.
3. Chen, S., Huang, F., & Zeng, W. (2018). Comments on systematic methodologies of action research in the new millennium: A review of publications 2000–2014. Action research, 16(4), 341-360. https://doi.org/10.1177/1476750317691103
4. Coccia, Mario, The Fishbone Diagram to Identify, Systematize and Analyze the Sources of General Purpose Technologies (January 11, 2018). Journal of Social and Administrative Sciences, vol. 4, n. 4, pp. 291-303, Available at SSRN: https://ssrn.com/abstract=3100011.
5. Clark, V. L. P., & Creswell, J. W. (2015). Understanding Research A Consumer’ s Guide (2nd editio). Pearson Education Inc.
6. Dagnew Gebrehiwot, G., & Elantheraiyan, P. (2023). A study on the effect of training on employee performance in the case of Mekelle City, Tigray, Ethiopia. Social Sciences and Humanities Open, 8(1), 100567.  https://doi.org/10.1016/j.ssaho.2023.100567.
7. Emerson R. Social exchange theory. Ann Rev Sociol. 1976; 2:335-62. https://doi:10.1146/annurev.so.02.080176.002003.
8. Gatotrianto, B., & Nadirah, A. (2024). Determination of Motivation, Competence and Training on Employee Performance Throught Job Satisfaction. International Journal of Economics (IJEC), 3(1), 50-61. https://doi.org/10.55299/ijec.v3i1.504.
9. Groot, W. (2021). Root cause analysis – what do we know? Maandblad Voor Accountancy en Bedrijfseconomie, 95(1/2), 87-93. http://doi.org/10.5117/mab.95.60778.
10. Helms, M. M., & Nixon, J. (2010). Exploring SWOT analysis – where are we now? Journal of Strategy and Management, 3(3), 215-251. http://doi.org/10.1108/17554251011064837.
11. Hosen, S., Hamzah, S. R. A., Ismail, I. A., Alias, S. N., Abd Aziz, M. F., & Rahman, M. M. (2024). Training & development, career development, and organizational commitment as the predictor of work performance. Heliyon, 10(1). https://doi.org/10.1016/j.heliyon.2023.e23903.
12. Indrayani, I., Nurhatisyah, N., Damsar, D., & Wibisono, C. (2023). How does millennial employee job satisfaction affect performance? Higher Education, Skills and Work-Based Learning. https://doi.org/10.1108/HESWBL-01-2023-0004.
13. Iqbal, S. M., Leavitt, M. A., Pedilus, G., Mahgoub, I., & Asghar, W. (2024). A wearable telehealth system for the monitoring of parameters related to heart failure. Heliyon. https://doi.org/10.1016/j.heliyon.2024.e26841
14. Keltu, T. T. (2024). The effect of human resource development practice on employee performance with the mediating role of job satisfaction among Mizan Tepi University’s academic staff in Southwestern Ethiopia. Heliyon, 10(8). https://doi.org/10.1016/j.heliyon.2024.e29821.
15. Kovačević, N., Stojiljković, A., & Kovač, M. (2019). Application of the matrix approach in risk assessment. Operational Research in Engineering Sciences: Theory and Applications, 2(3), 55- 64. http://doi.org/10.31181/oresta1903055k.
16. Kovaçi, I., & Tahiri, A. (2024). The interconnection between training and job performance in hotel organizations. Calitatea, 25(199), 19-26. https://doi.org/10.47750/QAS/25.199.03.
17. Kumar, N., & Ali, R. (2024). A smart contract-based robotic surgery authentication system for healthcare using 6G-Tactile Internet. Computer Networks, 238, 110133. https://doi.org/10.1016/j.comnet.2023.110133.
18. Loftus, T. J., Filiberto, A. C., Upchurch Jr, G. R., Hall, D. J., Mira, J. C., Taylor, J., … & Sarosi Jr, G. A. (2021). Performance improvement with implementation of a surgical skills curriculum. Journal of Surgical Education, 78(2), 561-569. https://doi.org/10.1016/j.jsurg.2020.08.030.
19. Mallory, D. B. (2024). Participatory action research. In Elgar Encyclopedia of Organizational Psychology (pp. 468-474). Edward Elgar Publishing. https://doi.org/10.4337/9781803921761.00093
20. Mitchell, T. R., Holtom, B. C., Lee, T. W., Sablynski, C. J., & Erez, M. (2001). Why people stay: Using job embeddedness to predict voluntary turnover. Academy of management journal, 44(6), 1102-1121. https://doi.org/10.5465/3069391.
21. Mohd Nasurdin, A., Tan, C. L., & Naseer Khan, S. (2020). Can high performance work practices and satisfaction predict job performance? An examination of the Malaysian private health-care sector. International Journal of Quality and Service Sciences, 12(4), 521-540. https://doi.org/10.1108/IJQSS-06-2019-0090.
22. Mundinger, A., & Mundinger, C. (2024). Artificial Intelligence in Senology-Where Do We Stand and What Are the Future Horizons? European Journal of Breast Health, 20(2), 73. https://doi.org/10.4274%2Fejbh.galenos.2024.2023-12-13.
23. Namugenyi, C., Nimmagadda, S. L., & Reiners, T. (2019). Design of a SWOT analysis model and its evaluation in diverse digital business ecosystem contexts. Procedia Computer Science, 159, 1145-1154. https://doi.org/10.1016/j.procs.2019.09.283
24. Noor, N., Rehman, S., Ahmed, Y., Sarmad, M., & Mehmood, R. (2023). Discriminatory practices and poor job performance: A study of person-related hostility among nursing staff. Heliyon, 9(3). https://doi.org/10.1016/j.heliyon.2023.e14351.
25. Ohunakin, F., & Olugbade, O. A. (2022). Do employees’ perceived compensation system influence turnover intentions and job performance? The role of communication satisfaction as a moderator. Tourism Management Perspectives, 42, 100970. https://doi.org/10.1016/j.tmp.2022.100970.
26. Pacheco, P. O., & Coello-Montecel, D. (2023). Does psychological empowerment mediate the relationship between digital competencies and job performance? Computers in Human Behavior, 140, 107575. https://doi.org/10.1016/j.chb.2022.107575.
27. Prasetyo, D. E., & Arvitrida, N. I. (2025). Risk Analysis in The Implementation of Construction Projects Using Fault Tree Analysis and Risk Matrix. Asian Journal of Engineering, Social and Health, 4(5). https://doi.org/10.46799/ajesh.v4i5.616
28. Probosari, N., Ningsih, L. T., & Ardhanariswari, K. A. (2024). The Influence of Job Embeddedness and Employee Engagement on Job Performance Mediated by Organizational Citizenship Behavior (OCB) in Cilacap District Education and Culture Employees. Indonesian Interdisciplinary Journal of Sharia Economics (IIJSE), 7(1), 1187-1199. https://doi.org/10.31538/iijse.v7i1.3971.
29. Putzier, M., Khakzad, T., Dreischarf, M., Thun, S., Trautwein, F., & Taheri, N. (2024). Implementation of cloud computing in the German healthcare system. NPJ Digital Medicine, 7(1), 12. https://doi.org/10.1038/s41746-024-01000-03.
30. Sakdiyah, S. H., Eltivia, N., & Afandi, A. (2022). Root cause analysis using fishbone diagram: company management decision making. Journal of Applied Business, Taxation and Economics Research, 1(6), 566-576.
31. Soares Ito, A., Ylipää, T., Gullander, P., Bokrantz, J., & Skoogh, A. (2022). Prioritisation of root cause analysis in production disturbance management. International Journal of Quality & Reliability Management, 39(5), 1133-1150. https://doi.org/10.1108/IJQRM-12-2020-0402
32. Somuah Claudia Omari. O., Mensah, H. K., & Gyimah, P. (2024). Training practices and job performance in public universities: leveraging on self-efficacy and organizational politics. Cogent Business & Management, 11(1), 2328309. https://doi.org/10.1080/23311975.2024.2328309.
33. The Matrix Method for Literature Reviews. (2020). Brandeis University. Retrieved July 19, 2024, from https://www.brandeis.edu/writing-program/resources/faculty/handouts/matrix-method-literature-reviews.html#:~:text=What%20is%20the%20Matrix%20Method,articles%20about%20a%20research%20topic.
34. Theories and Frameworks: Introduction. (2024). Walden University. Retrieved July 20, 2024, from https://academicguides.waldenu.edu/library/theory.
35. Xiong, X., Braun, S., Stitzer, M., Luderer, H., Shafai, G., Hare, B., … & Maricich, Y. (2023). Evaluation of real‐world outcomes associated with use of a prescription digital therapeutic to treat substance use disorders. The American Journal on Addictions, 32(1), 24-31. https://doi.org/10.1111/ajad.13346.
36. Weihrich, H. (1982). The TOWS matrix. A tool for situational analysis. Long range planning, 15(2), 54-66. https://doi.org/10.1016/0024-6301(82)90120-0
37. Wiyanto, J., Ratnaningsih, D. J., & Suratini, S. (2024). Self-efficacy, career development, and work engagement on employee performance: Evidence from aviation sector organizations. Journal of Enterprise and Development (JED), 6(1), 223-236. https://doi.org/10.20414/jed.v6i1.9395.