Professional Identity Formation of Paramedic Trainees in the German Vocational Education and Training System: A Mixed-Methods Study

Background: Professional identity formation (PIF) helps paramedics understand their role, purpose, and values, and it supports resilience in challenging work environments. NotSan trainees (German paramedic trainees) learn how to become paramedics within a dual vocational education and training (VET) system. NotSan currently face specific challenges when forming their professional identity (PI) within this system, including academisation, an expanding scope of practice, and a profession extending beyond traditional prehospital emergency care roles. Purpose: The study examined PIF among NotSan trainees in Germany. It aimed to describe trainees' self-reported PI, identify training factors influencing its formation, and explore how education providers can better support PIF. Methods: A sequential explanatory mixed-methods design was used. An online survey of NotSan trainees (n = 377) included demographic questions and a German version of the Macleod Clark Professional Identity Scale (MCPIS-9). Quantitative analysis included descriptive statistics, internal consistency, ANOVA, and Pearson's correlation coefficient. Semi-structured hermeneutic phenomenological interviews (n = 15) explored trainees' lived experience of PIF. Reflexive thematic analysis was conducted, and integration of data was guided by Role Identity Theory and the Mixed Methods Reporting in Rehabilitation & Health Sciences (MMR-RHS) checklist. Results: Participants reported strong PI scores (mean MCPIS-9 of 38.13/45, SD = 4.5; range 18‒ 45; Cronbach's α = 0.795). There was a significant association between higher MCPIS-9 scores and longer planned employment in EMS (F(5,371) = 12.264, p < 0.001, ω² = 0.130). Interview participants described a strong growth mindset and emphasised that ambulance placements support PIF, while hospital placements often create confusion and role conflict. Trainees valued supportive mentors on ambulances but frequently reported a lack of guidance and understanding of the NotSan role in hospitals. Conclusion: The German VET system appears to support PIF among NotSan trainees. Ambulance placements offer opportunities for identity verification. However, poorly structured hospital placements can undermine developing professional identities. NotSan schools should strengthen cooperation with hospitals, ensure adequate clinical instructor support, and explicitly teach non-clinical skills and growth mindset. These findings provide baseline data for future research during an important period of educational and professional transition in German EMS.