With the continual addition of skills and competencies to the ever-expanding role of the paramedic, it is essential that staff are adequately equipped for the demands of the modern day NHS. Blaber (2012) supports this, stating that as well as the expectations required within registration by the Health and Care Professions Council (HCPC) (HCPC, 2014), there are many legal, ethical and moral dilemmas to be faced on a daily basis while under difficult and distressing circumstances. It is vitally important that paramedics keep up-to-date with all aspects of training, as to fail to do so could incur fitness to practise investigations as well as civil or criminal charges being faced (Blaber, 2012). In order to achieve this, the course curriculum for paramedic education at diploma or degree level must be fit for purpose (Allied Health Solutions, 2013).
Benton (2011) reinforces this, discussing the need to appease all three major stakeholders. He highlights how regulatory bodies insist the practitioner be ‘fit for practice’, so ensuring patient safety; the employer requires practitioners to be ‘fit for purpose’, especially within specialised areas; and the university must ensure the practitioner is ‘fit for award’, so maintaining the academic standards in line with the Quality Assurance Agency (Benton, 2011: 276).
While the department and our mentors within practice strive to ensure that the student is fully prepared for professional life upon qualification, there are always going to be uncertainties in a newly qualified paramedic's mind. The aim of this study was to highlight these perceived concerns and identify any recurring trends within them. The intended outcome will help to inform educational institutions as part of the continuous review of student support and curriculum design.
Methods
This pilot study focused on a single cohort of full time two-year diploma-qualified paramedics in the initial months post-qualification. Ethical approval was obtained for the project from the institutional research ethics committee, and the study was approved by the relevant ambulance service.
The study employed a focus group approach to collect qualitative data from a purposive selection of newly qualified paramedics who were previously full time students within the department. The study was limited to full time students only and not the technician conversion students, as their previous experiences in practice could slant the results and require further consideration too in-depth for this current pilot study. A focus group was chosen as the methodology, due to the freedom it allows to clarify responses, pose further questions and observe non-verbal interactions (Gray, 2014). The focus group approach also allows the participants to respond, and add to, viewpoints expressed by others (Gray, 2014).
The cohort were all contacted via email, detailing the study and inviting them to participate. Given that these paramedics were working shifts, a range of several possible dates and times was given to accommodate this and then the date chosen with the most able to attend. They replied via email to register their interest but no pressure was put upon the students to attend as it was an important factor that coercion into the study was avoided, as discussed by Smith Iltis (2006). The focus group session was attended by four newly qualified paramedics and facilitated by the author. A moderator was also present who the students had never met before. Having been made fully aware of the purpose of the study, the participants voluntarily gave written informed consent prior to the session, as recommended by Kumar (2014).
Using a semi-structured question guide, the facilitator asked the participants about their general experiences immediately post-qualification and their initial concerns upon being clinical lead. Further questioning around how they had addressed these concerns and the support received were also posed.
The focus group session was audiotaped and transcribed. The transcripts and observer notes were analysed by the author using an adaptation of the Ritchie and Lewis Thematic Framework (Ritchie et al, 2014). Member checking for correction, verification and confirmation (Kumar, 2014) was accomplished by distributing the transcript to the participants for comment following the session. This also worked to enhance validity of the study, as suggested by Creswell (2014).
All sources remained confidential and all data were kept in a secure location at all times.
Results
Four newly qualified paramedics attended the focus group session and the following themes were elicited from analysis of the transcript. These were: confidence, concerns about registration (defensive practice) and theory-to-practice application.
Confidence
All the newly qualified paramedics expressed understandable feelings of doubt in their own confidence at the start of their new careers:
‘I feel like I haven't got the confidence…I know that it will take time for the experience and confidence to come’
‘It is a bit daunting because you suddenly realise you don't have that safety net’
‘It was horrible not having that safety net, I would constantly overthink things all the time and think, “am I doing this right?”’
Participant 3 explains the ‘safety net’ with the following statement:
‘Having the decision-making responsibility was the toughest that first time‥[as a student] you had that back up in the sense of having someone to look at…and just back up your decision.’
Participant 3 is referring to the presence of a mentor to support the student while in practice prior to qualification.
Participant 4 explains how they relied heavily on their technician colleague when first out in practice post qualification:
‘I found myself looking at him to make sure I was doing the right thing and he said yes you are fine and I found he was encouraging me throughout the whole shift.’
This reliance on their colleague is evident through several comments by the participants. Participant 1 reflects how they:
‘…start every shift by saying if I do anything stupid let me know.’
This is reciprocated by Participant 2 who adds:
‘I do the same. I say listen if you see me doing something wrong or you don't know why I am doing something let me know.’
As well as the removal of the mentor and reliance on their colleague, another aspect that challenged the paramedics was having the confidence to deal with other ambulance staff appropriately.
Participant 3 notes while discussing working with an experienced but less qualified colleague:
‘If they have been doing the job a lot longer than you and are comfortable, it's still difficult to decide what they are allowed to do.’
Participant 3 sums it up, stating:
‘It's finding that balance between life experience and knowledge, because for some people it will be their first job and you have to learn so much about how to deal with people.’
Concerns about registration (defensive practice)
This links back to the confidence issues previously raised but is more specific about their HCPC registration and the responsibilities appertaining to that.
‘I feel like its defensive practice because every single day I feel that one of my patients will try and take my registration. Not every person I have left at home but it would just take one and this would be my registration gone’
Participant 4 corroborates Participant 2's feelings:
‘I can manage a situation, it's just about making the wrong decision. There are always rumours about watching your registration, you have to watch what you do and what you say.’
While there will always be an element of defensive practice required as a registered health professional, it is obvious here that their lack of exposure and experience makes them feel more vulnerable. As experience grows and confidence improves, the practitioner will begin to feel more comfortable in their role.
Theory-to-practice application
The application of theory to practice is known throughout the health professions as a barrier that must be overcome in order to become a proficient practitioner. All the points previously mentioned under different headings above are relevant to this section and a few further points were mentioned by the paramedics.
Participant 3 recognises that barrier between theory and practice in the following statement:
‘It is bridging that gap between theory in the nice, safe classroom environment and actually having the experience and being exposed to the situation.’
Participant 1 also acknowledges this with their comment:
‘I think that was a learning curve because I felt that at the end of the two years I should know everything and I think the learning curve is sometimes sitting there and thinking I haven't got a clue what's wrong and then admitting it. Knowing that it is actually alright to say I don't know the answer.’
Participant 4 goes further to describe how they felt that it was a lack of actual exposure to variety while out on the ambulance placements that gives this doubt in their own abilities.
‘Personally I felt like I was thrown to the lions…I personally don't feel like two years is enough. I thought the placements were excellent, I thought the underpinning knowledge we got from uni was fantastic, but I personally would have liked to spend more time on the ambulance being exposed to the different varieties of things.’
Another aspect of this perceived theory to practice gap was identified as not being a direct clinical issue but rather a lack of knowledge regarding the future care of a patient.
‘The important bit when you are out on the road is what happens next and having an understanding of what care that patient is going to need, what care is available. It was the decision bit that certainly tripped me up’
Participant 1 agrees with these sentiments and adds that:
‘Yes that would be good to incorporate into the scenarios [at university]. So that when you have done your bit what would you do now—which hospital would you take them to, why would you go there, etc?’
This apparent lack of knowledge around the correct place to take the patient and the subsequent course of treatment they may encounter was made harder for the paramedics who had moved to other areas rather than the area they did their original student training in.
‘Mine would just be area specific about what speciality hospitals have what in what areas, where you should be going…Being in a different area, mine was “I don't know where I am going with this one” or “I don't know where I should go with this one”’
This aspect faces all new ambulance staff, but as the lead clinician it is perhaps a more daunting challenge. Again, it highlights the participants' reliance on colleagues for advice.
Another aspect that the paramedics commented on was how reflection helped them in their new role.
‘Reflective practice that we were taught in uni. It's boring at uni but it really works for me now I'm on the road. I have had quite a few jobs where I have gone home at night and made notes and thought, “could I have done that any better?”’
Reflection is also commented on by Participant 2:
I think you naturally reflect with your peers. I still also speak to my mentor if I have had a job that has troubled me; I can phone him up. He will still say, “tell me why you did that” and “you are silly for worrying about that.”'
Discussion
It is evident from the analysis of the transcript of the focus group that confidence plays an important role in the transition to becoming an autonomous practitioner. Gregory (2013) highlights the ‘reality shock’ faced by the newly qualified paramedic upon registration, when the safety net of the mentor is removed and they become the lead clinician. The responses of the participants in the study indicate that they felt this acutely, but it is not a phenomenon seen only in the paramedic arena. While there is a dearth of information in the paramedic field regarding research into this subject, there is a plethora of resources from allied health professionals facing the same predicaments.
Brown et al (2007) studied the transition from medical student to qualified doctor and noted how, as a new doctor, feelings of anxiety were commonplace as they were uncertain how to adapt to their new role. A study by Avis et al (2013) highlights how newly qualified midwives exhibit a delay in the development of confidence, something that Maben et al (2006) suggest may be due to unrealistic levels of self-expectation. This tallies with Participant 1's comment regarding the learning curve in the results section. An Australian study by Kelly and McAllister (2013) looked at perceptions of nursing students prior to and following graduation. They note confidence, being thrown in at the deep end, peer support and inadequate support as themes raised, all of which resonant with this study's findings. Higgins et al (2010) note that the transition period from student to qualified nurse is recognised as being stressful and causing anxiety, uncertainty and fear in newly qualified nurses. The study from Ali et al (2011) also concludes that novice nurses lack confidence.
The newly-qualified paramedic faces a barrage of challenges on a daily basis. This study highlights some of the more concerning ones in the eyes of the participants. However, these challenges appear to be around ‘softer’ skills such as people management, decision making and defensive practice rather than clinical challenges about patient assessment and treatment. These ‘softer’ skills are often learnt through experience, and the newly qualified paramedic needs to feel supported in their role in order to gain a positive experience and develop their confidence.
The participants highlight their reliance on colleagues and previous mentors for support in the time immediately post qualification, and the importance of preceptorship cannot be highlighted enough during this time. The Department of Health (DH) (2010) defines the role of preceptorship as guidance and support for all newly qualified practitioners to enable the transition from student into qualified health professional. It further notes how the support will enable the health professional to develop their confidence as an autonomous practitioner (DH, 2010). Ambulance Trusts provide a preceptorship programme to all newly qualified paramedics, and further research around this area would help smooth the transition from student to paramedic.
Within the university setting, the participants' concerns have highlighted additional avenues of development for students. During scenario work, greater emphasis focuses on the further care of the patients once they have received their initial treatment. Deeper questioning techniques are now utilised to enhance the student's decision-making skills, and further reflection around their practice is encouraged. Future correspondence with practice mentors will also highlight their role in developing student confidence, decision making and taking the clinical lead. This research will further enhance the curriculum as part of the continuous review of student support and curriculum design.
This study has identified the need for further research in aspects of all of the themes raised.
Limitations
Given the small scale of the study, it is impossible to say whether these results would be generalisable to the general population of newly qualified paramedics. For further sessions, it would be appropriate to remain consistent to the original approach wherever possible to enhance reliability (Gerrish and Lacey, 2010).
While this study represents only a single focus group with a small number of participants, it can be argued that the results are trustworthy due to the rigorous methodology used and the adherence to guidelines, as previously mentioned in the methods section. The transcript has not been altered in any way nor have the comments been used in a manner unintended by the participants. The study is transferable and consistent, and could be repeated.
The participants had been students taught by the author for the two years previous to their qualification. This ‘insider’ research has been noted to reduce validity due to the observer no longer being objective (Robson, 2011).
While every effort has been made to maintain confidentiality within the group, it is acknowledged by Williams (2012) that it is impossible to control what may be discussed outside the focus group venue subsequent to the study.
Conclusions
This study highlights the importance of initial and ongoing support for newly qualified paramedics. The fears and concerns the participants expressed during the focus group are all understandable and felt by many new paramedics just as acutely. A newly qualified paramedic will always feel that they need more experience, but the time comes when the background theory is all in place, they have passed their diploma or degree, and they must venture into the role of lead clinician. Providing good preceptorship and a strong support network to newly qualified paramedics will help them to gain experience in a safe environment, and so will increase their confidence in their own abilities and enable a smoother transition into the role of lead clinician.
An awareness of the necessity to develop these softer skills should be incorporated into the curriculum of all pre-registration courses, to ensure students feel fully supported and confident to make the transition into the professional workplace.