Human factors in student paramedic practice

Case description

An experienced band 6 paramedic and a final year student paramedic were called to a 64–year-old man with chest pain. On arrival, the patient said he had been trying to contact his doctor's surgery to obtain a repeat prescription and to discuss his mental health issues as a result of a recent bereavement but had been transferred to the out-of-hours service. He said he had experienced central chest pain approximately 20 minutes before the crew arrived. A 12–lead electrocardiogram (ECG) was conducted alongside some observations (Table 1). The ECG showed a normal sinus rhythm with no signs indicating arrhythmia, ischaemia, infarction or pulmonary embolism.

The patient began to call his doctor while the crew was in the room; he said he did not expect an ambulance crew but just wanted an appointment with the doctor. He was successful in obtaining an appointment within the hour. When asked, he said his chest pain had eased and he did not want any further assistance from the crew.

The patient was told to tell his doctor about the crew attending, as well as the chest pain and his worsening mental health.

Student's perspective

Despite having a good relationship with the mentor supervising them that day, the student has worked with this mentor only once previously. On that occasion, the mentor questioned the student in front of a patient, which made them feel uncomfortable. The student may therefore have already felt nervous about having this mentor supervise them again. They may also have had trouble sleeping the night before so also felt fatigued. Additionally, this patient's history was not obvious and he was not talking clearly so it was hard to decipher events, but the student believed that the patient looked reasonably well.

On returning to the vehicle, the mentor questioned the student about why the patient might have had confusion and chest pain, and the student only then considered an organic cause such as a chest infection. They then realised that they had not auscultated or taken the patient's temperature, and felt mortified as they would normally have had no issues in recognising the need for and conducting these tasks. The mentor did not seem angry but appeared disappointed as they knew the student's standard of practice.

Equally, it is important to the student that mentors and peers see them in a positive light and they feared this may have dented their reputation. They might also have been asking themselves why the mentor did not say anything while with the patient, given they had done this on a previous occasion.

Mentor's perspective

While conducting their assessment, the student omitted several aspects of a satisfactory physical assessment including auscultation, taking the temperature and measuring blood sugar. This was unusual for this student, who had previously demonstrated a high level of competence.

This paramedic is experienced and used intuition to deduce that the patient's symptoms were caused by psychosocial issues and did not feel the need to intervene. In general, the mentor enjoyed working with students and this student was hardworking and easy to work with. Although this paramedic had completed a day course on mentorship, they did not always feel comfortable or confident when mentoring students and felt unsure about how to manage them effectively. The paramedic delayed raising their concerns until back in the vehicle as they noticed the student appeared anxious and did not want to make this anxiety worse.

Evaluation of the scenario

Although this was neither a complicated medical scenario nor an intense interpersonal situation, it raises some important points regarding the effects mentors can have on student performance and issues mentors themselves face when managing students. While the relationship between a student and mentor is a human factor in itself, numerous other human factors are highlighted in this scenario (Table 2).

From the perspective of current guidelines, an electrocardiogram (ECG) was conducted on arrival (National Institute for Health and Care Excellence (NICE), 2016; Joint Royal Colleges Ambulance Liaison Committee, 2016). However, after ruling out cardiac causes such as ST-elevation myocardial infarction, the student froze with their assessment and did not consider other causes. They did not conduct a full set of observations, including temperature, blood sugar and auscultation of the chest. Auscultation would be necessary to rule out numerous conditions such as pulmonary oedema, pneumonia and pleurisy (Lane and Rouse, 2011). Although the patient did not have diabetes, a raised blood sugar level is an indicator of sepsis alongside confusion, an elevated temperature and a source of infection (The UK Sepsis Trust, 2017).

At the time, all other observations and history were pointing towards a psychosomatic cause, but additional observations would have confirmed this.

Although the patient ultimately refused further care and received a rapid assessment by a doctor within the hour, the student may have reacted hastily and did not try to fully work out the patient's situation. This could have been detrimental to the patient's outcome. However, the supervising paramedic did not intervene with the assessment and, from previous experience with this paramedic, the student may have interpreted this as the mentor not being overly concerned. Instead, the supervisor waited until afterwards to mention their concerns. The student may not have felt confident enough with this clinician to ask if they had missed anything and feared this would come across as a failing in itself.

Many of the issues encountered by both student and mentor are attributable to human factors. Human factors in the prehospital setting are described by Summers and Willis (2010) as:

Summers and Willis (2010) were among the first researchers to discuss human factors in the paramedic profession specifically. They refer to the work of Grogan et al (2004), who discuss the ‘transfer of awareness of crew resource management’ (CRM) from the aviation industry into health care. CRM training involves becoming aware of human factors and how they can cause an error (Grogan et al, 2004). Examples of human factors that affected this scenario appear in Table 2.

Analysis and discussion

On this occasion, it was not necessarily a lack of knowledge of what was expected that hindered the student's assessment of this patient but the human factors discussed in Table 2. Many of these can affect both pre and postregistration practice; however, the relationship between the student and their supervising paramedic is unique to the realm of mentoring students.

Human factors relating specifically to the student paramedic role have not been studied in depth. Stressors relating to a student paramedic's academic life have been investigated (Ambrose, 2014; Caffey et al, 2016) but factors affecting practice placements have scarcely been examined.

Training to become a paramedic includes undertaking higher education as well as a placement aspect in a highly emotive environment. This requires students to develop a high level of emotional intelligence to deal with both the public and their own emotional wellbeing; this can be a major task, especially for those who go directly into training from school.

Williams (2013a; 2013b; 2015) discusses the awareness of emotional work related to the job and how students deal with emotional stress. These are useful pilot studies into the emotional aspect of paramedic training and highlight the importance of including training on coping mechanisms in paramedic education.

Kennedy et al (2015) investigated the transition from student to graduate paramedic and identified struggles that are analogous to this case, including meeting expectations, stress management, a determination to be accepted and respected, and the discrepancy between theory and practice. With the development of the newly qualified paramedic (NQP) role in the UK and its emphasis on encouraging a better transition, it would be beneficial to begin tackling these topics during training.

Coping mechanisms in qualified paramedics were discussed by Clompus and Albarren (2016) and these mirrored those used by students in the early days of their student placement (Williams, 2013a; 2013b). This includes the importance of having a good support network at home and within the workplace, which further highlights the importance of positive colleague interactions on performance.

Anecdotal evidence suggests student paramedics have little contact with their designated mentor and are often with different clinicians on each shift whom they may have never worked with before. Students may feel they have to start from the beginning each time they work with a new practitioner and develop different working styles as they respond to each clinician's teaching styles or practice.

Ryan and Halliwell (2013) discuss mentor-student relationships in paramedic practice between those who have gone through different training programmes, and when this causes conflicts that arise from variations in assessment styles and decision-making. Examples from mentoring preregistration teachers show that co-teaching—equivalent to sharing the attending role—benefits both student and mentor by acting as a ‘catalyst for change’ for both parties (Gallo-Fox and Scantlebury, 2016).

Another example, from Bradbury and Koballa (2008), reflects on a relationship between a specific paramedic mentor and student, and the tensions that arose between them. Tension was a common theme and was caused by poor communication of expectations of the role and of the mentorship relationship. In this case study, neither the student nor the paramedic discussed what they wanted or expected from the other before or during the shift, showing that their communication was poor.

Students are frequently expected to attend the whole shift as it is seen as an opportunity to practise skills; however, this may contribute to stress and fatigue, which may prevent the student from actually seeing how the supervising paramedic practises and learning from their techniques.

Croskerry (2005) states that when a clinician is stressed, they are more likely to reach intuitive decisions than make them from an analytical viewpoint. Intuition may not be a common decision-making style in a student (Dreyfus, 2004); however, chest pain is the reason for 9% of ambulance calls and is one of the four major conditions that require ambulance attendance (Department of Health and Social Care (DHSC), 2009). Therefore, intuition may play a part in student assessments of chest pain as a result of frequent exposure.

In addition, clinicians are more likely to make rash decisions or take too long to make a decision when they feel stressed (Croskerry, 2005).

Negative experiences with clinicians can still be used by students as a learning experience concerning what not to do in their future practice.

A personality clash with a frequent mentor may hinder a student's progress as they lose self-confidence. In contrast, if there is a good relationship, this could improve the student's learning experience; the development of a friendship is often considered an important factor in a positive mentorship experience in other fields (Bradbury and Koballa, 2008; Jokeleinen et al, 2011). The nursing profession tends to act as a precursor to changes within paramedic practice and, in 2017, the Royal College of Nursing (RCN) congress debated the issue of tensions between students and mentors (Jones-Berry, 2017).

Previously, Wilkes (2006) highlighted the complicated aspects of student-mentor interactions in nursing education and how they can influence the experience of both parties. Students rank a mentor with a nurturing personality higher than one who may be more qualified for the role; however, nurturing a positive relationship with a student can make the role of mentor difficult when it comes to critiquing and honestly assessing failing students (Wilkes, 2006).

Jokeleinen et al (2011) discuss how the 1:1 ratio of students per mentor has a positive effect on developing a good relationship in nursing education but this may not be possible during placements (Bradbury and Koballa, 2006). Despite the appeal of having a 1:1 student:clinician ratio in paramedic practice, it is not practical because of the shortage of clinicians and the student would not be exposed to different styles of practice; in addition, there is no guarantee a personality clash would not occur further down the line. Even when mentors are paired with students using personality matching, conflicts can still arise (Bradbury and Koballa, 2008). Perhaps by having several mentors, there is a greater possibility of the student developing a positive relationship with at least one to provide them with emotional support.

Not all paramedics go through the same degree of training in mentorship but mentoring students is a compulsory component of the band 6 paramedic role in the UK (NHS Employers, 2017). In the nursing environment, additional teaching qualifications have not always correlated with better mentors (Wilkes, 2006). However, many nursing mentors feel unprepared and overburdened for the role of mentor and feel they would benefit from more support (Wilkes, 2006).

This is mirrored by the findings of Bradbury and Koballa (2008) on teacher training, where increased support from the university and from other mentors was perceived to be beneficial.

Students also need to find means of coping with difficulties they face in practice, whether these concern stress or personality clashes, which could be through self-help or increased support from educators (Williams, 2013b).

Conclusion and recommendations

Human factors are often specific to the individual and what affects one person may not hinder another. Relationships between students and mentors also vary greatly, resulting in vastly different experiences. Understanding what factors affect an individual and learning how to accept and counteract them will aid any clinician's practice. Although this was a clinically simple case, it highlighted non-clinical issues within paramedic practice and training. Demands on paramedic students are high and, equally, there is a gap in mentorship training for those supervising them in the placement environment.

Adaptations could be made to the way students are treated on placement to aid learning and emotional wellbeing. For example, ensuring that there are opportunities for students to both observe and attend on shift, especially when working with a new clinician, can help both parties learn from each other. Increasing the level of communication between mentors and students seems to be paramount in ensuring the best learning and mentoring experience by making both student and clinician aware of each others' expectations (Bradbury and Koballa, 2008; Jokelainen, 2011).

Student paramedic training and NQP preceptorship would benefit if openness about emotional struggles were encouraged, and from employers providing increased emotional support during the transition to qualifying; for example by setting up a buddy system. This may result in a healthier approach to mental wellbeing post registration; and greater emotional support during this transition may also aid staff retention (Jokelainen, 2011).

The official mentor role varies between ambulance trusts and further investigation is required to determine which method is the most favourable. Although a 1:1 ratio of student per clinician akin to nursing education is appealing, it is not feasible.

Anecdotally, there is not enough interaction between students and their designated mentors in paramedic practice and mentors can struggle to balance providing criticism with developing a positive relationship with the student.

Providing students with a designated mentor for emotional support, and management of the placement period as well as a group of band 6 paramedics with whom they regularly work to act as clinical assessors may address conflicts with mentors. Working with a familiar group of paramedics will allow each clinician to become familiar with the student's abilities, enabling the student to develop more quickly; it may also mean that at least one positive relationship can form, allowing for emotional support even if this is not with the designated mentor. Ultimately, increasing the number of willing mentors will address the lack of communication that students currently experience.

Although mentoring students is compulsory in the band 6 paramedic role, many may not be willing to take this on. Those who do become mentors require more preparation for the role. In addition, band 6 paramedics who have students should be prepared to encourage cooperative learning by sharing the attending role where possible. Paramedics are not trained to teach; therefore, providing standardised mentorship training requirements that focus on how to overcome tensions that may arise as well as teaching styles may improve the learning experience. Additionally, setting up support networks with other mentors and higher education institutions will help clinicians new to mentoring feel more confident when dealing with complex scenarios. The extent to which these human factors can be overcome by the individual will be limited, and much of the change may need to come from policy regarding managing students because of staff shortages.

Both students and paramedics would benefit from reflecting on their current communication regarding their expectations from the placement period. Further investigation into techniques used in student and mentor training, nationally and internationally, and what is considered effective would allow for improvement in the overall student paramedic experience and aid a successful transition into the realm of postregistration.

Key points

CPD Reflection Questions