The use of lecturer practitioners in the education of paramedics stemmed from the move from in-house apprenticeship style models of training to that of higher education (Bradley, 2005), and broadly follows the nursing model. Bradley (2005) also suggested that there was the potential to share tutors between the ambulance service and the higher education institutions.
The role of the lecturer practitioner
Several studies identify lack of clarity of purpose for the lecturer practitioner role (Fairbrother and Mathers, 2004; Williamson, 2004; Williamson et al, 2004; Hancock et al, 2007) and this in itself causes difficulties in defining it. Hancock et al (2007) suggests that the lecturer practitioner role was developed to include clinical teaching and support for students in practice. Redwood et al (2002) concluded that the role of the lecturer practitioner is to help bridge the theory to practice gap and address any conflict between classroom teaching and clinical placements. Henderson et al (2006) would agree with Redwood et al (2002), but also adds that mentors need support.
Furber (2008) suggests that the lecturer provides a visible link in the workplace between the higher education institutions and the ambulance service.
Current successes and challenges
Work by Driver and Campbell (2000) appeared to show that lecturer practitioners were considered by students to have a more realistic approach in their teaching, in particular when linking theory and practice. Richardson and Turnock (2003) found that generally the removal of the lecturer practitioner would have a negative impact on student's practice and patient care. Hartigan et al (2009) believes lecturer practitioners to be very effective at assisting both students and registered nurses in integrating theory into practice. Redwood et al (2002) contends that because the role of the lecturer practitioner is ill-defined and role variation exists between various geographical locations it is difficult to evaluate the effectiveness of the role.
Challenges facing the lecturer practitioner
Williamson et al (2004) identified role clarity as a concern amongst lecturer practitioners. Part of the problem seemed to be managers not agreeing exactly what was required of the lecturer practitioner.
Maintenance of clinical standing was also identified by Williamson (2004) as a concern amongst lecturer practitioners. Ramage (2004) explains that the lecturer practitioner needs to demonstrate that they have skills and attributes in common with the group with which they are working.
McCall et al (2009) point out that as students are paying for education, they expect a high standard of placement. In a study by Aston et al (2000) students expressed a desire to see a higher priority given to their support in practice. In particular, it was identified that providing a liaison between the practice staff and the universities was essential.
Fairbrother and Mathers (2004: 541) identified four challenges to the lecturer practitioner from their research, ‘Living a dual role, academic culture, professional practice, and combining cultures.’
The ‘dual role’ related to the lecturer practitioners perceived need to serve both the higher education institute and the employing agency equally. In most cases the lecturer practitioners felt it was almost impossible to achieve.
‘Academic culture’ related to an expectation by universities that the lecturer practitioner would produce some form of academic research regardless of the time spent in practice.
‘Professional practice’ related to the importance the lecturer practitioner attached to their clinical practice. The lecturer practitioners saw their practice as giving them credibility in both the workplace and the teaching environment. This is supported by Hancock et al (2007), Jowett and McMullan (2007).
The final theme ‘combining cultures’ is perhaps the most interesting and problematic of the four themes. Ramage (2004) believes that acceptance in the clinical environment depended on the approach adopted by the individual lecturer practitioner. Maintaining clinical credibility by creating a balance between practice and teaching was seen as important by several authors (Fairbrother and Mathers, 2004; Ramage, 2004; Carnwell et al, 2007; Jowett and McMullan, 2007) However, due to conflicting demands on the lecturer practitioner's time, this was not always achievable.
Williamson and Webb (2001) and Williamson et al (2004) identified conflicting responsibilities and role overload as difficulties encountered in the practice environment. Aston et al (2000) highlighted the logistical difficulties of the lecturer practitioner visiting practice placement areas and specifically students in these areas.
Driver and Campbell (2000) and Hancock et al (2007) believe that being managed by both a higher educational institute and the employing authority means that the lecturer practitioner has to serve two masters. This conflict according to Fairbrother and Mathers (2004) is not uncommon amongst lecture practitioners in many professions. Hancock et al (2007) expand on this concept by adding that without support and clear direction for the role there is a danger that neither the education nor practice elements of the lecturer practitioner would be effective.
‘A need for change is essential if the lecturer practitioner role is to be successful within the ambulance service’
Ramage (2004) believes there is a conflict between the teaching role and professional practice role of the lecturer practitioner. She identified that the lecturer practitioner may witness poor practice from practice placement staff when with students, and thus be obliged to challenge it. The manner in which this challenge is accomplished is crucial and relies on good relations with the nursing staff. There is a fine balance between conforming and informing practice that is crucial in the role of the lecturer practitioner. Those lecturers who had prior knowledge of the clinical role and attempted to fit into the group by actively participating in all aspects of nursing by helping the qualified staff as well as students, seemed to fit in better than those who remained more aloof. This phenomenon was not wasted on Bradley (2005) when he suggested that paramedic education should be in the main delivered by paramedics.
Evaluation of future strategies
A need for change is essential if the lecturer practitioner role is to be successful within the ambulance service. Managers in both academia and the employing organisations will need to work together with the lecturer practitioner and support this role (Hancock et al, 2007). Carnwell et al (2007) and Williamson et al (2004) believe that regular meetings between universities and the practice placement providers helped improve communications between the two organisations.
Time in practice to attain and retain credibility is advocated by several authors (Redwood et al, 2002; Fairbrother and Mathers, 2004; Carnwell et al, 2007; Hancock et al, 2007; Hartigan et al, 2009). No quantifiable definition of the length of time needed in clinical practice could be found within the literature reviewed, making it impossible to know when this criterion was met.
Bradley (2005) believes that clinical supervisors should ultimately hold a degree level qualification. Time set aside to assist in the academic development of the lecturer practitioner in the form of study leave may assist in achieving this aim. However, it should also be borne in mind that paramedics must also take on responsibility for their own professional development (Health and Care Professions Council, 2000) and this may include paying to attend courses and seminars themselves.
‘It is essential if students have been identified as failing that they are supported in practice’
Whilst the literature presents the dichotomy of serving two organisations simultaneously with differing priorities as a problem for the lecturer practitioner (Fairbrother and Mathers, 2004; Hancock et al, 2007) there was little by way of resolution.
Support for newly qualified students in practice was a role identified by Dearmun (2000) that currently seems not to have been addressed. McCall et al (2009) identified reduced clinical contact time with patients as a significant difference between university-educated paramedics and the apprenticeship style of training. McCall et al (2009) believe that this reduction in clinical hours is significant as there is a reduced opportunity for experiential learning to take place. It is the author's contention that the lecturer practitioner could aid the transition between education and practice by supporting these newly qualified staff in the workplace. As the lecturer practitioner has a presence in the workplace, they are easily accessible and would be familiar to the new staff. Furber (2008) suggests that newly qualified paramedics should not work alone for a period of 150 hours following employment, nor should they be expected to have responsibility for new staff for the first 12 months post registration. Dearmun (2000) suggests that nurses experience a three month period of heightened anxiety following commencement of independent clinical practice. During these early stages in a paramedic's career the lecturer practitioner should be available to these staff for pastoral as well as clinical advice.
Carnwell et al (2007) suggested that the lecturer practitioner alone cannot close the theory to practice gap and sees the lecturer practitioner as one of a variety of significant positions such as mentors and link tutors that are necessary to address this problem. Hunt et al (2011) support this contention and established that there is a 5:1 ratio of fails in theory compared to practice amongst nursing students. It is essential if students have been identified as failing that they are supported in practice. Mentors should also be supported not only in writing action plans and developing student confidence but also educated about the process of failing students. Hunt et al (2011) highlighted that mentors believed that the universities would not take them seriously and overturn any failure decision they may make. As part of the lecturer practitioner's role, support for the mentors was seen as a way of preventing such a situation happening. Indeed, Carnwell et al (2007) suggests that the lecturer practitioner is in an ideal position to offer support to mentors. McCall et al (2009) identifies supervising clinicians as perhaps being concerned by their own perceived lack of clinical knowledge. Development of mentors perhaps to diploma level may assist in dispelling this perception and in closing the practice to theory gap. Watkins (2000) would support this notion from within nursing as she identified elements of poor practice from research in the 1960s and 1970s, where students were imitating outdated practices they had seen in operation but, without the critical analysis skills afforded them by higher education, were not questioning their validity. It is for this reason that the resources of the lecturer practitioner should be focused on the mentors first, then the students. In supporting the mentors the students would also be supported indirectly by the lecturer practitioner.
The inclusion of mentors in, for example, scenario days and student assessments at university, may also assist mentors to appreciate the academic expectations of the university.
Discussion
Both Hancock et al (2007) and Carnwell at al (2007) suggest that the fact that the lecturer practitioner is supernumerary and able to concentrate on the student's development without having the pressure of clinical demands, allows for greater analysis of the student's clinical practice. However, logistically this is a problem for the ambulance service in that mentors operate either as part of a double-manned ambulance crew or as a solo responder in a car with the student being supernumerary. The alternative might be for the mentor and student to form a crew, with the lecturer practitioner remaining supernumerary. This also could be problematic as it would mean that the student would be in the rear of the ambulance treating the patient and the lecturer practitioner would be forced to take on a clinical supervision role, as students may not have clinical responsibility for the patient under some circumstances. The issue of paramedic lecturer practitioners being supernumerary remains a problem. The creation of hubs, whilst controversial, may assist in allowing greater contact between students, lecturer practitioners and mentors. Advantages to this model include the lecturer practitioners having a higher possibility of seeing more students or mentors there than if they were distributed over a larger area. If teaching or revision sessions were needed, the lecturer practitioner's time could be maximised due to the higher probability of students and mentors being in attendance. Aston et al (2000) may give support to this notion as they highlight travelling time to reach placements as a constraining factor on the lecturer practitioner's value. Another advantage would be that students would have the security of being with other students.
Continued development of mentors is also vital in supporting students in practice. Ramage (2004) suggests that the students develop more supportive relationships with mentors than with teachers.
Rowe (2008) believes that it is important to produce a clear definition of the role of practice educator in order to be able to evaluate the role. He believes that by producing a clear definition the practice educator could be supported by the employer.
The lecturer practitioner could be used as the ‘research interpreter’ in such instances as suggested by Thompson et al (2001). They have academic credibility and work in the practice setting (Carson and Carnwell, 2007). As such, they could develop and/or deliver occasional teaching and learning sessions to ambulance service personnel and students alike. A case in point would have been the Mental Capacity Act 2005 (c.9). Ramage (2004) states that evidence from her study suggests that a lecturer practitioner would take around four years to build up the necessary educational presence needed in clinical practice to be accepted by clinical colleagues. However, Fairbrother and Mathers (2004) identified the role of lecturer practitioner as being seen as developmental in nature and thus the four years spent building up a clinical presence would be lost if the lecturer practitioner either returned to clinical practice or became a full-time lecturer.
Reacting to information from mentors regarding student practices is an important part of the lecturer practitioner role (Furber, 2008). Students are reluctant to self-identify problems and when problems are identified mentors need to be supported through the process of what to do about a failing student (Hunt et al, 2011). Hunt et al (2011) also accept that some mentors believe that any decision made by them would be overturned by the university. However, the author believes that by giving mentors an appreciation of the processes involved in failing a student, this perception may be dispelled and make the process more robust against potential challenges from students who do fail.
Further mentor development may be achieved by updating at conferences, electronic updates, visits in practice and higher education courses such as diploma, degree and masters qualifications. Owing to the peripatetic and unpredictable nature of ambulance work, the lecturer practitioner may not be able to meet students or mentors at stations at specific times or be sure of their case load, thereby wasting time. One option might be for lecturer practitioners to meet the students and/or mentors on station before the shift commences, and work a full shift with the student. However, as highlighted by Carson and Carnwell (2007) and Williamson et al (2004), lack of time in practice is one of the problems already encountered by hospital lecturer practitioners, where it could be argued that logistical planning would seem to be less complex compared to paramedic education. It is unrealistic to expect every student to experience a shift with the lecturer practitioner. However, where mentors or students have identified problems in practice and working a shift with the student is deemed necessary, then the lecturer practitioner should demonstrate their support of both mentor and student by accommodating any request where possible. Working a shift would, however, allow the lecturer practitioner to observe the practices of mentors as well as students and offer assistance in a timely and appropriate manner to both parties.
Conclusions
The lecture practitioner is a viable model for the ambulance service to follow in the education of student paramedics and may also play a role in post-registration education. However, although some transferability from nursing practice exists, due to the logistical diversity of the ambulance service the wholesale transfer of the role without modification may not be wise. The author feels that the core focus of the lecturer practitioner should be the student's development. However, according to Caplin-Davies (2001), it seems almost impossible to devote the time needed to support the individual students directly and also manage the other tasks demanded by the role. In addition to this, the practicalities of directly supervising paramedic students in practice, as outlined in this review, make this less of a reality. This mismatch of expectations should be managed by the lecturer practitioner in conjunction with the placement provider. The lecturer practitioner should be responsible for ensuring students and mentors are aware of each other's role and responsibilities through education of both parties.
As students currently spend far more time in practice with mentors than they do with lecturer practitioners, it would seem logical to develop the mentor's skills with the help of the lecturer practitioner. The fact that higher education for the paramedic profession is a relatively new concept means that there are currently relatively few mentors who have a clear understanding of the process. Based on the precept that people cannot teach what they do not know, the author feels that opportunities for mentors to be involved with student's education should be offered to them. In the future, when university-educated paramedics begin to become mentors and current mentors are developed, it may follow that the paramedic lecturer practitioner may be able to revert back to a more directly student-centred role.