In 2014, 15% of the Australian population were aged 65 years or greater, an increase from 12.5% in 2001 (Australian Bureau of Statistics, 2015). The proportion of the population in this age category is predicted to increase to approximately 23% by 2060 (Australian Bureau of Statistics, 2013). An ageing population is associated with an increased prevalence of chronic disease; influencing both health policy and delivery owing to the growing demand it places on health services—including paramedicine (Lowthian et al, 2011; Australian Health Ministers' Advisory Council, 2017).
Focus on hospital avoidance and community-based health service delivery has led to the development of new models of ambulance service delivery. These models aim to provide safe and effective care for older people who may experience injury or illness that is complicated by age or comorbidity, or who present with complex chronic health problems (Bigham et al, 2013; Thompson et al, 2014). However, education that prepares paramedics for practice has traditionally focused on resuscitation and management of acute injuries or health emergencies and has not addressed the health needs of older patients (Hou et al, 2013).
For example, approximately 5% of the emergency call caseload in New South Wales, Australia, involves older people who have fallen, with a reported non-transport rate of 25% (Simpson et al, 2013) and evidence of a high risk of further falls among non-transported cases. As such, paramedics must be able to perform a focused health assessment of the older person to make safe clinical decisions regarding treatment, referral or non-transport, and reduce the risk of inappropriate clinical decisions (Mikolaizak et al, 2013).
There are numerous challenges associated with the development of student skills in caring for older patients in the ambulance service environment. These include:
Student placements within residential aged care facilities (RACF) present an opportunity to observe the multidisciplinary delivery of aged care while also learning the skills required to provide safe and effective community-based health care for the elderly. However, similar initiatives have identified poor educational design as a major barrier to student satisfaction with their learning (Lucas et al, 2013). From student reports, negative experiences included factors such as a lack of clarity regarding the placement structure; infrequent opportunities to participate in meaningful care; and inadequate clinical liaison support (Lucas et al, 2013). However, other research reports positive learning experiences if students are adequately prepared for placement; supported during the placement; and have an appropriate learning framework to underpin their learning (Lea et al, 2014).
The current report describes the design, implementation and evaluation of a project developed to embed aged care within the first year of an existing entry-to-practice paramedic programme at the University of the Sunshine Coast (USC). It explores student perceptions following a 2-week placement in a RACF. The theory being tested is that the development of a structured series of learning activities in a RACF under the supervision of a trained facilitator will help students to develop specific competencies which are required to care for older people.
Methods
Placement design
The intended outcomes, learning activities and assessment were aligned with the paramedic curriculum. The learning outcomes required the student to:
The design of the learning activities involved an analysis of student learning needs based on contemporary evidence of paramedic practice as well as interviews with paramedic educators and nurses working as facilitators in RACF to achieve consensus on learning objectives. Academic staff met with key staff from RACF and community nursing organisations in the region to explain the aims of the project, gain support and recruit aged care nurse facilitators. This enabled the development of a reference group of key stakeholders. During the early negotiations, it was clear that there was overwhelming support for paramedic student placements in regional RACF.
The following eight learning modules were developed to support the learning objectives associated with the placement:
These modules included both pre-placement and in-placement learning activities. Modules were available through the online portal for the placement course, and a printed version of the workbook was completed by students during the placement. A series of video vignettes based on the experiences of a fictitious patient, ‘Edna’, guide the student from an initial encounter with the patient following a fall at home through to care in the emergency department and discharge to an RACF. A local actor played the part of the patient, with the videos filmed from the point of view of the student. In addition, students attended a compulsory orientation to the placement on campus, and also completed orientation within the assigned RACF at the commencement of the placement.
Study design
Participants
All first-year students enrolled in Paramedic Foundation Practicum 1 (n= 123) undertook the first aged care placement in January 2014. This is the first clinical placement for the students enrolled in BSc Paramedic Science. The second cohort completed this placement in January 2015 (n=115).
Placement setting
Nine sites agreed to provide placements for the pilot in 2014. All sites were based in the Sunshine Coast and Brisbane Metropolitan North region. The RACF selected for this project were required to be fully accredited and to meet the Australian Aged Care Quality's agency standards. In addition, each agency had prior experience with the placement of university students, and agreed to meet the paramedic learning objectives outlined in a pre-placement meeting.
Data collection
In both 2014 and 2015 cohorts, students were surveyed at the completion of the placements to evaluate the benefits and limitations of this initiative. Data were collected on two separate occasions within the cohorts to examine differences in student experience following the 2014 placement, and subsequent improvements to the programme based on this evaluation feedback. An online survey was used to collect student data from those completing the placement. This report evaluates the initial placement in 2014, and the following placement in 2015 that surveyed a new cohort of students undertaking the placement following changes that were informed by the evaluation of the 2014 placement.
A qualitative study of student attitudes to aged care was undertaken to evaluate the student experience and the suitability of the learning environment. An online survey used a 5-point Likert scale that required responses that ranged from ‘strongly disagree’ to ‘strongly agree’ regarding each of the following aspects of the placement:
The evaluation of the effect of the learning modules was measured through the students' responses to the ‘learning outcomes’ section of the Likert scale survey items. Students were also able to add comments to questions about the least and most enjoyable aspects of the placement, and could include suggestions for future changes. The survey was not based on a previously validated instrument owing to the lack of methods to measure paramedic student attitudes and experiences during or following clinical placements. However, construct and face validity was assessed by paramedic academic staff at USC prior to the implementation of the online survey.
Data analysis
Survey results were exported from the online survey tool (Opinio). Descriptive analysis was used to report frequency of responses for categorical variables. Chi-square tests were used to analyse change in item rank by year.
Content analysis was used to analyse the free text (Krippendorff, 2013). Inductive codes were added on the basis of information that emerged as the authors reviewed the survey data. NVivo (v. 10 QSR International) was used to structure, summarise and organise the unstructured data. The words or phrases selected from each text field were linked to a theme within the inductive codes (Table 2).
| Construct | Strongly disagree | Disagree | Neutral | Agree | Strongly agree | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Year | 2014 | 2015 | 2014 | 2015 | 2014 | 2015 | 2014 | 2015 | 2014 | 2015 |
| I accomplished my learning objectives during this clinical experience | 0.0 | 0.0 | 9.2 | 5.3 | 15.4 | 15.8 | 53.9 | 36.8 | 21.5 | 42.1 |
| This placement improved my knowledge about how an aging population can be supported to maintain independent living in the community and remain socially connected | 0.0 | 0.0 | 9.1 | 3.5 | 18.2 | 17.5 | 47.0 | 31.6 | 25.8 | 47.4 |
| The skills students learn in aged care settings are transferable to paramedic practice settings | 3.0 | 1.7 | 12.1 | 8.8 | 39.4 | 14.0 | 24.2 | 40.3 | 21.2 | 35.1 |
| There are insufficient learning experiences in aged care settings | 1.5 | 15.8 | 22.7 | 42.1 | 25.8 | 17.5 | 36.4 | 17.5 | 13.6 | 7.0 |
| The aged care placement helped me to develop a good understanding of health and community support mechanisms for people with limited independence | 1.5 | 0.0 | 6.2 | 5.4 | 16.9 | 12.5 | 64.6 | 46.4 | 10.8 | 35.7 |
| I have a stronger appreciation of the role and responsibilities of nurses, allied health and other staff working in aged care | 0.0 | 1.7 | 1.5 | 3.5 | 13.6 | 7.0 | 40.9 | 29.8 | 43.9 | 57.9 |
| Following this placement I feel more confident about my paramedic practice | 1.5 | 7.0 | 15.4 | 8.8 | 21.5 | 17.5 | 44.6 | 24.6 | 16.9 | 42.1 |
| The aged care placement was not able to develop knowledge or skills I will need to practice as a paramedic | 12.1 | 28.1 | 34.9 | 36.8 | 28.8 | 14.0 | 15.2 | 7.0 | 9.1 | 14.0 |
| I feel more confident in communicating with and caring for older people | 1.5 | 0.0 | 1.5 | 5.4 | 21.2 | 7.1 | 40.9 | 30.4 | 34.9 | 57.1 |
| I am now more positive about the value of aged care placements than I was prior to the placement | 7.6 | 1.7 | 13.6 | 12.3 | 25.8 | 19.3 | 36.4 | 29.8 | 16.7 | 36.8 |
| This placement helped me to develop useful professional skills | 4.6 | 3.6 | 7.6 | 7.1 | 18.2 | 14.0 | 51.5 | 29.3 | 18.2 | 35.6 |
| Theme, code and positive and negative experience | Frequency | ||
|---|---|---|---|
| 2014 | 2015 | ||
| Interpersonal contact | |||
| Contact with facility staff | + | 12 | 6 |
| - | 17 | 2 | |
| Contact with other students | + | 3 | 2 |
| - | 5 | 0 | |
| Contact with residents | + | 15 | 18 |
| - | 0 | 0 | |
| Facilitator support | + | 2 | 5 |
| - | 6 | 4 | |
| Placement structure | + | 1 | 2 |
| - | 17 | 17 | |
| Learning | |||
| Aged care | + | 3 | 1 |
| - | 0 | 1 | |
| Clinical skill practice | + | 8 | 10 |
| - | 13 | 5 | |
| Pharmacology | + | 4 | 4 |
| - | 2 | 0 | |
| Needs of the older person | + | 10 | 5 |
| - | 1 | 1 | |
| Soft skills | + | 25 | 20 |
| - | 2 | 2 | |
| Watching other experts | + | 1 | 3 |
| - | 2 | 0 | |
| Wound care | + | 7 | 1 |
| - | 0 | 0 | |
+ valuable experience
- not valuable experience
Ethics
Ethics approval was granted by the Human Research Ethics Committee of the University of the Sunshine Coast, approval code: A/13/527.
Results
The student experience survey during the 2014 placement was attempted by 69 out of 123 students—a response rate of 56%. The median student age was 21 years (interquartile range (IQR) 19–27) and 58% were female. Seventy-eight per cent reported no prior healthcare experience preceding the placement, and 39% reported that they had not previously visited an RACF. Table 1 shows the frequency of responses to the survey items by year in the category addressing learning outcomes.
The 2014 results show that 75.4% of respondents agreed that they were able to achieve the required learning outcomes during this placement, with 72.8% agreeing that the placement improved their knowledge of community-based care for the elderly. The majority of students agreed that the placement improved their confidence as paramedic practitioners and that the experience helped to improve communication skills with older people. Fifty-three per cent of respondents agreed they had a more positive attitude towards the value of an aged care placement than before the placement. A chi-square analysis of item rank by year did not reveal any statistically significant differences.
A survey item that asked the respondent to compare his or her attitude to aged care placements pre- and post placement showed an increase in positive attitude post placement in 2014 (Figure 1). The student experience survey during the 2015 placement was attempted by 67 out of 115 students—a response rate of 58%. The median student age was 21 years (IQR 19–25) and 60% were female. Seventy-eight per cent reported no prior healthcare experience preceding this placement, and 39% reported that they had not previously visited an RACF.
In 2014, 50% of respondents agreed with the statement: ‘There are insufficient learning experiences in aged care settings.’ Following this feedback, changes were made to the 2015 programme to ensure that students were more actively involved in activities associated with their learning objectives. The 2015 cohort response to this survey item showed that 24.5% agreed with this statement. The 2015 survey result also showed a higher proportion of respondents agreed with the statement: ‘I am now more positive about the value of aged care placements than I was prior to the placement’ (2014, 53.1%; 2015, 66.6%).
Figure 2 shows the students' response to a survey item that compares their attitude to aged care placements prior to and following the 2015 placement, which shows an increase in the frequency of agreement to the statement when compared with the 2014 result.
Comment responses to the 2014 and 2015 placement surveys (n=150: 2014, 83; 2015, 67) were coded into separate themes. Some responses contained multiple themes. The constructs that emerged from the data were:
There were 58 comments referring to relevance (2014, 37; 2015, 21) and 156 comments referring to improvement (2014, 89; 2015, 156). Table 2 shows the number of comments for interpersonal contact and learning which were divided further into valuable experiences (2014, 83; 2015, 67) and not valuable experiences (2014, 67; 2015, 101). Several students commented on their positive experiences:
‘This placement has been very helpful and I think all paramedics need to do it.’ (2014 participant)
‘The facility I went to was great and my facilitator was really knowledgeable and taught me a lot. We got a lot of hands on experience and I really enjoyed my placement.’ (2015 participant)
However, low perceptions of relevance were associated with involvement in activities of daily living such as bathing, dressing and toileting:
‘Copious amounts of time standing idle’ and ‘spending hours doing jobs we won't be using in the paramedic setting such as making beds and clearing up plates.’ (2014 participant)
Discussion
The engagement of facilitators in the development of the USC aged care placement, the allocation of trained preceptors, and the development of clear learning activities and objectives contributed to the success of this initiative. This helped to overcome previously documented deficiencies in student aged care placements.
This project generated high levels of support from aged care facilities and community nursing organisations, evidenced by the number of placements offered exceeding the demand. Despite some initial student resistance in 2014 to the introduction of an aged care placement, overall students reported that they valued the learning opportunities offered by aged care placements.
Following the 2014 placement, the scheduling of aged care and ambulance placements was reviewed based on student feedback. Positioning the aged care placement prior to the ambulance placement markedly reduced resistance to the placement in the 2015 cohort. Additionally, having this learning activity as the students' first clinical experience facilitated the development of skills that were directly transferable to paramedic practice, but which were enabled without having to deal with the often stressful and time-critical situations encountered during ambulance placements.
Students reported that the placement was associated with an improved understanding of health problems associated with ageing. In addition, the placement provided a better understanding of the role of other health professionals in the maintenance of an older individual's health, social and spiritual needs. Improvements made to the design of the placement that followed the evaluation of the 2014 placement translated to improved levels of student engagement and satisfaction with the placement, as evidenced by the results of the evaluation of the second placement.
The major weaknesses of this placement was the variability of learning across placement sites and reluctance of some RACF staff to involve students in components of care linked to learning objectives. Without a clear understanding of the learning needs of the student and the scope of paramedic practice, there may be a tendency by RACF staff to restrict student involvement in higher level health assessment and care tasks. As such, further work may be required to achieve higher levels of staff preparedness to engage students in appropriate care in some settings. It should be noted that there is also evidence of failure to involve students in patient care in ambulance placement settings, and this may reflect a broader reluctance to delegate responsibilities when the supervisor is unfamiliar with the student's capabilities (McCall et al, 2009).
Some students reported that they were uncomfortable with involvement in activities of daily living, particularly showering and toileting residents. However, they also realised that these tasks may occur in paramedic practice when caring for patients suffering incontinence. Comments related to ‘downtime’ or perceptions that time was not always spent productively reinforces a need to develop the students' skills in negotiating learning and proactively seeking learning opportunities.
However, some feedback demonstrated student disappointment with unsuccessful attempts to collaborate in or initiate care activities. Again, this may reflect staff unfamiliarity with the students' role or scope of practice. Several students found caring for patients with advanced dementia challenging. The emotional impact of caring for patients at end-of-life was evident in some feedback, which reinforces the need for adequate preparation of students to deal with death and dying.
Limitations
There are several limitations affecting the generalisability of this study. First, a validated survey was not used, nor was pre-/post-testing conducted. Second, the students perception of professional identity may bias the data if they believed that the role of a paramedic does not included aged care and has no place in an entry-to-practice programme of education. Evidence for this is that moving the placement reduced resistance, which suggests role identity may have affected the first placement cohort data. The anonymous responses to the survey may have helped to limit this bias. Third, the survey participants were self-selected and participants may have been more inclined to answer in a particular way. Fourth, it is unknown whether the prior knowledge, experience and motivation of the participants are similar to those of other cohorts of student paramedics.
Conclusion
The current study has guided the development of the USC paramedic aged care placement as an important ongoing clinical experience. Aged care placements provide opportunities to learn about the health care of older people and this project has shown that it is possible to enable important learning outcomes that are directly related to core paramedic competencies. However, educational facilities that are considering the introduction of aged care placements for paramedic students should consider the enablers and barriers to learning identified in this project. Doing so would optimise the learning that can be achieved during the limited time available for clinical placements.
Paramedic students can benefit from learning within an aged care setting, but this requires careful attention to educational design principles to develop appropriate learning activities, support resources and assessment tasks. Students must know what to expect during the placement and understand their role and the role of others within the RACF.
Pre-engagement activities must ensure that students are able to assist with activities of daily living, if this is one of the intended learning activities. These may include skills such as assistance with feeding and mobility support that are required to participate in safe care. This may require a pre-placement workshop to develop specific skills to work safely in aged care. Facilitators must be prepared for their role, as many will have limited experience in supervising paramedic students and need to understand differences between nursing and paramedic student roles and responsibilities.
Finally, regular feedback during the placement helps to identify learning needs and achievements, and summative evaluation of the placement provides important data to monitor and improve the quality of the placement.