Embarking on a journey into higher education involves entering a period of significant change with consequences rippling into the financial, residential and social aspects of an individual's life. Levels of psychological distress increase during this transition into university (Bewick et al, 2010). Between 2006–2 007 and 2016–2017, the proportion of undergraduate students reporting poor mental wellbeing rose by 500% (Thorley, 2017). Rates of self-harm and suicide among students have seen an increase (Sivertsen et al, 2019) as well as reported rates of depression and anxiety (Campbell et al, 2022).
UK university students have been shown to have similar levels of mental health issues to the general public but are less likely to access professional help (Macaskill, 2012). Furthermore, risk factors for poor mental wellbeing are compounded by age (transitioning to adulthood), social isolation (because of too large teaching groups, difficulty in making friends and moving away from home) and a lack of academic support (because of pressures on academic staff and cuts to support services) (Macaskill, 2012; Hernández-Torrano et al, 2020).
Emergency health workers such as paramedics work in unpredictable and uncontrolled environments and will be exposed to trauma as part of their job role on a regular basis (Lanza et al, 2018). There is strong evidence to suggest that emergency health workers experience higher rates of mental illness than the general public (Lawn et al, 2020). When surveyed, 75.8% of ambulance service staff and volunteers reported having personal experience of mental health problems (Mind, 2019). Supporting this, an array of statistics indicates that 24% of student paramedics report experiencing anxiety (Alzahrani et al, 2023), 28% experience depression (Fjeldheim et al, 2014) and rates of post-traumatic stress disorder fluctuate between 8.3% and 11% (Wild et al, 2016).
In the UK, student paramedics attend an ambulance placement as part of their paramedic training, which requires them to work as a supernumerary member of an ambulance crew (Givati et al, 2018). This exposes the student paramedic to the same trauma, work patterns and stresses as the qualified paramedic. However, for student paramedics, these risks to mental wellbeing are exacerbated through inexperience, rudimentary coping mechanisms, academic demands and reduced social support (Lowery and Stokes, 2005; Fjeldheim et al, 2014). This can culminate in reduced engagement and an increased likelihood of withdrawing from paramedic education (Abiola et al, 2015; Ericsson et al, 2022).
The evidence base has explored mental wellbeing in qualified health personnel in many studies; however, literature exploring this issue within the student paramedic population is limited. Furthermore, it is clear that student paramedics have unique risk factors and will face particular challenges when undertaking their undergraduate paramedic training. This study aims to address this lack of evidence.
Aims
The aim of the study is to describe and explore the mental wellbeing of UK student paramedics before and after their first ambulance placement.
Methods
Research design
This study used a mixed-methods approach, with two questionnaires, one completed before and the other after placement, to gain both quantitative and qualitative data to explore student wellbeing and answer the research question.
Each questionnaire had two parts. First, the study gathered numerical data before and after students were exposed to the ambulance placement using the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), which is a well-established tool to measure psychological wellbeing (Tennant et al, 2007). The authors gained a non-commercial licence for research to use the WEMWBS before starting the study.
Second, the questionnaire collected qualitative data before and after placement using open-ended questions. These questions aimed to explore the participants' thoughts and feelings before and after experiencing their placement.
This study was a pilot project to test the methodological approach of this style to ascertain whether it could be applied to a larger project exploring mental wellbeing in student paramedics in multiple educational programmes over the full course length in the UK.
Both methods were adopted so the mental wellbeing of the participants could be first quantified with an established metric, then the qualitative data would allow this quantitative figure to be explored. The team planned to use triangulation within the data analysis to link participants to their qualitative, lived experience.
Study population
The study took place at the University of Sunderland (UoS), which is a higher education institute in the north east of England, which offers an undergraduate student paramedic course leading to registration as a paramedic in the UK.
The population was a group of first-year student paramedics studying a BSc degree in paramedic science and out-of-hospital care at UoS. Potential participants were invited to take part in the study via email during December 2022, and those interested signed informed consent forms to do this.
Data were then collected from December 2022 to February 2023. The participants had their first emergency ambulance placement in January 2023 over 4 weeks with ambulance services covering the north east of England. The students were supernumerary members of the emergency ambulance crews.
Sample size and recruitment
A convenience sample was used because of the nature of the research design and question. The sample could only include first-year student paramedics who had not yet attended an ambulance placement as the researchers wanted to capture pre-placement data and identify the specific effects of the first ambulance placement on undergraduate student paramedics.
As the study was a pilot project, the target sample was kept intentionally small to test feasibility as well as to explore the lived experience through the qualitative data in greater detail. A target of a minimum of 30 participants was set as per the WEMWBS guidance (Warwick Medical School (WMS), 2023).
All students who met the eligibility criteria (n=43) were sent an email invitation with the participant information sheet and an informed consent form. To take part, they replied with an electronically signed informed consent form. They then received a unique participant code to ensure they could give data anonymously. There was no financial reward for taking part in the research and the students could withdraw their consent at any time.
Out of the 43 students available for recruitment, 30 consented to participate (69.8%).
Inclusion and exclusion criteria
To be included, participants: had to be first-year student paramedics studying BSc paramedic science and out-of-hospital at UoS; and had not yet undertaken ambulance placement.
Participants would be excluded if they did not undertake ambulance placement as planned during their first year of study at UoS.
Ethics
The study was granted ethical approval by the UoS ethics panel during December 2022 (application 015015). The study followed the ethical guidelines for its protocol and adhered to good research principles throughout. No further ethical approvals were required because of the nature of the project. No adverse events occurred during the study.
Data collection
The participants were issued a questionnaire 2 weeks before their first ambulance placement. They filled this out in physical form before their placement started. They were then sent the post-placement questionnaire 2 weeks after their ambulance placement as per the WEMWBS guidance (WMS, 2023).
The data were then transcribed into a central database using Microsoft Excel and Word, which was managed as per ethical approval and GDPR regulations. WEMWBS scores were calculated using the guidance from the tool (WMS, 2023) after the scores were inputted into the
Data analysis
Quantitative data such as age, sex and other demographic characteristics were summarised using descriptive statistics. The WEMWBS was analysed using t-testing, with P set at 0.05 to identify statistically significant results. For the quantitative statistical analysis, SPSS software (v 28.0) was used.
The qualitative data were analysed using thematic analysis informed by the work of Braun and Clarke (2006). The team used an inductive and semantic approach during the thematic analysis.
Results
Quantitative analysis
Twenty participants were included in the quantitative analysis (Figure 1). The mean age was 21.9 years (SD±4.93), 75% (15/20) were women and the majority (75%; 15/20) described their relationship status as single. One in 10 (10%; 2/20) had a disability and 30% (6/20) reported that they had mental wellbeing issues (self-defined) before beginning placement (Table 1).
| Variable | Overall cohort (n=20) |
|---|---|
| Age | |
| Mean (SD) | 21.9 (±4.93) |
| Sex | |
| Female (%) | 15 (75%) |
| Male (%) | 5 (25%) |
| Relationship status | |
| Single (%) | 15 (75%) |
| In a relationship (not married) (%) | 5 (25%) |
| Disability status | |
| Reported yes (%) | 2 (10%) |
| Previous relevant experience* | |
| Reported yes (%) | 12 (60%) |
| Wellbeing issues present prior to placement | |
| Reported yes (%) | 6 (30%) |
| Ambulance placement hours completed (mean average hours completed by entire sample) | |
| Mean (SD) | 177.5 (±36.5) |
| Traumatic experience on placement | |
| Reported yes (%) | 15 (75%) |
| Traumatic events | |
| Number of events | 15 |
| Median (interquartile range) | 3 (1–4) |
| Mean (SD) | 4.2 (±2.77) |
Table footnote:
Previous relevant experience was defined as any in healthcare, emergency services, armed forces or care work. Participants self-selected responses
Participants self-selected if they had ongoing issues affecting their mental wellbeing
The participants completed an average of 177.5 (SD±36.5) hours on ambulance placement. Three out of four (75%; 15/20) reported having witnessed at least one traumatic event during their placement; those in this group reporting attending an average of three traumatic events in total during the placement (interquartile range 1–4).
Before and after placement, WEMWBS data were summarised. Before the placement, the group had a mean WEMWBS of 48.45 (SD±6.73). Two weeks after placement, the group had a mean WEMWBS of 50.55 (SD±5.9). There was a mild increase of 2.1 between before and after placement WEMWBS, which would be associated with improved wellbeing. However, this was not significant on statistical testing (P=0.30) (Table 2).
| Variable | Before placement (n=20) | After placement (n=20) | P |
|---|---|---|---|
| WEMWBS score | 48.45 (±6.73) | 50.55* (±5.9) | 0.30 |
| Mean (SD) | 49 (45–53.25) | 50 (47–55.2 | (t-test for two independent means) |
| Median (interquartile range) |
The t-test value is −1.04934. P= 0.300648. The result is not significant at P<0.05
Qualitative results
Twenty participants returned both their pre- and post-placement questionnaires. These provided a rich qualitative data set for thematic analysis. Braun and Clarke's (2006) thematic analysis model was followed to produce the qualitative data analysis.
Themes
Positive learning experiences
The qualitative responses showed that, overall, the majority of the participants had positive learning experiences while on their first ambulance placement. Placement was an eye-opening experience for them. Several reported that it had improved their confidence as a student paramedic:
‘I feel my knowledge increased significantly.’
‘Helped me grow confidence and improve.’
‘I had a really good placement experience, I loved every second and took something away from every call.’
‘I felt like I was in such a privileged position as a student to meet so many different people from all walks of life and positively impact their lives at time that could be their worst.’
Theory-practice gap
The participants reported that, before placement, they were excited to apply their theory to practice. The post-placement survey captured that they experienced opportunities to do this:
‘Excited to put the theory from the last few weeks into practice.’
‘I'm excited to put all my hard work into practice and learn as much as I can.’
‘Also, [I am] looking forward to being able to put my theory into practice.’
‘Overall, placement was a huge learning experience for gaining knowledge into practical aspects and theory behind illnesses and patient interaction.’
Student-paramedic mentor relationship
Multiple participants reported experiences related to the relationships they had with their paramedic mentors. Most reported positive experiences and that mentors had a significant effect on the enjoyment and utility of the clinical placement but two participants shared that their mentor experience was negative:
‘I felt extremely welcomed… and got on amazingly well with my mentor.’
‘When I didn't do something correct… it would get me down. However, when I talked to my mentor… it built up my confidence again.’
‘I often felt like a spare part.’
‘I felt like more of a hindrance.’
Student resilience: dealing with traumatic cases
The quantitative data showed that students' mental wellbeing did not change after exposure to their first ambulance placement, and that the majority of them reported experiencing traumatic cases. This finding was mirrored and explored further within the qualitative results. Participants experienced a range of traumatic incidents:
‘[It was] upsetting to see an end-of-life patient.’
‘There were hard times when there were difficult jobs or a string of difficult jobs in one shift or week.’
Three students spoke about how they coped with their emotions after experiencing a traumatic case. They reported being aware of support mechanisms and using their paramedic mentors through debriefs:
‘Some calls affected me in a negative way… I found them upsetting and emotional. I wouldn't say that they were detrimental to my mental health… This is because I talked about them in a debrief with my mentor.’
‘I struggled to emotionally detach [from] patients. [However], I know of the support services available if I need additional support.’
One comment related to isolation affecting wellbeing after placement:
‘I did feel lonely at times sitting in the apartment and I felt a lot more homesick.’
Career consolidation
Multiple participants reported a sense of feeling that experiencing the ambulance placement confirmed that they had made the right career choice:
‘It confirmed that this is my future career.’
‘Overall, I really enjoyed getting a look at what the job is like and it made me excited for the future.’
‘[Ambulance placement] showed me I am definitely in the right job going forward.’
‘During placement, any doubts that I had about continuing with this career were erased.’
‘It confirmed this is the job I want.’
Discussion
This pilot mixed-methods study covering a small group of student paramedics in their first year of study found that mental wellbeing after exposure to their first ambulance placement did not change significantly. Furthermore, thematic analysis of the qualitative results showed that placement was, overall, a positive experience for this group of student paramedics.
Ambulance placement: essential for learning
The data indicated that the clinical placement had been a positive experience for the participants. Clinical placements are integral to paramedic education and provide students with opportunities to apply theory to practice. In these opportunities, students attempt to assimilate professional values and attitudes, and consolidate their clinical knowledge (Warren-James et al, 2021).
It is during this process that the student is said to move from a peripheral to a central learner (Ross et al, 2015). This should encourage the student to become an empowered, active participant in their learning. Difficulties such as a negative relationship with a mentor can restrict the shift from peripheral to central, resulting in disempowerment and a loss of confidence in ability (Ross et al, 2015).
The value that participants placed on their placement experience was apparent, with comments such as ‘privileged position’ and ‘knowledge increased significantly’, as well as reporting that they had ‘loved every second’. This high value potentially indicates they were aware of the advantages of placement and how it complemented their university education.
If a student perceived their placement as a negative experience, this may have a damaging impact on their wellbeing, in contrast to where someone had a positive experience and found it valuable.
In addition, clinical placements facilitate key developmental processes for students. These involve career choice confirmation, construction of professional identity and role, integration into the professional culture and processing traumatic incidents. All of these are difficult to replicate in the classroom environment with adequate parity, which confirms how important clinical placement is for paramedic education.
Career choice confirmation
Confirmation of career choice was a key theme identified in the results. The results highlight the importance of the first clinical placement on an undergraduate paramedic education programme for consolidating the career aspirations of students who may otherwise have limited exposure to the reality of the profession.
The role of a paramedic frequently carries high social prestige in most societies (Majchrowska et al, 2021). Often regarded as a respectable profession, paramedicine has been ranked the eighth most prestigious profession after doctors, scientists, firefighters and nurses (McCarthy, 2016). Media portrayals further solidify this image with depictions of responsible, heroic, stoic, resourceful, charismatic and hardworking individuals who run towards threat to life and limb (Majchrowska et al, 2021). This forms a narrative that paramedics are professionals completely unfazed by the prospect of difficult and life-threatening situations.
However, the reality of paramedic work may contrast starkly with the media portrayal students are exposed to. The prehospital care environment can undoubtedly be tough, but its challenges may not be those depicted by the media. Accounts of physical and verbal abuse, antisocial working patterns, high rates of burnout and occupational stress are commonplace and contribute to a high attrition of registrants (National Health Executive, 2015; Iliffe and Manthorpe, 2019; Beldon and Garside, 2022). For students who are naive to the reality of contemporary paramedic work, this may be a harsh reality shock. This phenomenon is considered a jarring experience of having your expectations of an event conflict with the reality encountered (Wakefield, 2018). Some academics are concerned that this juxtaposition of expectation with the reality of the role contributes to attrition from student paramedic programmes (Lazarsfeld-Jensen, 2014).
Participants used the phrase ‘eye opening’ to describe their placement experience, in both a positive and negative context, supporting the idea that placement provides an insight into the role of a paramedic that may not align with the impression provided by outside sources.
High levels of nervousness and anticipation were reported before the placement. This could be because of the timing of this placement. At this point in their educational development, the students generally had a limited frame of reference as to what to expect from the clinical environment. This caused participants to feel unsure of social norms and expectations, and how their skills would transfer from the classroom into the clinical environment. In a sense, this can be summed up using the term ‘belonging’.
Student belonging
Humans are inherently a social species and a sense of belonging or group inclusion is reported to be a key factor for indicating wellness and ability to thrive.
As well as being one of the seven biopsychosocial domains of health and wellbeing (Clark et al, 2021), belonging contributes to a sense of self (Stallman et al, 2023) as well as resilience and coping (Huang et al, 2022); it also reduces the risk of illness and suicide (Hatcher and Stubbersfield, 2013).
Study participants reported feelings of inclusion and involvement. Belonging can be defined as a sense of being valued, included and accepted (Pedler et al, 2021). It is fundamental for any student regardless of their subject. Students who report a greater sense of belonging are associated with higher rates of motivation and satisfaction and are less likely to withdraw from their academic programne (Pedler et al, 2021). In addition, belonging is also significantly associated with reduced psychological distress in emergency service workers (Shakespeare-Finch and Daley, 2017).
Belonging is crucial for first-year students in particular as they transition into novel social and professional situations (Meehan and Howells, 2017), in what is considered a period of significant change (Rowley et al, 2008). This time can also be considered a ‘loss experience’, as students lose their former identities, social networks and sense of place (van Herpen et al, 2020). Burke et al (2016) reported that during this transition into higher education, students have a fragile sense of self, which predisposes them towards feelings of inadequacy and fears of not being capable. This suggests that the timing of academic development was potentially significant in this study. If repeated with second- or third-year student paramedics, the findings may be different as these students will have a more concrete sense of self and professional identity.
An individual constructs their sense of self through their participation and association with particular social roles. These roles are positions within society that are associated with specific behaviours, attributes, values and beliefs. These roles can be powerful indicators to the individual as to how they fit into the wider environment and their place in the world (Thoits, 2012).
This offers one potential explanation for the powerful impact of placement participation on student paramedics and, equally, its potential to strengthen or reduce a student's sense of wellbeing. Role-affirming experiences, such as a positive experience on placement and feeling part of the crew, reinforce the stability of that identity and affinity to the social role. When the experiences align with the perceived role, it creates a sense of purpose and meaning (Thoits, 2012). Having purposeful work is linked to an increase in personal wellbeing and considered protective of this.
While placement offers an opportunity to cultivate a greater sense of wellbeing, it can also become problematic. Conflict can arise between the student's lived experience of that role and their expectation of it. If a student is unable to fulfil the role of student paramedic in the way they believe is required or that they feel others such as their mentor and peers might demand, it can introduce conflict to their role identity (Mausz et al, 2022). This conflict was reported by participants when they expressed statements such as they felt ‘like a spare part’ or ‘a hindrance’, indicating feelings of inadequacy or segregation.
Ultimately, when empowered to be active participants in their experience and clinical role, students become empowered and report feelings of inclusion (Ross et al, 2015). Conversely, when denied this opportunity, they feel rejected, isolated and excluded.
Student–mentor relationship
The student–mentor relationship was also identified as a key theme and is closely associated with the developing sense of self and belonging. While the mentor provides educational interventions, they also provide pivotal support throughout the duration of a placement.
Often, placement mentors are the first point of contact immediately following a traumatic event. Students who reported their mentors were friendly and approachable were more likely to raise concerns, seek guidance and feedback (Brown et al, 2020). These qualities also encourage the student's identity formation and enhance the overall educational experience (Levett-Jones et al, 2007; Webb and Shakespeare, 2008). This was mirrored in the results, when a participant reported an increase in confidence after seeking guidance from their mentor. Support from a mentor may be crucially important for students who may have moved away from their existing support network to study.
Mentors are often viewed by the student as gatekeepers of their acceptance and integration into the clinical environment. Therefore, achieving a positive working relationship with their mentor is seen to have high social capital. It is this ability to integrate that indicates a level of capability and belonging (Kennedy et al, 2015). Students who find themselves unable to build a positive relationship with their mentor may interpret this as a form of rejection from the profession, which can culminate in profound negative consequences for wellbeing.
Dealing with traumatic incidents
A majority of participants reported attending traumatic incidents while on placement.
It has been suggested that students who are exposed to and endure traumatic events with their qualified colleagues are more likely to be socially accepted (Kennedy et al, 2015). Because of the emotional bond formed through a shared adverse event, the student gains social capital (Kelly and McAllister, 2013). This facilitates a greater sense of belonging through improved group engagement, integration and support. The attainment of this social capital is prized highly by the student and is seen as acceptance into the desired social role—it is a role-affirming experience. As a result, it reinforces the student's perception of themselves as a novice paramedic and stimulates their sense of belonging. A sense of belonging is protective to an individual's wellbeing (Stallman et al, 2023).
Students who perceive they have not obtained this social capital are more likely to report a lack of support, trust and productivity (Kelly and McAllister, 2013). This could also result in identity and social role dissonance. The student is unable to confirm their behaviours and actions are those they believe are expected of them in the role of a student paramedic. From a wellbeing perspective, this can be damaging and could reduce confidence, perception of ability and sense of wellbeing.
Methodology reflection
This pilot project tested a mixed-methods approach to explore the research question. On reflection, the researchers noted that the questionnaires were an effective tool for gaining rich data on the lived experiences of student paramedics. The use of open questions was particularly effective in gaining a deep and meaningful understanding of the experience.
The researchers hypothesised that the anonymous survey offered an opportunity to give honest feedback, in contrast with an interview with a researcher, which could influence their willingness to be completely open. The WEMWBS also provided a quantitative angle to the project, which helped support the qualitative work; however, this would need to be delivered to a larger sample than the small sample in this study to be generalisable. The sample was insufficient for this under WEMWBS guidance (WMS, 2023). Furthermore, not enough staff time was allocated in the project to triangulate the data with an analysis of individual WEMWBS linked to the qualitative responses.
There were issues with both recruitment and retention. First, owing to the nature of the research question, the authors could invite only students who had not yet experienced placement. One solution could be to widen the study to other higher education institutions. Retention was an issue as 10 participants who initially consented did not return their questionnaires. Upon discussion with the those students, anecdotal feedback showed that they had lost interest, forgotten or been too busy to respond. To rectify this, the team will offer a financial reward as part of the larger project to encourage participation.
The mixed methods that were used were effective, and the researchers plan to use the same mixed methods with the aforementioned adaptations for a larger-scale future project, which will monitor mental wellbeing and explore the factors that help and hinder it over a longer period in a larger, national sample.
The team will also explore the relationship between the quantitative and qualitative data to explore what kind of student has what type of experience—for example, if mature students have a more positive experience than younger students. A larger project of this nature will help to inform university and placement provider strategies to support all undergraduate paramedics across the spectrum.
Future research
The authors recommend that a larger study of a similar design be conducted to track student wellbeing over the entirety of their educational programme to identify factors that protect and damage wellbeing. Knowing about these factors would allow opportunities for wellbeing initiatives to be implemented and targeted during known intervals of poor student paramedic mental wellbeing.
A larger study could also link population characteristics to wellbeing. This would allow educational programmes to identify at-risk students and tailor mental wellbeing initiatives to each demographic group.
Limitations
This pilot mixed-methods project had several limitations. Most notably, the sample size hindered the generalisability of the quantitative results. This study did not reach the target sample of 30 for the quantitative analysis.
Furthermore, because the project had limited resources, the team was unable to complete the data triangulation and explore how the quantitative data interacted with the qualitative data, which could have yielded in further depth what type of student has what type of experience. This will be done as part of the main project that this pilot study has informed.
Conclusion
This pilot study explored the mental wellbeing of student paramedics before and after their first ambulance placement taking a mixed-methods approach. The quantitative sample size achieved limited the conclusions that could be drawn, but showed some evidence that ambulance placement can have a positive effect on wellbeing in novice student paramedics.
The qualitative results showed that for this cohort of student paramedics, ambulance placement was an overall positive educational experience that confirmed their career choice and narrowed the theory-practice gap.
The study also showed the mentor relationship is an important aspect of the ambulance placement, and that students experience traumatic events on placement.
Further research will adopt a similar research design, with adaptations, at a larger scale to improve the understanding of mental wellbeing across the entire student paramedic population in the UK. This will help to inform university and placement provider strategies to support all undergraduate student paramedics.