Establishing rapport is said to be central to any health professional-patient encounter (Leach, 2005). Paramedics operate in highly charged, unpredictable and emotionally driven environments on a daily basis where well-developed interpersonal communication skills are imperative and allow paramedics to establish a relationship or rapport with patients. O'Toole (2008) defined rapport as the development of a therapeutic relationship based on mutual understanding (respect, empathy and trust). Developing a positive relationship with a patient enables the health practitioner to elicit pertinent information and make informed clinical decisions about their treatment and on-going care (Barnett, 2001). However, rapport is more than that. It promotes communication, collaboration, and a shared understanding of the patient's perspective (Norfolk et al, 2007). It also requires much more than good intentions and is developed by the words and actions of the individuals involved (Rosenzweig, 1993). Much of the health care literature describes the importance of establishing rapport early in the patient encounter (Leach, 2005); however, it should be remembered that rapport is dynamic and complex threading through the entire course of the patient encounter (Arnold and Boggs, 2010).
The most imperative reason for paramedics and other health professionals to establish rapport with patients is the positive impact this has on patient outcomes (Hook and Pfeiffer, 2007; Egnew and Wilson, 2010). A positive trusting relationship between a health care practitioner and patient facilitates the garnering of information vital to the establishment of a diagnosis and correct treatment options (Leach, 2005). In addition, a patient in a collaborative relationship with a health practitioner they trust and respect is more likely to adhere to their treatment (Clever et al, 2011). Studies by Hojat et al (2011) and Del Canale et al (2012) have confirmed the link between the establishment of this positive empathetic relationship and patient outcomes. Furthermore, patients who have experienced a positive rapport with their health practitioners report better levels of satisfaction with their treatment and are less likely to make a complaint or file malpractice suits (Deveugele et al, 2005).
With the skill of building patient rapport integral to patient care and outcomes it is vital that the teaching of these skills be included in undergraduate health care education. This has become more imperative in undergraduate paramedic education in recent times with a move to university-based pre-employment training, which attracts more school leavers than mature aged students (Pointon et al, 2009). School leavers naturally have had less life experience and time to develop their interpersonal skills through interaction with people beyond their families and social spheres (Willis et al, 2010). Many institutions attempt to teach these skills in the traditional didactic fashion, but this is notoriously complex and difficult (Deveugele et al, 2005, Stephenson et al, 2001; Egnew and Wilson, 2010). Following a review of communication teaching and learning in medicine, Aspegren (1999) concluded that:
‘Instructional methods should not be used in the teaching of communication skills, since they are ineffective in comparison with experiential methods’
A literature review investigated methods used to teach undergraduate nurses’ and paramedics’ interpersonal skills and concluded that the most successful methods appeared to use a combination of teaching strategies, and engaged the students in an activity which had as much realism as possible (Ross, 2012). Instructional methods are therefore often coupled with practical applications including role plays with other students or standardised patients (actors playing the part of a patient) (Wind et al, 2004; Turan et al, 2009). Often these teaching practices will include feedback from peers, educators and/or the patients themselves. Some programmes also integrate video-taped interactions to aid the discussion and feedback process. Another means for students to practice and develop these skills is in the field through clinical placement. Unfortunately, opportunities to hone rapport building skills and personally connect with patients in the field are often limited due to lack of clinical placement opportunities, or can be overridden by the expectation to solicit information and make clinical decisions in a timely fashion (Egnew and Wilson, 2010).
Another method for developing these skills is through encounters with ‘real patients’ with the explicit purpose of practising interpersonal communication and rapport building skills. ‘Real patients’ have been utilised in medical education for decades in the teaching and learning of physical examinations, clinical skills and communication skills (Towle et al, 2010). Not surprisingly most of the literature relating to using ‘real patients’ to teach rapport is centred on this discipline. A recent literature review found several studies that positively reported the use of ‘real patients’ in communication skills training for health professionals. A key finding from this review was that experiential communication skills’ training heightens student awareness of their own abilities, allows for self-reflection and increases motivation. Turan et al (2009) and Norfolk et al (2007) observed that practising communication with ‘real patients’ followed by self-reflection was a great motivator and fostered improvement and development in these skills. Clever et al (2011) and Meili et al (2011) also reported results supporting the benefit of interactions with ‘real patients’ with respect to the patient-centred approach and relationship development. Participants found interactions with ‘real patients’ to be more authentic and meaningful which resulted in them experiencing the development of a true emotional relationship rather than the often feigned simulated relationship. Results illustrated a strong association between the value of the learning experience and the opportunity to develop a relationship with the patient (Clever et al, 2011). Meili et al (2011) also found that students were able to gain greater meaning from forming authentic relationships which had a positive impact on preconceived stereotypes and implications for future practice. Another theme emerging was an overwhelming increase in confidence and comfort when engaging with patients after participating in training utilising ‘real patients’. Students in the Norfolk et al (2007) study self-reported a significant improvement in confidence while students in the Clever et al (2011) project reported feeling far more comfortable interviewing patients than they had done previously. The opportunity to concentrate on, and gain confidence in communication skills and relationship building without the pressure of clinical decision making would appear to be an essential consideration.
While there are definite similarities between all health care professions, the environment and nature of paramedic practice renders it unique and therefore should be the subject of independent research in this area. This project therefore has two aims:
Methods
Design
This pilot study utilised mixed methods incorporating an interventional study design with focus groups.
Participants
Eleven second year paramedic students enrolled in Monash University's Bachelor of Emergency Health (Paramedic) degree were the subjects of this study. The paramedic students were recruited during a second year lecture. The project was explained verbally and via an explanatory statement. The information provided highlighted to students that participation was voluntary and was independent of their academic programme. Each paramedic student recruited for this project was randomly allocated a participant code number. Students were then divided into groups via these participant codes. Participant code numbers 1–6 became the intervention group and numbers 7–11 became the control group. The students were notified of their group during the pre-activity briefing. While all students were members of the same student cohort it was not possible to control for other variables such as age, gender and previous experience. At no stage were the students able to swap groups.
Also participating were eleven independently living elderly residents from Patterson Lakes Village. These participants all lived in their own units and look after their daily living requirements. They were recruited with the assistance of the village staff and were provided with transport to the university. In addition to an explanatory statement the participants were briefed prior to the activity and instructed to ‘just be themselves’ and communicate and engage during the activity as they normally would.
Instrumentation
The Rapport Questionnaire (RQ) was designed by the author and was reviewed by two colleagues to ensure adequate content and face validity. It was based on seven key traits fundamental to rapport development according to Nelson (as cited in Bakic-Miric and Bakic, 2008: 74). It asks participants to rate perceptions of themselves across the 7 traits: confident, empathetic, humane, personal, frank, respectful and thorough, across a five point Likert scale from 1 (low) to 5 (high). In addition it includes an overall ability to build rapport with the elderly ranking and a free text question on how the engagement activity impacted on rapport building ability.
Procedures
On the day of the engagement activity, prior to meeting the elderly participants each student paramedic completed the RQ and a demographic survey. The engagement activity was set up so that each student paramedic sat opposite an elderly participant at individual tables (Figure 1). Each pair engaged in a 10 minute conversation. After 10 minutes the paramedic students rotated to the next table and began a new conversation with another elderly participant. Each student would engage in a total of six 10 minute conversations with the elderly participants.
After three conversations a 10 minute break was taken. During this break the elderly participants and half of the paramedic students (control group, n=5) left the room for refreshments. The remaining paramedic students (intervention group, n=6) remained seated and were joined by paramedic educators.
During the intervention the paramedic educators sat down one-on-one with the six students and guided them through a 10 minute self-reflection process. Students were asked to discuss how their conversations had gone thus far and what techniques had worked or not worked for them. During these exchanges the educators offered tips and advice on how to enhance rapport development. This process culminated in the students highlighting strategies they would use in the subsequent conversations to improve their rapport building.
Two weeks after the engagement activity the student paramedics and elderly residents were invited to participate in focus groups. Four volunteers from each group participated in their respective focus group and were asked questions about their perceptions of the activity. These focus groups were audio recorded for further analysis.
Five weeks after the initial activity student paramedics completed the RQ again. This time period was chosen to allow for sufficient wash-out prior to students participating in clinical placements and potentially encountering elderly patients.
Data analysis
The Statistical Package for the Social Sciences Version 20.0 (SPSS) was used for entry, storage, retrieval and analysis of the quantitative and demographic data. Due to the abnormal distribution of data and small sample size non-parametric tests—Mann-Whitney U Test and Wilcoxon Signed Rank Test—were performed. Results were considered statistically significant (p<0.05) and effect size was considered large (r >0.5), medium (>0.3) or small (r>0.1) (Pallant, 2010).
The qualitative data from the two focus groups was transcribed verbatim. It was subsequently analysed by the authors in order to identify major themes. The final themes identified for further analysis were agreed upon through a collaborative process. The RQ open ended questions were analysed utilising the same approach.
Ethics
Ethics approval for this project was granted by Monash University Human Ethics Research Committee (MUHREC).
Results
Demographics
A total of 11 undergraduate paramedic students participated in this pilot study (n=11). Of the second year student participants 63.6% (n=7) were female. The majority of students were less than 23 years old (n=10, 90.9%); the median age was 20 years.
Engagement activity rapport results
Data analysis of the Rapport Questionnaire (RQ) for the entire group revealed three items to be statistically significant and have a large effect size: Confident (p<0.01, r=0.55), Empathetic (p=0.03, r=0.48) and Overall ability to develop rapport with the elderly (p<0.01, r=0.58). Two items trended positively with medium effect size; Humane (p=0.16, r=0.30) and Thorough (p=0.08, r=0.37). See Table 1 for a full representation of results.
| Rapport questionnaire (RQ) | Pre-activity Md(IQR) | Post-activity Md(IQR) | Sig. p value | Effect Size (r) |
|---|---|---|---|---|
| Confident (I display self-confidence) | 4(2–4) | 4(4–5) | <0.01 | 0.55 |
| Empathetic (I try to understand what the person is feeling and experiencing, physically and emotionally, and communicate that understanding with them) | 4(4–4) | 4(4–5) | 0.03 | 0.48 |
| Humane (I am caring, compassionate) | 4(4–5) | 5(4–5) | 0.16 | 0.30 |
| Personal (I have genuine interest for the person and remember them as an individual) | 4(4–5) | 4(4–5) | 0.32 | 0.21 |
| Frank (I am able to explain things in a plain and forthright manner) | 4(3–4) | 4(3–4) | 0.18 | 0.29 |
| Respectful (I listen to their perspective and work with them) | 4(4–5) | 5(4–5) | 0.26 | 0.24 |
| Thorough (I am conscientious and persistent) | 4(3–4) | 4(4–5) | 0.08 | 0.37 |
| Overall (Overall ability to develop rapport with the elderly) | 4(3–4) | 4(4–5) | <0.01 | 0.58 |
p<0.05 considered statistically significant
r>0.5 considered large effect size, >0.3 considered medium effect size
In addition to these results, an analysis of the quantitative data from the RQ free text item pre and post the intervention indicated the student participants felt their rapport building with the elderly improved greatly from the experience. One student stated:
‘I believe this experience has improved my ability to build rapport with elderly individuals. It allowed me to develop my approach and the easiest ways to begin to build rapport and establish a good relationship.’
An analysis of the focus groups data identified key themes which are indicative of rapport development. The elderly participants (EP) focus group key themes were:
The student paramedic (SP) focus group highlighted the following themes:
Guided self-reflection versus control
The intervention group who were guided through a self-reflection process with experienced paramedic educators at the mid-point of the activity improved most substantially across three areas: Confident (p=0.09, r=0.37), Empathetic (p=0.18, r=0.29) and Overall (p=0.14, r=0.3). The control group had no changes in median scores with the exception of the Empathetic item which increase from 4–4.5, but this was not statistically significant, nor did it display an adequate effect size (p=0.75, r=0.07). In addition, three items from the control group had medium effect sizes; however, there was a negative or no change in median and interquartile range; Humane (p=0.05, r=0.43, Frank (p=0.16, r=0.3) and Respectful (p=0.16, r=0.3). The full comparison results can be seen in Table 2.
| Intervention group (n=6) | Control group (n=5) | |||||||
|---|---|---|---|---|---|---|---|---|
| Rapport questionnaire (RQ) | Pre-activity Md(IQR) | Post-activity Md(IQR) | Sig. p value | Effect Size (r) | Pre-activity Md(IQR) | Post-activity Md(IQR) | Sig. p value | Effect Size (r) |
| Confident (I display self-confidence) | 2.5(2–4) | 4.0(4–5) | 0.09 | 0.37 | 4.0(3.5–4) | 4.0(4–4.5) | 0.64 | 0.10 |
| Empathetic (I try to understand what the person is feeling and experiencing, physically and emotionally, and communicate that understanding with them) | 4.0(3.7–4) | 4.5(4–5) | 0.18 | 0.29 | 4.0(4–4.5) | 4.5(4–5) | 0.75 | 0.07 |
| Humane (I am caring, compassionate) | 4.5(4–5) | 5.0(4.7–5) | 0.33 | 0.21 | 4.0(4–4.5) | 4.0(4–4.5) | 0.05 | 0.43 |
| Personal (I have genuine interest for the person and remember them as an individual) | 4.0(4–5) | 4.5(4–5) | 0.83 | 0.05 | 4.0(4–5) | 4.0(4–5) | 0.75 | 0.07 |
| Frank (I am able to explain things in a plain and forthright manner) | 4.0(2.7–4) | 4.0(3.7–5) | 0.84 | 0.04 | 4.0(2.5–4.5) | 4.0(2.5–4) | 0.16 | 0.30 |
| Respectful (I listen to their perspective and work with them) | 4.0(4–5) | 5.0(4.7–5) | 0.83 | 0.05 | 4.0(4–5) | 4.0(4–5) | 0.16 | 0.30 |
| Thorough (I am conscientious and persistent) | 4.0(3–4) | 4.5(4–5) | 0.56 | 0.13 | 4.0(3–5) | 4.0(3.5–5) | 0.55 | 0.13 |
| Overall (Overall ability to develop rapport with the elderly) | 3.0(3–4) | 4.5(4–5) | 0.14 | 0.30 | 4.0(3.5–4) | 4.0(4–4.5) | 0.33 | 0.21 |
p<0.05 considered statistically significant
r>0.5 considered large effect size, >0.3 considered medium effect size
Discussion
The first aim of this pilot study was to investigate the effect an engagement activity with elderly people would have on student paramedics’ ability to establish rapport with this demographic. While the small sample size makes it difficult to pay any credence to the RQ items (Confident, Empathetic and Overall), with statistically significant results and large effect size it was pleasing to see an overall trend in the positive direction. It is not surprising that empathy improved alongside overall rapport building given the link established by many researchers between empathy and rapport (Hojat et al, 2012; Del Canale et al, 2012). O'Toole (2012) includes empathy in the definition of rapport, while Nelson (as cited in Bakic-Miric and Bakic, 2008: 74) lists it as an essential element of rapport development. Similarly, the confidence item reflects the notion that improved confidence translates to better rapport establishment. This is supported by studies by Norfolk et al (2007) and Clever et al (2011), who both reported increased student confidence after engagement activity with ‘real patients’, resulting in better relationship (rapport) development.
The RQ free text responses, which asked participants to answer if and how the engagement activity improved their ability to build rapport with the elderly, were overwhelmingly positive. All 11 participant responses suggested their rapport building ability with elderly people had been greatly improved by participating in the engagement activity. A common theme to emerge, which is supported by the above discussion, was the increased confidence students felt in their ability to establish rapport with the elderly after the activity. One student stated:
‘I believe that this experience greatly improved my confidence in interactions with elderly people. This confidence enables me to establish rapport in a more efficient fashion.’
It is evident from this and similar statements that there is an association between confidence in ability to build rapport and actual rapport establishment. A second theme to arise was the value of the experience interacting with ‘real’ elderly patients—an experience many participants had never been afforded prior to this activity. This was highlighted by student comments such as, ‘this activity gave me an opportunity to engage with the elderly that I wouldn't usually have had the chance to.’ Clever et al (2011) and Meili et al (2011) similarly found students gained more from experiences with ‘real patients’ as they were more authentic and meaningful than practising encounters with peers or simulated patients.
The general consensus from the student focus group discussion was that the engagement activity had improved the students’ ability to establish rapport with the elderly. They also reiterated the themes from other sources discussed above, that confidence was key to rapport building and that engaging with ‘real’ elderly people was invaluable for students with little prior exposure to this demographic. The elderly focus group participants provided glowing praise for the activity and students involved. They highlighted skills paramount to rapport establishment, such as respect, communication and empathy. They also felt rapport had been established based on their feelings of comfort and ease with the interactions.
The secondary aim was to determine if self-reflection would impact on paramedic students’ development of rapport with the elderly. The intervention group (n=6) received a 15 minute guided self-reflection session with an experienced paramedic educator at the half way point of the exercise. The guided self-reflection session was designed to raise the student's awareness of their strengths and weaknesses with regards to rapport development and to come up with improvement strategies for the remaining encounters. The results showed that the intervention group's median scores trended in a positive direction for seven out of the eight items. The Confidence and Overall items again stood out with the most substantial improvements and effect size. Studies by Turan et al (2009) and Norfolk et al (2007) likewise observed that practising communication with ‘real patients’ followed by self-reflection was a great motivator and fostered improvement and development in these skills. The control group (n=5) who received no guided self-reflection recorded little or no change at all across all eight RQ items. These results strongly support the value of reflection during rapport building activities with elderly patients and the value of developing strategies and key areas to focus on.
Implications for practice
As previously stated, paramedics operate in an environment that requires them to be adept at developing rapport and putting patients at ease in a timely fashion. Their ability/inability to do this can have consequences for patient care and eventual outcomes. It is therefore imperative that undergraduate training programmes prepare future paramedics for the job in its entirety which includes the non-clinical aspects such as rapport building.
Study limitations
This pilot study had several limitations which potentially impacted on the results. Selection bias was a factor as students with confidence and enthusiasm for communication activity were more likely to self-select. The students all bought varying degrees of personal and professional experience with the elderly to the activity. The self-report data from the RQ was not necessarily indicative of improvement in rapport building skills, nor was the RQ psychometrically tested. The sample size was not sufficient to present any conclusive findings.
Future research
The results of this pilot study are sufficiently positive to warrant further research in this area with larger more diverse populations. In addition, observational methods could be employed to test actual improvements in behaviour and ability to communicate and build rapport rather than merely measuring participant perceptions. In combination, observational data, patient and student perceptions would build a more comprehensive picture of paramedic student rapport-building skills.
Conclusions
Student's recorded improved confidence, empathy and overall ability to build rapport with the elderly through this engagement activity. In addition, students who received guided self-reflection displayed greater improvements in the above three areas than their control counterparts. Essentially the results of this pilot study suggest the value of this type of interaction in undergraduate paramedic education to facilitate the development of rapport building skills.