Paramedics rely heavily on their communication and listening skills. These skills are drawn on before they arrive at the scene, during patient management, and finish with the patient handover at definitive care, often the emergency department. During this time, a paramedic will potentially have to communicate with a range of people: patients, family, general public, other emergency services, media, and other health professions in what can be emotionally charged situations. Communication and listening skills are essential to ascertain the nature of a patient's presenting problem, gain control of the situation, and ensure that the necessary information is passed on when handing over to the next level of care.
To our knowledge, very little research has been undertaken in the examination of communication (verbal or written) and listening styles of paramedic students and those employed in the field. Two studies that have been undertaken reported that communication between paramedics and staff in the hospital emergency department are not as effective as it ideally should be. For example, lack of a structured approach, lack of a ‘common language’, and the difficulty paramedics have in making medical and nursing staff understand what the incident scene was like, have been identified as communication issues (Scott et al, 2003; Owen et al, 2009).
Responsibility for such breakdowns in communication does not rest entirely with the paramedics—however, every effort should be made to ensure that paramedics communicate and listen appropriately, particularly when involving the care of patients. Listening and communication (verbal and written) are cornerstone skills of being an effective paramedic, therefore, there is a need to identify if current undergraduate paramedic students have the appropriate attributes to ensure they are effective listeners and communicators, both verbal and written, and whether additional, or specific elements need to be added to the paramedic curriculum.
The listening styles profle
The listening styles profile (LSP) has been used widely as a standardized measure (Watson et al, 1995). The LSP was originally administered to young adults in the US (Watson et al, 1995). The LSP measures four listening styles: people, action, content and time. It has been found that most people adopt a preference for a particular combination of listening styles. This is important because a person's listening style tends to be a function of habit, rather than a considered use of the most appropriate style for the situation (Watson et al, 1995).
Accordingly, the LSP will give an indication of how students will listen when on the job. The people style is characterized by an awareness and concern for the feelings of others. The action style is characterized by a desire for precise, error-free presentations and frustration with disorganized presentations. The content listening style is adopted by those who like to consider facts and details closely. Finally, the time style is adopted by those who are conscious of the time while listening and often prefer brief and hurried interactions (Watson et al, 1995).
Communication style measure
Considering communication more broadly, the students’ preferred styles of communication were measured using the communication styles measure (CSM). Again, this is a widely used standardized instrument (Norton, 1978). The CSM was originally administered to first-year undergraduate students at one American university (Norton, 1978), but has been used by other researchers investigating the communication styles of physicians and nurses. The CSM measures ten different communication styles, which Norton (1978) describes as ‘the way one verbally and paraverbally interacts to signal how literal meaning should be taken, interpreted, filtered, or understood’.
The dominate communicator style is characterized by a desire to take control of conversations. ‘Dramatic’ involves exaggerating, understating and otherwise stylizing a conversation. ‘Contentious’ is characterized by being argumentative. The ‘animated style involves using many non-verbal, physical cues, such as hand gestures or nodding. The ‘attentive’ style involves letting the conversation partner know that he/she is being listened to. ‘Impression’ leaving is a memorable style of communication. ‘Relaxed’ is characterized by a lack of anxiety when communicating. ‘Open’ is characterized by being affable, unreserved, extraverted and approachable. Friendly ranges from not being hostile through to deep intimacy. Finally, ‘precise’ involves a focus on accuracy and detail in conversations.
Investigating the communication and listening style preferences of student paramedics is therefore timely. The objective of this study was to identify the listening and communication style preferences of undergraduate paramedic students at a major Australian university.
Method
Design
A cross-sectional study using a paper-based version of the listening styles profile (LSP) and the communication style measure (CSM) were administered to a cohort of undergraduate paramedic students.
Participants
Students enrolled in any year of the Bachelor of emergency health (paramedic) at Monash University were eligible to participate. There were no specific exclusion criteria. For the total number of students enrolled in each year of the course and the total number for each gender, refer to Table 1.
| Course number students | Emergency health (paramedic) |
|---|---|
| Year 1 (females) | 55(36) |
| Year 2 (females) | 80(52) |
| Year 3 (females) | 62(41) |
| Total number of students enrolled | 197 |
| Total number of female students | 129 |
| Total male | 68 |
Instrumentation
The listening styles profile (LSP) is an instrument designed to assess four styles of listening: people, action, content and time (Watson et al, 1995). It consists of 16 items rated on a 5-point Likert scale (0=Never, 1=Infrequently, 2=Sometimes, 3=Frequently, 4=Always). The higher the reported score, the higher the participant's preference for that style. The instrument has a sufficient internal consistency as measured by Cronbach's alpha for each of the four constructs: people (a=0.563), action (a=0.660), content (a=0.578) and time (a=0.674). These alphas are below the commonly accepted level of 0.80; however, as each construct consists of only four items, this is considered a good internal consistency and is similar to that reported in other studies (Watson et al, 1995; Bodie and Villaume, 2003; Worthington, 2008). Furthermore, in a test-retest the LSP was found to be stable over a two-week period (Watson et al, 1995).
The communicator style measure (CSM) is an instrument designed to assess ten styles of communication and a person's perception of his/ her communication ability (Norton, 1978). The instrument consists of 51 items; however, once the filler items and items related to communication image (ten items), which are not relevant to this study, are set aside, each communication construct consists of four items which are rated on a 5-point Likert scale (YES=5, yes=4, ?=3, no=2, NO=1), of which three items were reversed for analysis. The constructs derived from the CSM have scores ranging from 4 to 20, with higher scores indicating a stronger preference for that communication style.
The CSM has sufficient internal consistency as measured by Cronbach's alpha for each construct: friendly (α=0.654), impression leaving (α=0.762), relaxed (α=0.775), contentious (α=0.667), attentive (α=0.498), precise (α=0.467), animated (α=0.651), dramatic (α=0.652), open (α=0.708) and dominate (α=0.742). As with the LSP, each construct in the CSM consists of four items and consequently alphas below the commonly accepted level of 0.80 are acceptable. Other studies to use the CSM have reported similar levels of internal consistency (Graham, 2004).
Procedures
At the conclusion of a lecture, students were invited to participate in the study. Students were provided with an explanatory statement and were informed that participation was voluntary and anonymous. A non-teaching member of staff facilitated the process and students were administered a questionnaire containing the LSP, CSM and a brief set of demographic questions. The questionnaire took approximately 10 minutes to complete and consent was implied by completion and return of the questionnaire.
Data analysis
Descriptive and inferential data analysis was undertaken using SPSS (Statistical Package for the Social Sciences Version 17.0, SPSS Inc, Chicago, Illinois, USA). Descriptive statistics, means and standard deviations, were used to summarize the demographic and some LSP and CSM data. Inferential statistics, T-test and analysis of variance (ANOVA), including post-hoc tests, were used to compare the difference between courses, age groups, gender, and year of the course. All tests were two tailed unless otherwise stated, with the results considered statistically significance if the P value is < 0.05.
Ethics
Ethics approval was obtained from the Monash University Standing Committee on Ethics in Research Involving Humans (SCERH).
Results
Demographics
A total of 114 students participated in this study, 57.9% were enrolled students. Students enrolled in first year (n=52), second year (n=39), and third year (n=23) provided an adequate coverage of students across the duration of the course for statistical analysis. Approximately two-thirds of the students were female (67.5%) and the ages of students were predominately under 21 years of age (40.4%) or between 21 and 25 years of age (38.6%). These results are consistent with the actual demographic profile of students enrolled in the Bachelor of emergency health (paramedic) and hence provide a reasonable sample from which to draw inferences.
Listening styles
As is shown in Table 2, preference among students overall was for the people listening style (3.29 out of a maximum of 4.00). This was followed by a moderate preference for the content style (2.45 out of a maximum of 4.00). Students generally did not show a preference for either the action or time listening styles. For the most part, there were no differences between the genders; however, a statistically significant difference was noted between the genders for the content listening style, with males reporting a slightly higher preference for this style.
| Listening style | Gender | Mean | SD | P value |
|---|---|---|---|---|
| People | Female | 3.31 | 0.47 | 0.670 |
| Male | 3.26 | 0.43 | ||
| Total | 3.29 | 0.46 | ||
| Action | Female | 1.53 | 0.68 | 0.062 |
| Male | 1.78 | 0.52 | ||
| Total | 1.61 | 0.64 | ||
| Content | Female | 2.37 | 0.55 | 0.036 |
| Male | 2.62 | 0.56 | ||
| Total | 2.45 | 0.57 | ||
| Time | Female | 1.35 | 0.65 | 0.697 |
| Male | 1.40 | 0.55 | ||
| Total | 1.37 | 0.62 |
Likewise, there was little difference between the students enrolled in the 3 years of the paramedic course, which is shown in Table 3. Where a statistically significant difference was reported, it was towards the content listening style. A post hoc analysis (Sidak) found third-year students to have a significantly lower preference for the content style than students enrolled in either second year (P=0.001) or first year (P=0.002).
| Listening style | Year | Mean | SD | P value |
|---|---|---|---|---|
| People | 1st year | 3.30 | 0.49 | 0.661 |
| 2nd year | 3.33 | 0.42 | ||
| 3rd year | 3.21 | 0.44 | ||
| Total | 3.29 | 0.46 | ||
| Action | 1st year | 1.66 | 0.68 | 0.500 |
| 2nd year | 1.62 | 0.63 | ||
| 3rd year | 1.46 | 0.56 | ||
| Total | 1.61 | 0.64 | ||
| Content | 1st year | 2.51 | 0.51 | 0.001 |
| 2nd year | 2.60 | 0.42 | ||
| 3rd year | 2.03 | 0.73 | ||
| Total | 2.45 | 0.57 | ||
| Time | 1st year | 1.43 | 0.67 | 0.422 |
| 2nd year | 1.38 | 0.60 | ||
| 3rd year | 1.21 | 0.47 | ||
| Total | 1.37 | 0.62 |
Communication styles
The students’ reported communication styles ordered from most preferred to least preferred styles are seen in (Table 4). To reiterate, scores range from 4 to 20, with 20 being the strongest preference possible. Accordingly, the friendly and attentive styles were the most preferred styles amongst students. Multiple ANOVAs by gender and year level found no statistically significant differences.
| Communication style | Mean | SD |
|---|---|---|
| Friendly | 15.53 | 2.73 |
| Attentive | 14.09 | 2.60 |
| Animated | 13.15 | 3.11 |
| Impression leaving | 12.92 | 2.80 |
| Relaxed | 12.42 | 3.23 |
| Precise | 11.88 | 2.60 |
| Open | 11.76 | 3.34 |
| Dramatic | 11.60 | 3.15 |
| Dominant | 11.11 | 3.20 |
| Contentious | 10.80 | 3.30 |
Discussion
The findings of this study demonstrate that the students are all generally predisposed to a particular combination of listening and communication styles, which are highly suited to their chosen discipline. However, it should be noted that there are no right or wrong ways of listening or communicating as each style has its advantages and disadvantages. The purpose of both the LSP and CSM are to describe aspects of the students’ style and not to evaluate them. The styles that these students have exhibited lend themselves to their chosen discipline and are likely to have stemmed from an outlook on life that also steered them towards the altruistic-nature of being a paramedic (Williams et al, 2009).
This point is supported by the similarity in preferences across the year levels where first-year students who have minimal education in the programme and exposure to the discipline share similar listening and communication styles as those who have already progressed further through the course.
Student preferences
The students reported a strong preference for the people listening style. This style of listening is characterized by a tendency to pay particular attention to the concerns and feelings of others. Likewise, their top two preferred communication styles are friendly and attentive. Norton (1978) suggested that the communication styles are multicollinear—such that certain styles tend to cluster together and the results of this study would tend to support this idea (Norton, 1978). The friendly style of communicating includes anything from displaying a lack of hostility in a conversation through to deep intimacy, and consistent with this style is the attentive style which involves ensuring the conversation partner feels they he/she is being listened to. Thus, the top preferences reported for both the LSP and CSM indicate that these students display styles that are consistent with their having a concern with the welfare of others (Norton, 1978; Watson et al, 1995). This is an important result and entirely consistent with the students choice to pursue a career as a paramedic.
The other listening style that students reported moderate preference for was the content style. This style of listening is characterized by an interest in the facts and details of what is being said. Needless to say, when establishing a patient's diagnoses, facts and details can be crucial. For this reason, a stronger preference for this listening style would perhaps have been ideal. The communication style which is conceptually linked to the content listening style is the precise style, which is characterized by a similar interest in details; however, students showed a weak preference for this style. At the outset, a stronger preference for the precise communication style was expected given the preference for the content listening style. However, a closer analysis of the items which constitute each listening style construct show some important differences in the wording which accounts for the students preference for one construct but not the other.
The CSM asks how students engage in conversation, whereas the LSM asks students what they prefer (Norton, 1978; Watson et al, 1995). Thus, these students evidently like others to be precise and factual in how they speak but do not necessarily like to be, or maybe feel that they are particularly accurate and detailed in their own communication.
Less preferred styles
It is also important to highlight those styles that the students did not prefer. Little preference was given to both the action and time listening styles. The action style is characterized by a desire to do and frustration with meandering, disorganized presentations, while the time style is characterized by a constant awareness of how long a particular conversation is taking.
While it is important that paramedics act in a timely manner, it is perhaps a good thing that this need does not characterize their listening styles. Regarding modes of communication, the dominant and contentious styles were the two least preferred communication styles. The dominant style is characterized by a tendency to take over the conversation and the contentious style is characterized by a tendency to be argumentative. Both of these styles would likely incite conflict in some situations where emotions are already charged and are, therefore, best kept as the least preferred communication styles.
Potential for a follow-up study
To a certain extent, the listening and communication styles reported here are highly suited for the role of a paramedic and are relatively consistent across the cohort. It is important to remember, however, that the focus of this study is on students and not qualified paramedics. The roles of student and qualified paramedic have some significant differences, such that caution is required in making inferences about the listening and communication styles of qualified paramedics based on this data. Kiewitz et al (1997) suggested that the pressures of the workforce may have an impact on the preference some people have for certain listening styles (Kiewitz et al, 1997).
It would, therefore, be interesting to complete a follow-up study assessing the listening and communication styles of these students after working as a paramedic for a year or two. For instance, would the time pressures faced in an emergency situation encourage these students to exhibit a stronger preference than they currently do for the
time listening style? Currently these students are shielded from such pressures and when they go out on clinical placement they are under the aegis of senior paramedics. Thus, the pressures of the workplace may encourage a change in the listening and communication styles of these students.
There is sufficient evidence from this study to suggest that the students already exhibit, or the curriculum is informally promoting, an appropriate listening and communication style that is required of a paramedic in clinical practice. These findings are important since undergraduate paramedic education in Australia is non-standardized, and the discipline is not nationally registered (Williams et al, 2009). The additional body of knowledge within this domain provides curriculum developers, educators, and researchers with important information regarding how best to integrate listening and communication into core competencies.
Limitations
The use of a self-report questionnaire further limits the ability to make inferences about how these students are likely to communicate when they eventually begin working. It is a common problem with such scales that they measure stated intent and not actual behaviour. The students’ self-perception is unlikely to be perfectly accurate. Nevertheless, how these students see themselves is a strong predictor of how they would like to behave. It is therefore important to be mindful that when exposed to the myriad of demands and pressures of life, these students are likely to exhibit different listening and communication styles than they imagine while calmly completing a questionnaire.
This study is potentially limited as the sample of undergraduate paramedic students has been drawn from one university in Australia and caution is required in extrapolating these findings to paramedic students more broadly. Furthermore, some caution is required in generalizing the results to other students in the same course who declined to participate in this study because convenience sampling was used. The demographic data would tend to suggest this is not a concern; nevertheless, there is the possibility that the sample is skewed because those students who self-selected themselves to participate may have different personalities to those who declined to participate. These final two points are important to mention, but not of serious concern to the external validity of this study.
Conclusion
This study suggests that the overall listening and communication style preferences by the students showed consistency across the cohort and are well suited for the role of a paramedic. It is likely that people disposed to such styles have been drawn to the discipline which is, among other things, characterized by an interest and concern for others. Additional research is warranted to determine whether such styles are maintained as students progress to working in full-time clinical practice.