Preparing ‘road-ready’ paramedics capable of working effectively in the unpredictable, and often uncontrolled, social world in which they operate (Campeau, 2008; Lazarsfeld-Jensen, 2010) presents a challenge to educators responsible for teaching undergraduates in this emerging discipline (Willis et al, 2010; Edwards, 2011). The demographic and epidemiologic transitions (Omran, 2005) being experienced in much of the developed world, including an ageing population, an increase in chronic illness and an escalation in the incidence of dementia are changing the nature of paramedic work (World Health Organization and Alzheimer's Disease International, 2012; Arendts and Lowthian, 2013). The transition of the paramedic from the traditional role of emergency responder to holistic, person-centred health practitioner (Joyce et al, 2009; O'Brien et al, 2013) means producing graduates with the requisite balance of clinical and non-clinical skills to meet these changing needs is critical.
The Australian Learning and Teaching Council's (ALTC) report Paramedic education: developing depths through networks and evidence-based research (Willis et al, 2009) found that existing models of paramedic education are producing graduates who are clinically competent but lacking the ‘soft skills’ necessary to meet the changing demands of the profession (Lazarsfeld-Jensen, 2010). Soft skills may refer to proficiency in communication, teamwork, empathy, compassion and human relationships (Willis et al, 2009: 39). In this paper we argue that the use of the term ‘soft skills’ is part of a discourse that, during paramedic students' education, is characterised by the privileging of technically-focused clinical skills, such as cannulation, intubation and resuscitation, over interpersonal skills such as building rapport, empathic understanding, and open and closed questioning. This discourse is reinforced in the traditional paramedic curriculum, as identified in the ALTC report. Evidence indicates that educators view facilitating the development of interpersonal skills as a challenge (Deveugele et al, 2005; Levinson et al, 2010) in the context of a strong focus on mastery of technical expertise, especially the complex task of translating training into practice (Laker and Powell, 2011; Rosenbaum and Axelson, 2012). More specifically, educating students about person-centred care, as a component of interpersonal skills education, has been recognised as presenting its own unique challenges (Lévesque et al, 2013). Paramedic placement experiences where developing interpersonal skills and understanding person-centred care are a key focus, such as working with people who have communication issues (e.g. neurocognitive disorders such as dementia), may be one way to emphasise the importance of these critical skills within the current paramedic curriculum, and also meet the demands of translating learning objectives on ‘soft skill’ development into practice. From here on in we refer to ‘interpersonal’ skills, rather than ‘soft skills’, as this term does not have the strong pejorative connotations associated with the latter.
This paper reports on a clinical placement programme that provides undergraduate paramedic students with an opportunity to develop interpersonal skills in a supportive learning environment. The Wicking Dementia Research and Education Centre (WDREC) collaborated with the University of Tasmania's (UTAS) School of Medicine (Paramedic Practice) in developing placements for final year paramedic students as part of the Wicking Teaching Aged Care Facilities Program (TACFP). The TACFP has two primary aims: a) to improve workforce capacity; and b) to provide students with a positive experience of aged care. This five-day placement programme seeks to enhance students' understanding of working with older people, including those with dementia, by providing opportunities for them to interact with aged-care facility residents and staff. The TACFP has previously been identified as providing a unique opportunity for undergraduate paramedic students to develop a better understanding of dementia and improved strategies for caring for these clients (Lucas et al, 2013). The most recent placement programme was designed to improve students' interpersonal skills through opportunities to interact with residents with dementia, students from other disciplines and facility staff. Evidence from the previous two rounds of placements informed the programme, which included both structured and unstructured interactions with residents, based on evaluation of these previous placements.
Research methods
Research participants
A group of final year fast-track undergraduate paramedic students (n=31) participated in a five-day residential-aged care facility clinical placement as part of a supervised interprofessional out-of-hospital placement. Students were aged between 19–45 years, with a mean age of 25 years (SD=6.91). The majority of students were female (58%).
Research setting
Four residential-aged care facilities (RACFs) in the Australian state of Tasmania participated in the TACFP by providing clinical placements for students during September and October 2013. Each facility offered high-care and low-care places for residents, and two of the facilities had secure units for people with moderate to severe behavioural and psychological symptoms of dementia (BPSD). The facilities ranged in size from 70 to 140 beds.
Placement programme
Prior to placement, students participated in four introductory information sessions that included an overview of the Wicking TACFP, a workshop on dementia palliation, and information sessions about clinical tools that students would be using to conduct assessments of residents while on placement.
During the five-day placement, students engaged in a range of structured learning activities, including the use of cognition and pain assessment tools for people with advanced dementia. Students also participated in interprofessional learning (IPL) activities, where they worked alongside first and second year nursing and final year medical students who were on clinical placement at the same time. A key focus of the IPL activities was the assessment of residents with dementia and collaborating with the other students to develop a formal presentation about aspects of the resident's care, which was delivered to staff and students. Conscious that a great deal of health professional education takes places in isolation from other disciplines (Ramsammy, 2010), the TACFP has structured the IPL activity into the placement programme to provide students with an opportunity to learn with, from and about other professions (World Health Organization, 2010).
In addition to these activities, the programme was structured so students could spend time engaging with residents, observing their daily routines and practising their communication and assessment skills. Where possible the placements were structured so that students could witness changes in behaviour of residents with dementia at different times of the day. At some facilities, students were rostered on an afternoon shift so they could gain exposure to ‘sundowning’, a commonly occurring BPSD where people with dementia sometimes become more confused, restless or anxious late in the afternoon or in the early evening (Khachiyants et al, 2011). It was through this interaction with residents, and students from other disciplines, that the paramedic students were provided the unique opportunity to work on developing their interpersonal skills.
Data collection and analysis
Qualitative data
UTAS project officers at each of the facilities conducted feedback meetings with students on the final day of the five-day placement. Meetings were audio recorded and summaries developed from the recording transcripts. These summaries represented a first-level analysis of the data, which was initially scrutinised and subject to an open coding process to identify any clear themes or concepts that might be evident in the data (Rice and Ezzy, 1999). Themes identified during this stage were then sorted and ordered into a manageable set of analytical categories (Pope et al, 2006).
Quantitative data
Students participating in the research project completed a range of surveys before and after their placement. Pre-placement surveys measured a range of variables including students' perception of their interpersonal skills, and their attitude towards the placement and the prospect of working with older people. Their knowledge of dementia was also measured using the 21-item Dementia Knowledge Assessment Tool Version 2 (D-KAT2) (Toye et al, 2014). Post-placement, students were surveyed about their learning experience, their perceptions of their interpersonal skills, and their knowledge of dementia. These surveys also collected qualitative data through the use of open-ended questions. Data were managed using IBM SPSS Statistics (20.0.0). Descriptive statistical analyses were conducted, including frequency analyses and cross-tabulations. A paired-samples t-test was used to determine statistical significance of the change in D-KAT2 scores during the placement. However, attitudinal data displayed non-normal distributions and, therefore, the Wilcoxon signed ranks test was used to examine the significance of the change in proportions in attitudinal variables from pre- to post-placement.
Ethics approval
Ethics approval for this research was obtained from the UTAS Human Research Ethics Committee (No. H11576).
Findings
Data from the student surveys and end-of-placement feedback meetings informed the findings discussed here. Analysis of the data indicated that the students had benefited from the placement in terms of developing their interpersonal skills. Salient findings included: improved understanding of dementia and communication strategies for working with people with dementia, improved communication skills in relation to working with students from other disciplines and RACF staff, and increased empathy and understanding of older adults with dementia and the aged-care sector.
Improved understanding of dementia
Students' knowledge of dementia was assessed prior to and at the end of their placement. A paired-samples t-test showed a statistically significant increase between the pre- and post-placement mean scores (Table 1).
| Mean score | Standard deviation | |
|---|---|---|
| Pre-placement | 14.1 | 3.326 |
| Post-placement | 17.2 | 2.294 |
(t(28)=-4.831, p<0.010)
The majority of students considered the placement to be valuable and commented specifically about opportunities to spend time with residents, learning to communicate with them and observing a range of BPSD issues among residents with dementia. One student considered ‘the exposure to and time spent with residents was the most valuable [part of the placement]’ (BPm2026). Another recounted that ‘learning how to talk to residents with a cognitive impairment was really useful for understanding how to deal with different behaviours [like] wandering’ (BPm2021), and this was identified as a primary benefit of the placement.
Other students related the relevance of the placement to their future work as paramedics, where they would increasingly have contact with people with dementia in a range of settings. Students saw the opportunity to communicate with residents in a relaxed environment as a worthwhile learning experience:
‘I think especially if you are [working as a paramedic] in a rural setting you are doing a lot of driving, there's a lot of distance and you do have to talk with patients [with dementia] to make them comfortable’.
The structuring of the timetable, where some students had the opportunity to work in the late afternoon, served to provide additional insights for students who were able to observe commonly occurring BPSDs such as sundowning. One student reported:
‘[The placement was helpful for] picking up different behaviours throughout the day especially with dementia patients—their mood is often changing. I did my [assessment] on my resident and I decided to assess her just after morning tea around 10 am and at 4 pm just before sundown. I picked up a great change in her mood; she became quite agitated and [there was] a big change in her behaviour’.
Interestingly, some paramedic students reported concerns that the paramedic uniforms with reflective strips they wore on placement might exacerbate behaviour problems among residents with dementia. One student recounted:
‘Maybe we shouldn't be wearing these uniforms because there was this gentleman who was running away from me. According to the nurses, he saw me coming and he tried to escape into the nurses' station because he thought I was coming to get him’.
Improved communication skills
The pre- and post-placement surveys contained a series of questions about communication skills and learning with other students and health professionals. These data revealed that students had a statistically significant improvement in their interpersonal skills and understanding of other health professions (see Table 2).
| % agree or strongly agree | |||
|---|---|---|---|
| Pre | Post | sig | |
| I am comfortable working with people from other healthcare professions | 82.2 | 96.4 | 0.002 |
| I feel comfortable justifying recommendations/advice face-to-face with more senior people | 53.6 | 85.7 | 0.001 |
| I feel uncomfortable taking lead in the group | 50.0 | 21.4 | 0.021 |
| I have a good understanding of the roles of different health and social care professionals | 60.7 | 89.3 | 0.015 |
As outlined above, a key structured learning opportunity for paramedic students involved participation in an interprofessional learning (IPL) activity. For most paramedic students this was the first opportunity they had to learn and to work collaboratively with students from other disciplines. Several students reported that this was the most enjoyable aspect of the placement. Comments shared in feedback meetings indicated they enjoyed ‘the opportunity to teach nursing students about paramedic practice’ (FPm2003), and that ‘IPL made me realise the differences in nursing and paramedic professions’ (BPm2024). Other paramedic students working with first-year nursing students on the IPL activity found it was a good opportunity to provide guidance and advice to the novice nurses: ‘they [nursing students] didn't really have any assessment tools…I said to them, “you're probably going to be looking for skin tears, bedsores, falls risks”’ (EPm2009). Alternatively, another student working with second-year nurses on the IPL activity recounted how the nurse taught him useful strategies to engage with people with dementia during the performance of technical activities. This student reported:
‘[The second-year nursing student] taught me a lot of the practical stuff, like talking to some of the patients [with dementia]. Because…I'm quite used to just doing the blood pressure and stuff and just going in, strapping the thing [sphygmomanometer] on, and she [the nursing student] was like, “Oh just slow down a bit, because you've got some time. Just talk to them, talk them through what you're doing, hold their hand while you're taking their blood pressure, really ease them down a bit”’.
During the feedback meetings, paramedic students reflected on the benefits of the IPL activity and the opportunity to learn with, from and about students from other disciplines. For example, one student reported ‘being surprised by the positive interactions and discussions with the medical students’ (FPm2003). Others expressed the view that participation in the IPL task was helpful for developing their clinical practice: ‘working with [the medical student] was good because I definitely did learn from her. Her questioning was good and I will take that on board for my own clinical knowledge’ (EPm2004).
Increased empathy and understanding
The pre- and post-placement surveys also measured various aspects of the students' attitude towards the placement. Prior to the placement students indicated a general ambivalence towards the RACF clinical placement, with only 13% (n=4) reporting that they felt happy when notified about their placement allocation and 47% (n=14) saying they expected to enjoy working with elderly residents in the RACF. The post-placement surveys found that over 96% (n=25) reported they enjoyed working with elderly residents and 44 % (n=11) reported that the placement was better than expected. Additionally, 64% (n=16) reported that they felt more confident about their clinical practice. The post-placement surveys also show an increased understanding of RACFs with almost 77% (n=20) of students reporting that they felt their understanding had increased as a result of the placement.
‘The findings reported in this paper demonstrate that clinical placements in residential-aged care facilities provide a unique opportunity for students to prioritise the development of interpersonal skills that will help make them more ‘road-ready’ upon graduation’
Post-placement feedback from students indicates they developed some critical insights into the aged-care sector and the operations of RACFs, as well as increased empathy for the residents and staff in these facilities. Several students reported that the placement helped them better understand the day-to-day workings of a facility:
‘One of the most interesting things I found out about this week is just how the elderly live in places like this, because I haven't had much previous experience with aged care. It was interesting to see how they're looked after and how the enrolled nurses and the registered nurses all seem to know everyone very well and that also helps with the management as well’.
Not only did it help students to understand how the facilities operated, the placement also served to help break down preconceived ideas some had about such facilities:
‘It's relevant to know what people do because there's a lot of assumption I find in the paramedic community that they [staff] do nothing in retirement homes. They just shower them or they're [residents] treated badly or whatever. It's good to see what actually happens and how much effort people [staff] go to [in order to] keep these people [residents] happy and how hard it is’.
Such comments highlight a change in sentiment among the students, and a new appreciation of the complex care that is provided in aged-care facilities.
Discussion
The findings reported in this paper demonstrate that clinical placements in residential-aged care facilities provide a unique opportunity for students to prioritise the development of interpersonal skills that will help make them more ‘road-ready’ upon graduation. The learning experiences described here support paramedic students to develop essential skills that will better equip them to meet the challenges of a changing healthcare landscape (Williams et al, 2010).
A significant outcome of the placements involved addressing several key issues identified in the ALTC report on paramedic education. This includes paramedic students having access to alternative learning sites for clinical education, and the challenge of addressing the lack of interpersonal skills in graduates. Our research confirms that the residential-aged care clinical placements described in this paper provide students with an opportunity to develop and apply essential competencies, such as communication skills and the ability to work as part of an interdisciplinary team, in a supportive learning environment (Hou et al, 2012). Further, our research identifies the placements as a potential model for collaborative partnerships between education and health service providers, evident in the collaboration between the paramedic course staff and RACF staff in developing the programme; an issue the ALTC identified as a key challenge for paramedic education (Willis et al, 2009). In doing so, the research also addresses a concern identified by Ross about a ‘paucity of research into the teaching and development of interpersonal skills in undergraduate paramedic programs’ (Ross, 2012: 660).
A key objective of the TACFP is to improve students' understanding of dementia and dementia palliation. An increased understanding of dementia was identified in the qualitative data and the findings from the quantitative evaluation supported this. The findings suggest this outcome was achieved by facilitating opportunities for students to communicate with residents with dementia. As such, increasing students' knowledge of dementia and supporting them to develop their capacity to communicate effectively with older people living with dementia was a key outcome of the placement. This supports Ross' (2013) assertion that experiential training interventions involving ‘real patients’ are beneficial learning experiences that can foster a range of interpersonal skills, which in turn promotes person-centred care. Training healthcare workers in person-centred care is recognised as important in improving outcomes for people with dementia when being transported by ambulance (Roberts et al, 2010), and students reported the benefits of the placement in this regard.
Another key outcome from these placements was the involvement of paramedic students in an IPL activity that further enabled them to develop and deploy the interpersonal skills necessary to collaborate effectively with colleagues from other disciplines. The IPL exercise involved students learning with, from and about other student groups, and served to support their professional development and prepare them to be ‘collaborative practice-ready’ (World Health Organization, 2010). The findings highlight that participation in the IPL activity involved communication, teamwork, interpersonal, intrapersonal and, in some cases, leadership skills as they collaborated with colleagues from other disciplines in the assessment of residents. All these skills are of critical importance if students are to be road-ready upon graduation (Lazarsfeld-Jensen, 2010; Ross, 2012).
The final salient outcome of the placement was an increase in students' understanding of the aged-care sector and an increase in empathy for the residents, as well as staff working in the RACF. The epidemiologic and demographic transitions (Omran, 2005) being experienced in contemporary societies will impact on paramedics, and their work will increasingly bring them into contact with older people (Arendts and Lowthian, 2013), including those with dementia and those living in RACFs. It is essential for paramedic students to develop an understanding of the aged-care sector, and how RACFs operate, in order to achieve better outcomes when they are called to these facilities. The findings reported here suggest the antipathy many of the students had towards RACFs prior to placement lessened over five days and students felt more empathy for older people and the aged-care sector by the end of their placement. An ‘inability to empathise or support patients’ (Willis et al, 2009: 41), particularly the elderly, was recognised as a serious skill deficit in the ALTC report on paramedic education (Willis et al, 2010). Our research has identified clinical placements in RACFs as ideal opportunities for students to work on developing these skills. Indeed, one student interviewed as part of the ALTC study suggested the non-emergency sector might be a good environment for students to gain exposure to people outside their own social milieu (Willis et al, 2009), and our findings confirm that view.
Conclusions
This research has shown that the challenge of prioritising the development of paramedic students' interpersonal skills has been a significant achievement of the Wicking TACF program. Students participating in this placement programme are provided with unique learning experiences through real patient encounters that have been shown to be beneficial for developing students' interpersonal skills.
Elsewhere, RACFs have been identified as providing a unique sociocultural learning environment for medical students (Molema et al, 2014) and this research adds to the evidence base supporting the wider use of such facilities by educational institutions in training future health professionals, including paramedics, to meet the changing healthcare landscape of the 21st century.