Recent retraction of the Institute of Healthcare Development (IHCD) paramedic training programme and the concerted move towards all-graduate recruitment brings paramedics into line with other established healthcare professions; a move that has been championed by the College of Paramedics (CoP).
In 2011/12 the most common gateway into the paramedic profession was via an academic qualification through a Higher Education Institute (HEI) or HEI-accredited ambulance service training programme. In 2012 there were 25 universities offering 52 paramedic programmes and nine ambulance service trusts offering 12 in-house training programmes.
Practice placements are integral to all paramedic programmes, with students required to spend 50% of their time in the clinical practice setting to ‘permit refinement of practice alongside the acceptable academic level of development’ (CoP, 2014).
Within the paramedic profession, mentoring is performed by Paramedic Educators (PEds). These staff are ‘responsible for a student's education during their clinical or practice experience’ (Health and Care Professions Council, 2012), providing clinical supervision and are required to ‘sign-off’ students as clinically competent in predetermined ‘elements of practice’ in the Practice Assessment Document (PAD).
There are currently no national guidelines in relation to the qualifications, skills and experience required to be a PEd other than that they must ‘be a registered professional and have undertaken a programme of appropriate practice education training’ (CoP, 2014). The PEds who mentored the students involved in this research were required to have completed a one-day introduction into the mentorship role.
Background
This study aimed to address a lack of published literature surrounding PEds' mentoring role within paramedic education. As findings from other healthcare professions were used when creating the PEd model, most notably nursing, the current model remains to be tested for its suitability of fit within paramedic culture. Mentoring is still developing within the profession, and the effectiveness of this new skill is still the subject of internal debate.
Any literature review of mentoring in a healthcare context needs to acknowledge Darling's seminal 1984 study: What do nurses want in a mentor? This identifies three vital ‘A’ components of successful mentoring:
Prior analysis translated these into specific research themes, exploring student perspectives of three different aspects of the PEd role:
Understanding of these three themes is informed by eight further landmark studies, ranging from Gray and Smith (2000), a longitudinal cohort study of ten student nurses focusing on the qualities of an effective mentor from the student's perspective, to the most recent, the Dutch study by Huybrecht et al (2011), using validated questionnaires and interviews in seven regional hospitals to investigate practical characteristics of mentorship from the mentor's viewpoint.
Together, these works constitute much of the available knowledge base on effective mentoring and, in various ways, all validate Darling's components, illuminating the essential qualities of mentorship and how students perceive these.
While none of these works directly relate to paramedic students or PEds, their findings are valuable in referring to healthcare professionals who share broadly similar mentoring experiences. Even so, understanding of the PEd role is currently based on rather superficial foundations that may not recognise the distinctive culture and idiosyncrasies that exist within the paramedic profession.
Methods
This study aimed to identify student perceptions in relation to the Paramedic Educator (PEd) roles through narratives using semi-structured interviews, enabling students to share their experiences. They took place during January-March 2013, with interviews facilitated in private meeting rooms at their HEIs to encourage them to talk as students, rather than ambulance personnel.
Semi-structured interviews offer flexibility in relation to the structure, content and order questioning (Kumar, 2011). Focus groups were considered but rejected, as the aim was to identify PEd attributes rather than analyse student/PEd relationships.
Given the likely content of discussions, prior arrangements were made with relevant programme leaders to ensure students would be supported in the event of upsetting recollections. Indeed, interviews needed to be paused on two occasions.
Only final year students were considered for the research study due to the greater contact time they had spent with PEds. They were recruited to the research project via the paramedic programme leaders at each of the three identified HEIs. Although only nine students were recruited (one of whom failed to attend the interview), they represented a range of profiles (Table 1). Data interpretation was carried out by framework analysis and a theoretical framework based upon post-positivist assumptions was employed to interpret findings.
| Higher Education Institution | Participant number | Length of programme of study | Sex | Age |
|---|---|---|---|---|
| A | Participant 1 | 3 years | Male | 26–30 |
| A | Participant 2 | 3 years | Female | 26–30 |
| A | Participant 3 | 3 years | Female | 18–25 |
| B | Participant 4 | 3 years | Male | 26–30 |
| B | Participant 5 | 3 years | Male | 18–25 |
| C | Participant 6 | 2 years | Male | 18–25 |
| C | Participant 7 | 2 years | Male | 18–25 |
| C | Participant 8 | 2 years | Male | 26–30 |
Results
Learning through observation
Participants acknowledged the importance of learning through observation, with all but one explicitly recalling experiences where they had learnt from observing their PEd in practice. Further, it was identified that PEds needed to have good clinical knowledge and thorough understanding of the role of the paramedic, along with understanding of the student's chosen HEI programme, since the ambulance service trust supports several different HEI programmes with distinct assessment requirements.
‘I think sometimes a bit of knowledge on how my course works, because there is quite a lot of students…that come from different courses and different universities and all the courses work differently.’
Half the students praised PEds who recognised the limitations of their own knowledge when they got things wrong, as this provided opportunities for mutual learning. Students also highlighted the importance of enthusiasm and motivation whilst talking about observing PEds in practice. Half the participants said paramedics should only be PEds when they had a genuine desire to mentor and teach students. One student identified a bad experience with an unenthusiastic PEd that had limited his learning opportunities; however, two others praised enthusiastic PEds who had inspired them about long-term job satisfaction.
Communication
All students identified communication as a core PEd skill. Although the majority talked about this in relation to the clinical role, four students also identified the importance of being able to have ‘normal’ conversations with their PEd:
‘You are spending four days together and it's in close proximity, you know. You got to have this relationship where you can talk about, not just work, but things outside of work as well.’
Students identified many ways in which PEds encouraged independence, including setting homework and coaching through difficult jobs. Furthermore, five students identified that having a PEd present on a scene but in the background provided them with the confidence to take the necessary risks required to gain independence in practice.
However, some PEds did not allow students to practise their skills in the clinical environment, hampering their progress towards independence:
‘I told him she was very hypertensive and it was like 70/50 and that she is very out of it. Then all of the sudden he sort of almost barged me out of the way and said: “Right, OK let's stick some fluids up”. Although I was meant to be on my first paramedic placement to do those things, he wouldn't let me ’.
Support
All students talked about being ‘supported’ in practice when exploring the personal qualities of PEds, with five students providing examples of PEds' support in particularly demanding clinical tasks:
‘If I start when I was new, in the big sick cases he would say to me: “Right, do what you want to do to feel comfortablep” or he would say, if it was a big, big job, “Right, assist me and we'll talk about it at the end.”’
Students also identified how PEds supported them in undertaking technical clinical skills as well as the support they received after emotionally challenging episodes:
‘On my first PEd when I did my first ever (resuscitation) on someone and it wasn't a successful outcome…just having them say to you: “Look, at the end of the day this is the nature of the job, we did everything we possibly could to a high standard”…I think just having them there really.’
Characteristics of PEds
Students largely wanted to be with PEds who were ‘kind’, making them feel comfortable and not heavily criticising mistakes, thus reducing anxiety. Three students went further to suggest that they wanted the PEd to become their ‘friend’, though their PEds did not always reciprocate:
‘My other (set) PEd, it's almost like she doesn't want to make friends with me, so it's like she…I think my preference is someone who does kind of want to make friends with you, who does want to kind of, gives like a positive feeling for wanting to work with you.’
One student suggested that his ‘friendship’ with his PEd had improved his learning in clinical practice, although this had also meant it was difficult to hear critical feedback:
‘Sometimes it's a bit, it's a bit like you know, a big brother…If you get to that stage with a friend sometimes you don't want to hear someone you are comfortable with telling you (that) you're rubbish.’
In contrast, two students identified how unkindness prevented learning and that working with someone unfriendly was difficult:
‘You are still working with that person for twelve hours and that is quite tough if you feel like they don't want to spend twelve hours with you. ’
Two students mentioned the importance of ‘paramedic humour’ in helping get through the day with one identifying an instance where a PEd effectively used humour to defuse his emotions after a patient had died:
‘To try and get me to think about something else, or the fact that I just dropped this person, he turned around and stared me right in the eyes and said: “Like a sack of spuds”. So now every time I sort of think back of the fact that I dropped him I think, “just like a sack of spuds”. And that, sort of helped me then change my mind-set of how the job went and…the difficulties.’
Students emphasised the importance of being accepted by their peers while adjusting to new settings, even, in one case, where this had outweighed patient care:
‘…Because I try and get on with everyone, do you know what I mean? Because in that new situation you are the new boy, you smile and nod and agree, even if you think that they are not doing the right thing because you are the new person.’
Finally, there was evidence that some individuals behaved inappropriately to meet the expectations of the culture they were joining:
‘I think it's part of trying to posture to fit in, trying to be cool as they want to be accepted…I think people worry too much about trying to fit in and be accepted into, like, the brotherhood. It's a very masculine thing as well. ’
Organisational issues
Students frequently voiced anxieties about uncertainty surrounding placements, working with new people and ambulance service organisational issues. Having a consistent PEd for their clinical placements reduced anxiety for three students, though there were some drawbacks:
‘Spending all your time with one person completely is good, but it doesn't obviously let me see diversity…’
Another student talked about the significant personal challenge of having several PEds:
‘Because I've had so many, I always feel every placement I have had I'm sent back to square one again…That's what I've been feeling like for the last year with so many PEds is that I've always been under pressure.’
Six students identified that they had faced barriers in practice, referring specifically to PEds and including descriptions of poor role models, lack of teaching skills and unwelcoming personalities:
‘So then I sort of turned to her and said: ‘was that all alright because I didn't get any feedback during the job?”. And she was, like, “Yeah, you've done more than I would've done” kind of thing.’
Furthermore, two students identified ambulance service organisational barriers including hierarchies, disorganisation and a lack of PEds:
‘Because they (ambulance service trust) obviously can be marginally organised at the best of times and particularly when there is severe lack of PEds, huge amounts of new people being brought on. Everyone is just getting thrown around left right and centre.’
Discussion
Students' experiences in clinical practice greatly depended upon their mentor. ‘Good’ PEds possess the necessary skills to induct students into the culture of paramedicine, inadequate ones form barriers to entry.
Specifically, students seemed to be looking for experienced PEds who were knowledgeable about their Higher Education (HE) programmes and had a genuine desire to mentor them. Furthermore, students appreciated time spent by PEds in providing clear and objective feedback that improved their practice and encouraged independence.
The results validated the importance of the qualities identified by Darling (1984) and subsequent literature. They confirmed that students appreciated mentors who allow observation of modelled skills and behaviours in the clinical environment, as well as the importance of mentors who understand the requirements of their HE programme. However, the lack of PEds within the paramedic service has led students to look for other role models in practice—a role which could be assumed by APEds (Associate Practice Educators) and ambulance service technicians.
Student paramedics face similar challenges to students within hospitals, including lack of ‘face time’ with mentors as well as lack of opportunities and settings for structured feedback. As with nursing, this seemed to be due to general pressures on services rather than mentor reluctance. Effective PEds were also seen to enable students to transition from ‘observers’ to ‘doers’, where study participants wanted their mentors to support them to become autonomous paramedic professionals, rather than enforce ‘copied’ behaviours upon them.
One identified personal trait of PEds not apparent in the literature of other healthcare professions is the distinctive quality of ‘humour’. This quality seems to be used as an important coping mechanism within the culture of the profession to deal with an emotionally challenging working environment.
Current challenges to practice
The interviews highlighted several organisational issues in relation to challenges to practice, starting with an apparent need to invest more in the PEd role. The narratives reveal an apparent lack of PEds with sufficient experience and motivation. It is likely that the Centre for Workforce Intelligence (CfWI) forecast of an 11% increase in paramedics by 2016 (CfWI, 2012) and total transition of paramedic education to HE by 2015/16 will exacerbate these deficiencies (CoP, 2014). Furthermore, a 27% reduction in active PEds since the role's inception suggests an organisational need for a continuous investment in supporting PEds.
The findings suggest the physical lack of PEds is creating specific challenges for students, which may include being placed with several different PEds whilst on placements. Again, APEds could play a useful role in helping to ensure continuity in the student's mentoring experience. The CfWI (2012) identified a national resource of 960 technicians who could potentially take a more formal role in mentoring.
The findings identify that there is a conflict between achieving operational demands and PEds' wishes to spend time with students; in addition, it was found that there is a need to invest more in the culture of mentoring within the paramedic profession to develop the paramedics of the future. While PEds are providing emotional support, assistance with management decisions and technical skills in practice, these activities all take time and conflict with the general pressures of the clinical environment.
The study's results also question the motivation of some PEds, with some demonstrating a lack of interest and commitment in mentoring. Currently, there is little ‘reward’ for paramedics to take on the PEd role, with recruitment largely dependent on goodwill. In contrast, nursing has an established culture of mentoring, with clinicians actively engaged in the process for career progression and the creation of specialist roles such as sign-off mentors.
The study also identified ways in which the PEd model is yet to meet the idiosyncrasies of the paramedic role. One perceived deficiency is the lack of knowledge possessed by PEds, particularly in relation to their student's programme of study. The education of PEds on paramedic HE programmes is covered by the Certificate of Practice Education, a qualification still in its infancy. In contrast to nursing, where mentorship training has well-established links with HE programmes and includes annual updates and link tutors, PEds operate largely unsupported and may begin with only a single day of training.
When it came to mentor-student feedback, the study's participants identified the importance of discussion during hours of practice and verbal comments matching written feedback on the PAD. More significant was the way in which a significant minority of the participants identified desire to be ‘friends’ with their PEd, even when this sentiment was not always reciprocated. The unique one-on-one PEd mentoring model required in the ambulance setting may lead to students placing significant emphasis upon developing a good working relationship with their PEd. Whilst much of the literature talks about the importance of ‘kindness’ in mentors, little evidence was found to support the development of friendships within the PEd role. Indeed, due to PEds' involvement in students' academic and professional development, it is questionable whether it is appropriate that friendships develop and at least one of the comments made in the narrative suggest that trying to develop these can be counterproductive.
Limitations
The study's limitations mainly focus around the chosen method of research and deficiencies in sample size. Framework analysis served to collect variables and provided an insight into the richness of the data. However, a mixed methods approach may provide further evidence as to how these variables relate to one another. This was impractical in the current study due to time constraints, which also restricted the number of interviews that could be conducted.
The eight students interviewed represented only a small proportion of the 91-strong HE student body supported by PEds in practice at the time of the study.
The small number of participants and single study settings in an urban environment means that caution should be taken in generalising the findings from this study to other settings.
Other limitations concern use of narratives in semi-structured interviews, which only allowed for private accounts of events. The addition of focus groups would have promoted public accounts, adjusted by group dynamics that may have further enhanced the richness of the data.
Recommendations
The rapid ascension of the paramedic profession into HE depended on adopting mentoring practices from other healthcare professions. This study suggests that direct transfer of these models may have failed to address idiosyncrasies of the paramedic role.
Key attributes of the ‘mentor’ outlined in existing literature were found to be broadly relevant to paramedics, but they did not address aspects important to paramedics, e.g. ‘humour’ and the intense nature of relationships specific to the profession.
While based on a limited sample, the study raises key questions on how well the mentorship structure within ambulance services currently supports HE students. Particular issues relate to some mentors lacking the appropriate skills and understanding of HE, along with their levels of experience and motivation. These create significant barriers for new students trying to enter the profession and adapt to paramedic culture. Furthermore, it is unclear whether mentors are receiving the time, training or support to undertake their role effectively.
Further research is now required to determine the challenges faced by PEds in practice along with investigation of how effectively ambulance services and HEIs support mentoring roles. An increased understanding of these areas will help the paramedic profession further embed ‘mentoring’ into ambulance service culture.
This project does not suggest that current PEds are inadequate, rather that the relationship between students and PEds is complex. For mentoring to successfully embed itself within the paramedic profession, both students and PEds alike have a responsibility to reflect upon their experiences and be prepared to adopt the aforementioned changing culture.