Within the last decade, there has been a rise of 500% of undergraduates experiencing poor wellbeing (Thorley, 2017) alongside a national increase in demand on university counselling services (Macaskill, 2013).
Although precise data regarding student mental health is unknown, research suggests university students are at a high risk of mental health conditions (Office for National Statistics, 2018) because a multitude of complex biopsychosocial factors, including age (Kessler et al, 2007), social transition (Student Minds, 2018), financial strain (Richardson et al, 2017) and academic stressors (Banerjee and Chaterjee, 2016).
Furthermore, higher education institutions (HEIs) have seen a 79% increase in instances of death by suicide since 2007 (Universities UK, 2018). Student mental health is receiving growing attention and has been described as a core educational and governmental priority (Education Policy Institute, 2018).
Although evidence surrounding student paramedic mental health is limited, the broader narrative around healthcare students indicates they have a greater risk of poor wellbeing and experience of mental health conditions (Brennan and Timmins, 2012; Mao et al, 2019; Zeng et al, 2019).
Medical students have been the focus of the majority of research, which has found they have an increased risk of experiencing depression and anxiety (Dyrbye et al, 2006), and this has been supported by recent studies into midwifery (van der Riet et al, 2015) and nursing students (Bartlett et al, 2016).
Stress, shift work, fatigue and emotional labour have also been commonly cited risk factors (Brennan and Timmins, 2012; van der Riet et al, 2015) and, in the absence of literature specifically about student paramedics, provide context for the developing field of paramedic practice.
Paramedics are at an inescapable risk of exposure to traumatic and emotionally laborious situations. They frequently respond to mental health emergencies and are often a person's first point of contact during a mental health crisis (Green and Pound, 2020). Furthermore, evidence suggests that 91% of ambulance personnel experience poor mental health and wellbeing (Mind, 2016) and an increased risk of suicidal ideation (Vigil et al, 2019). Furthermore, paramedics have higher sickness levels than staff in other NHS occupations (Simmons et al, 2019).
This grave information results from a multitude of factors, including severe operational demand, antisocial shift patterns and emotional labour (Holmes et al, 2017). Despite the prevalence of these problems, paramedics remain one of the least likely professionals to seek mental health support and significant stigma is still attached to the disclosure of difficulty (Mellow, 2017).
Since attaining professional registration with the Health and Care Professions Council (HCPC) in 2001 (Fellows and Harris, 2019), paramedicine has seen an evolution that has demanded a shift in prehospital education from vocational qualifications to academic programmes (First et al, 2012); this has been synonymous with the regulatory mandate that all paramedics must now achieve a BSc award (HCPC, 2018).
This academisation has seen an increase in the number of paramedic students, in particular those from lower age demographics (Taxel, 2017), which has raised questions over emotional vulnerability (Whiting et al, 2019).
Despite university academics' essential role in providing student support, limited literature was identified in a structured literature search that specifically explored their perceptions towards student mental health and wellbeing, and no literature was identified relating specifically to paramedic lecturers.
Given the growing number of preregistration students, the current context of undergraduate mental health and the undisputed physical and psychological demands and vulnerabilities involved in prehospital practice, the role of academic staff in supporting clinicians of the future is a crucial area for exploration.
Aims
This study aimed to highlight the experiences of paramedic senior lecturers and their perceptions towards the wellbeing of student paramedics and to explore difficulties around supporting students.
Research design
As this project endeavoured to explore and understand the rich and detailed experiences of paramedic senior lecturers, a qualitative paradigm was selected. Interpretive phenomenological analysis (IPA) was used as this approach aims to illustrate the life-worlds of participants and explore a specific phenomenon. IPA embraces the subjective rather than searching for a singular ‘truth’ (Eatough and Smith, 2017) and is particularly useful in areas of study where there is a paucity of previous research, as is the case with paramedic faculty (Neubauer et al, 2019).
In an IPA framework, researchers must demonstrate curiosity and empathy, and recognise that they cannot prevent themselves from attributing meaning and therefore acknowledge their contextual and active position within the research (Smith and Osbourn, 2011). As the principle researcher is a current pastoral lead and senior lecturer within a paramedic department, self-awareness and the importance of reflexivity throughout the research process was crucial.
A purposive, predominantly homogeneous sample was undertaken in line with the IPA approach to enable a full exploration of shared experience and a rich synthesis of data (Smith, 2011).
Six paramedic senior lecturers (five men and one woman) were self-selected from three urban universities. The sole inclusion criteria were that participants had to have a student-facing role and a paramedic background. Each individual had more than 10 years of clinical experience and had been undertaking the role of senior lecturer on an undergraduate programme for an average of 5 years.
Although the sample was small, this aligned with IPA recommendations (Smith, 2011) to generate rich data from individual participants and identify clear themes. Data was collected until the point of saturation when there were adequate data to reach a clear understanding of the participants' perspectives (Saunders et al, 2018). Being a senior lecturer, although not initially stipulated by the principle researcher, was a uniting characteristic of the participants.
Methodology
Ethical approval was granted by City, University of London's research and ethics committee, and informed consent was gained from all participants. Because of the emotive nature of the research, participant emotional safety was paramount and information sheets with details of support services were provided.
Data collection took place between October and November 2019. All interviews were audio recorded, electronically transcribed then thematically analysed using the IPA framework and six steps suggested by Smith et al (2012). This involved reading and re-reading, initial noting, developing emergent themes, searching for connections, moving on to the next case and looking for patterns across cases.
Results
Four superordinate themes, outlined below, were identified:
Participants are referred to as P1–6.
Navigating the professional role
There was a sense among all participants that they perceived their role as a paramedic lecturer to include student support. However, it appeared that the extent of these pastoral demands were not fully understood before the role was taken up, which raised concerns about feeling underprepared:
‘The pastoral aspect of the job caught me off guard to be honest. I was expecting it to exist, but I wasn't expecting it to formulate such a primary role.’
Many participants described unfair assumptions that the paramedic lecturer role was comfortable, with a minimal workload and subject to privilege, which did not accurately reflect the demands of the role:
‘Because everyone thinks universities teach, brilliant, all you do is teach, mark, teach, mark, have long holidays; it's lovely.’
For all participants, being mindful of the limitations of their academic role and maintaining professional boundaries appeared crucial but was challenging to navigate.
P6 advocated the importance of setting expectations among the wider student body but acknowledged problems here and said careful moderation was essential:
‘I think sometimes that they come in with unrealistic expectations of what we can provide.’
Despite acknowledgement of the limitations of the paramedic lecturer role in supporting students, there was a need to balance their academic role with the requirements of being a registered professional. Participants seemed to consider their paramedic identity as pivotal, with an inference that it was this that drew students towards confiding in them:
‘They come to you because you're a clinician.’
All participants had a feeling of confidence in supporting students because of their professional background, with an acknowledgement that supporting students may be more difficult for academics in other areas. Furthermore, compassion and kindness were seen as a core aspect of their paramedic identity:
‘I think naturally, by the nature of being a paramedic, you tend to be far more caring, and actually we want to try and help everybody.’
‘You are giving a piece of you to all of your students.’
Terms and phrases associated with paramedic practice may further highlight this affiliation to prehospital identity:
‘There are other people here whose primary role is to deal with them from a clinical point of view and a wellbeing point of view. And that's where you sort of have to hand them over.’
‘You are going to refer that patient on, or the student on rather.’
These language choices suggest the participants' default position is as a paramedic, viewing issues around student wellbeing through a clinical lens. There seemed to be a process of constant internal role ‘checking’ that was evident and a frequent association between their lecturer and paramedic roles.
For the majority of participants, the issue of duty of care appeared multifaceted, transcending their role of academic faculty. Again, this was concomitant with their role as a paramedic, but concern around professional responsibility for student safety was apparent:
‘I think that it's everyone's big concern, that it happens and that it happens on their watch and perhaps they missed something or you know weren't available.’
Neither P1 nor P2 used the word ‘suicide’ but referred to ‘being the last person to see them’ (the student). Although this may highlight the taboo nature of suicide, the way participants communicated their thoughts highlighted a deep care for students, a burden of responsibility and the need to be vigilant to risk.
The whole student
Some participants seemed to find it difficult at first to articulate their understanding of student paramedic wellbeing but appreciated that the term encompassed a multitude of factors.
P5 and P1 highlighted that age and transition to university were important factors in the vulnerability of students:
‘We have a lot of students that are quite young, attending university, their first time away from home, everything like that.’
For P3, however, the age of paramedic students was equated with their efficacy to perform on the programme:
‘Some of the youngsters have only ever spoken to their parents—they are the only adults they have ever dealt with. They are very immature, sort of emotionally.’
All participants said they frequently supported students with a range of common mental health conditions and diverse wellbeing needs.
Recognition of the unique nature of student paramedic programmes and their impact upon wellbeing appeared important to participants:
‘They have the challenges of placement, being exposed to things that people at 18, 19 generally aren't.’
‘You are a student who does shift work and you can't engage in the sort of social activities that other students can engage in.’
In addition, there was a sense that some participants saw themselves as ‘role models’ and this professional insight enabled them to meet the holistic needs of their students:
‘I think having somebody that they can turn to who you know might have a bit of wisdom and experience and also empathy for their personal journey is incredibly important.’
‘I think sometimes they want to hear how I would manage the situation.’
Supporting resilience and preparedness for practice
The recognition of the emotional demands of student paramedic work was evident among all participants:
‘They are seeing things that they wouldn't ordinarily choose to see and it is completely unpredictable—we can't shield them, we can't ease them in gently.’
The challenge of the unknown in operational practice appeared to conflict with lecturer desire to protect students from human tragedy.
P6 recognised that not only the events that students witnessed and experienced but also their emotional investment were important, and that these could have an impact upon student wellbeing.
Participants acknowledged both the value of holistic support for student paramedics as well as problems with resourcing both on an individual level and within central counselling and wellbeing services.
They remarked upon the usefulness of general university welfare services for student paramedics, advocating for a more tailored approach to support:
‘They [the students] don't feel that those who are providing the support understand the role of a student paramedic.’
There was a clear sense from many participants that providing generic support services may lead to greater demands on paramedic senior lecturers.
The value of peer support was also highlighted by five out of six participants as an important aspect of holistic support to students:
‘We have a bi-weekly student-led drop-in chit chat session, with a focus on talking about academic worries, placement worries, sharing and swapping stories across the students.’
Being proactive, collaborative and preventive were key for participants and seemed to be central to providing effective support, along with a centralised approach to ensuring wellbeing is an essential and core aspect of the paramedic curriculum:
‘We need to have more timetabled sessions around wellbeing and discussion on their own health.’
‘Maybe we don't do enough to prevent, maybe we don't engage with students enough in talking to them about how they can manage their wellbeing better.’
There was a sense here that this dispersion of power and enabling the student voice would be useful in supporting resilience and preparedness for practice.
Enabling a cultural change
All participants highlighted that societal and professional stigma were major barriers to supporting student mental health and wellbeing:
‘The way things are out on the road on placement sort of leads them to believe that they have to deal with these things—it's part and parcel of the job.’
‘The stigma is still there that if they disclose something we don't like the sound of, whether that be they are struggling or not coping, that they are not worthy of being a paramedic.’
While P3 and P4 both remarked they felt that stigma within the ambulance service was decreasing, others felt there was still ‘a long way to go’ (P2).
For some participants, overt advocacy for positive student paramedic mental health and wellbeing and involving the lecturer role were central to enabling cultural change:
‘As a lecturer, we are in a powerful position to influence the mindset and the values and attitudes of our staff within the ambulance service.’
A sense of unity in a common cause and engagement in national schemes were deemed important enablers for supporting paramedic students.
Discussion
Considerable changes have been evident within higher education provision in recent years (Wong and Chiu, 2020, which have seen a diversification of the lecturer role (Daniels and Brooker, 2014) and an increased focus on pastoral support (Tryfona et al, 2013).
Participants within this study acknowledged that pastoral support for students was an aspect of their role; however almost all of them referred to feeling underprepared for the associated workload, a theme that is evident within wider literature (Hassel and Ridout, 2017).
All of the participants described the importance of maintaining professional boundaries yet remarked upon the challenges of managing student expectations. Recent research from the Higher Education Policy Institute (Hewitt, 2019) reported similar findings in other academic faculties.
Current evidence describes a general lack of confidence with pastoral support provision in HEIs and a need to increase academic understanding (Hewitt, 2019). Nonetheless, participants in this project described a sense of confidence in supporting students because of their paramedic background. This may be in part because of paramedics' frequent exposure to individuals in emotional distress and with mental health needs (Rees et al, 2017) and the autonomous working practices of UK paramedics (College of Paramedics (CoP), 2021a).
Participants, however, described challenges in balancing their professional paramedic identity against that of their academic position and an awareness of trying to strike a balance between these two roles.
The concept of academic identity has been subject to wide research (Wong and Chiu, 2020) and it has been suggested that lecturer identity is shaped by their academic backgrounds and communities of practice (Billiot, 2010). This may illustrate how, with paramedic senior lecturers, there was a distinct comparison of interactions with students to that with patients, with frequent use of clinical language and relation of their academic role to their clinical expertise.
Furthermore, participants described the qualities that they felt were associated with their paramedic identity as important to supporting students. Words such as ‘care’, ‘caring’ and ‘empathy’ were frequently evident and these traits are part of the cornerstone of paramedic practice (Kus, 2019).
For participants in this project, alongside a humanitarian and moral motivation for support of those in need (O'Hara, 2015), duty of care and professional registration were important in their role as senior lecturers. Lucas et al (2019) suggest that fear of accusations of negligence and repercussions from registrant bodies are key issues for paramedics and may be relevant to concerns around student suicidality and risk.
Another finding related to challenges in defining and conceptualising mental health and wellbeing, which are multifactorial (Barkham et al, 2019), with a general lack of understanding on the part of academic staff (Student Minds, 2018). This ambiguity was also evident with respondents in this research project. While some queried the usefulness of a singular definition of wellbeing (Dodge et al, 2012), in the context of student wellbeing it has been advocated as essential to ensuring student services are tailored to meet the needs of the student body (Barkham et al, 2019).
Despite the vagueness around definitions, there was considerable understanding of the complexity and diversity of needs among students. Many participants commented on their experience of students being a high-risk group for mental ill health, which was compounded by the emotional and physical labour of being a paramedic student.
Although cognisant of their professional boundaries, senior lecturers appeared to feel a shared emotional connection and empathy towards the students, perhaps as a result of their professional practice, and commented on how they were often seen by the undergraduates and, indeed, by themselves as role models.
Within university settings, the impact of stigma on student help-seeking behaviour has been widely documented (Student Minds, 2018); for participants in this study, this problem was compounded by issues of mental health stigma with regard to ambulance practitioners (Clompus et al, 2016). Paramedics have a high risk of experiencing mental health difficulties (Petrie et al, 2018) but are significantly less likely to reach out for support (Mind, 2016). Literature has highlighted that paramedics are deemed to be ‘invincible’ (Haugen et al, 2017) and fear disclosure may lead to a perception of ‘weakness’ (Mildenhall, 2019), a word that participants used frequently.
Five of the participants said there had been progress with regards to mental health stigma in paramedics, which is in line with recent research from Mind (2019). There was a strong feeling that they were in a position to address this stigma through advocacy in their role as university senior lecturers and this is supported by the professional bodies (CoP, 2021b).
However, it has been acknowledged that this cultural shift cannot be achieved by academics alone and a ‘whole university approach’ to mental health and wellbeing, which ensures a responsive and proactive approach to student health, is essential (Universities UK, 2020).
Although the definition and theoretical positions surrounding resilience have been subject to substantial debate (Hu et al, 2015), preparedness and access to relevant support have been advocated to boost resilience and positive mental health both generally (Ozbay et al, 2007), and within paramedic practice (Clompus and Albarran, 2016).
All participants in this project acknowledged they could not protect students from experiences in clinical placement settings, and most expressed a strong desire to prepare students for the gruelling nature of paramedic work. Participants raised the importance of embedding mental health and wellbeing within the curriculum to maximise awareness and develop student resilience. Similar recommendations from both paramedic students and course coordinators have been evident within Australian universities (Holmes et al, 2017)
Embedding wellbeing and mental health within the university curriculum has also been advocated in the recent university mental health charter (Hughes and Spanner, 2019). It is clear that this normalisation of discussion may promote a positive culture around mental health and encourage student empowerment (Thorley, 2017).
Participants in this project saw holistic and timely support as extremely valuable. The issue of resourcing student support is widely recognised among HEIs (Student Minds, 2018) and there have been calls for more funding for university support services (Brown, 2018).
Four participants said resourcing tailored support to paramedic students to meet the unique demands of the profession was important. This area requires further exploration and research.
Peer support for paramedic students was an important concept for participants. The value of peer support in both mental health contexts (Repper and Carter, 2011) and university settings has been widely discussed (Horgan et al, 2013) and is seen as an essential aspect of support for undergraduate students (Ali et al, 2015). Peer support models within the ambulance service have gained momentum, leading to positive cultural change (Donnelly et al, 2016; CoP, 2021a).
Limitations
The small sample size was a limitation of this research, so the findings may not be generalisable outside the context of this study. However, the rich data sourced provided clear and important themes for consideration.
In addition, all participants were senior lecturers, which may affect the generalisability of the data to other academic faculty grades.
Conclusion
Paramedic senior lecturers appear to experience a unique and significant demand in supporting students with a range of emotional needs.
Affiliation to paramedic identity and shared operational experience appeared to be of significance along with a strong desire to help students. Navigating their duty of care and professional limitations was highly relevant and there was a clear need from HEIs to formally clarify the boundaries and role expectations of faculty staff. It may be appropriate to incorporate this as an aspect of ongoing supervision for paramedic senior lecturers along with best practice discussions of student wellbeing during faculty meetings.
In terms of cultural evolution, paramedic senior lecturers have a significant and powerful role to play in challenging stigma and embedding wellbeing education within curricula to support the health and resilience of future clinicians. Similarly, they may be instrumental in preparing students by sharing their unique experiences in practice, along with adaptive strategies for developing resilience and psychological safety. Examples may include the use of small group teaching to encourage space for self-reflection among students, along with ensuring that psychological safety is at the heart of all programme teaching.
This approach may also positively influence the general discourse around paramedic mental health, while promoting a culture in which students are empowered to be mindful of and express their own emotional responses without the perilous expectation of invincibility.
It is clear that timely access to bespoke support may benefit student paramedics given the unique nature of their role. This may include trauma-focused interventions and peer support initiatives.
Standardised approaches to paramedic wellbeing strategies and curricula should be encouraged across HEIs along with the sharing of best practice and support for paramedic academics.
This paper highlights the experiences of paramedic faculty—an area that has not been previously explored but is arguably an intrinsic element of the wider context of student paramedic mental health and wellbeing. Further research in this area would therefore be beneficial, and it is advocated that IPA may be an effective approach for this exploration. There is no doubt that further investigation will improve understanding of the crucial issue of the welfare of student paramedics, and the unique position of the academics who support them.