Providing quality clinical placements for undergraduate paramedic students to prepare them for the looming dementia epidemic (Korczyn and Vakhapova, 2007; World Health Organization (WHO), 2011) is a significant challenge for health systems across the globe (World Health Organization and Alzheimer's Disease International, 2012). Concerned that paramedic students are not adequately prepared for this epidemiological transition (Omran, 2005), the Wicking Dementia Research and Education Centre's (WDREC) Teaching Aged Care Facilities Program (TACFP) facilitated the introduction of clinical placements in residential aged care facilities (RACFs) as a compulsory component of the undergraduate paramedic degree course.
These placements, first offered in 2011, aimed to provide opportunities for students to develop an extended skill set and enable them to work more effectively with people with dementia, and their carers. This is a pioneering clinical placement programme, and there is a lacuna in the literature reporting on such placements. As such, this paper will underpin the development of an evidence base and support the expansion of best practice clinical placements in this emerging field. It is intended the findings discussed in this research will be translatable to other jurisdictions that have similar models of undergraduate paramedic student education.
It is forecast by 2030 there will be almost 66 million people living with dementia worldwide (WHO, 2012). Dementia is a progressive terminal condition and care for people with end-stage dementia is increasingly moving towards a palliative approach with dignity, comfort and quality of life being the primary treatment aims (Amin off and Adunsky, 2004; Roger, 2006; Birch and Draper, 2008; Andrews et al, 2009). This change in the management of dementia will impact on how paramedics practice and their training must be tailored to cater for this changed healthcare landscape (Chilton, 2004; Kilner, 2004; Williams et al, 2010)
This paper reports on the second round of paramedic clinical placements under the programme that took place in 2012 and discusses barriers to students’ learning identified as part of the process of ongoing placement improvement. A companion paper discussing positive aspects of the placement has previously been published (Lucas et al, 2013).
Research methods
Research participants and placement setting
A group of second year fast-track undergraduate paramedic students (n=17) participated in a five-day aged care clinical placement in two residential aged care facilities (RACFs). Other participants included nursing and carer staff (n=31) in the role of mentors. Both facilities had between 140–150 beds and offered high and low care places for residents as well as respite and outreach services.
Placement programme
Staff from the University of Tasmania (UTAS) paramedic course, in partnership with mentors at the two facilities and members of the TACFP research team, developed the placement programme. Negotiating and planning the placements took a considerable investment of time and effort on the part of all stakeholders. Clinical liaison and support for students on placement was the responsibility of staff from the School of Medicine (Paramedic Studies). Mentors in the two RACFs supervised student learning when the paramedic tutors were not at the facility.
The placement included a range of clinical, non-clinical and interprofessional learning activities. Clinical activities included manual handling, outreach care, wound assessment and dressing. Non-clinical activities included gym sessions and walking programmes. Students also participated in several seminars on topics relevant to the placement including medication reviews and a three-hour workshop on dementia palliation, which was a key focus of the placement. They also engaged in interprofessional learning with nursing and medical students, who were also on clinical placement at the time, through a range of structured activities including assessment of residents and a simulated ambulance transfer.
Data collection and analysis
Project officers facilitated feedback meetings with students on the second last day of the five-day placement. Meetings were recorded and transcribed and case notes (meeting summaries) developed from the transcripts. Mentors also participated in weekly meetings while students were on placement and data from these meetings were managed in the same way. Case notes were initially coded using an open coding process (Strauss, 1987). The concepts developed through this process facilitated the identification of inductive codes (Willis, 2006). The data were then further scrutinised and subjected to a process of ‘focused’ coding (Ezzy, 2002) that enabled a more manageable set of categories to be developed. Quantitative data were also collected as another component of the research; some of the findings from this are reported in an earlier paper (Lucas et al, 2013).
Ethics approval
Ethics approval for the TACFP intervention, and mentor and student participation in the study, was obtained from the UTAS Human Research Ethics Committee (No.H11576).
Findings
Data from student surveys and student and mentor feedback meetings informed the findings discussed here. This paper focuses on the barriers to learning identified in the analysis of these data.
Facility orientation
To familiarise students with the learning environment of the RACF they were given a tour of the facility at the commencement of the placement. As part of this process they were also introduced to staff and provided with an overview of the operations of the facility. This was important, as appropriate orientation is considered a notable factor in positive clinical placement experiences (Abbey et al, 2006; Robinson et al, 2008).
Several students reported that they found their orientation to the facility problematic. A key issue identified with the orientation related to students being unaware who their mentors were.
‘I think the hardest thing for us has been that… we haven't been introduced to or allocated a mentor; no one knows what we're supposed to be doing or where we're supposed to be … we don't know where to go to find those people either (BP2013).’
‘Although mentors wore badges that identified them as such, they acknowledged this problem and felt it resulted from a lack of proper introductions at the outset of the placement “They've been introduced to the staff when they come on, but they're not being introduced as a mentor. I haven't been” (AMtr018).’
Hence, despite considerable efforts to develop a well-organised and highly structured placement, communication problems emerged on the first day of the placement.
Education sessions and lack of engagement with residents
Many students felt the education sessions on placement covered topics they had addressed previously in their course. For example, one student reported, ‘the content of all of this week has been pretty much just that regurgitated again which I found quite boring…It's all stuff we've done before’ (BP2013). Not surprisingly, several students felt more placement time should be spent working with residents rather than attending education sessions.
Indeed a number of students reported they had limited engagement with residents during their placement and noted this was a weakness. During the first few days of the placement students participated in seminars and workshops, as well as planning their inter-professional learning activities, and some reported having little or no contact with residents during this time. One student recounted that ‘It's day four and our first actual interaction with the patient was this morning, so that's three days where we haven't seen a resident’ (AP2018). Several students expressed frustration at the lack of ‘hands on’ learning opportunities during the placement and the limited engagement with residents is another example of this. Some felt education sessions they participated in would be more beneficial if held as part of their regular classroom-learning schedule prior to placement.
Placement structure
Students reported problems with the placement structure, in particular with their timetable. A recurring theme was limited opportunities to work alongside students from other disciplines who were also on placement. This reduced the potential for interprofessional learning (IPL), a key objective of the placement programme. Students considered the apparent lack of coordination between their placement schedule and those of other student groups was a missed opportunity to engage in IPL activities.
‘The link between the nursing timetable and ours is very much different. So we've been allocated times to spend with the [student] nurses and go through what they've got to do in their [IPL] assessments just to learn a bit off them. But at the same time they're [rostered] to be doing something else (BP2014).’
Students also perceived a number of gaps in the timetable, resulting in too much ‘down time’, and a lack of detail about where they were meant to be in the facility, was ‘frustrating’ (BP2013). Moreover, when their student nurse counterparts were not at the facility on placement paramedic students reported they spent considerable time feeling they had nothing meaningful to do because of these structural issues.
Mentors recognised some paramedic students were struggling to find meaningful activities to engage in, but also felt students needed to show initiative and let staff know if they were unsure of what they could do to facilitate their learning. For example, one mentor stated: ‘obviously we want to make it a good experience for them, so anything we can do to facilitate that we will; but they also need to be proactive [in seeking guidance from staff]’ (BMtr009). Another mentor commented: ‘they should come and ask, “what will I do?”’ (BMtrL006), while another reported that several paramedic students appeared to lack motivation and seemed unenthused about the placement. The students’ lack of enthusiasm for the placement has been reported elsewhere, with the majority indicating prior to the placement that they were not happy with the prospect of working in aged care (Lucas et al, 2013). The mentors queried whether this might have been a factor in the difficulties the students experienced. Other mentors agreed that some of the students appeared reluctant participants in the placement programme, exemplified by several being absent from the facility during the course of the week. This was also reflected in the lack of enthusiasm several students reported they had at the outset of the placement.
Student engagement with RACF Staff and paramedic tutors
Some students considered another weakness of the placement was what they perceived as limited interaction with nursing staff. As one student commented, ‘I haven't even spoken to the RNs [Registered Nurses]…I’ve seen them through the corridors, said “hi” and that's it’ (BP 2019).
Some students also expressed the view that staff struggled to recognise the skills they brought to the clinical area. For example, one student felt a lack of clarity about their scope of practice impacted negatively on the placement experience, stating that ‘I feel really sorry for them [staff] because they don't really know what we're doing here and we don't really know what we're doing here’ (BP2013). Another student said she felt that RACF staff perceived the students’ presence in the facility to be an inconvenience. She recounted:
‘I don't know whether we've been a bit of a burden to have here because…I sort of feel like they haven't really wanted to get us involved and teach us a lot of things. I'm sure that there's a lot we could learn from being here but I just feel like…a bit of a burden (BP2020).’
Another perceived problem was that students had very limited contact with their tutors while on placement due to the school having a limited capacity to provide paramedic tutors across the two facilities. One student noted how ‘we haven't really had much interaction with any of our tutors or anything, it's a bit hard, like half the time we're wandering around not knowing what we're doing’ (AP2017). The mentors identified this as an issue but also recognised the limited capacity of the School to provide adequate suitable support staff.
Lack of suitable assessment tools
One of the primary aims of the placement was to provide students an opportunity to assess residents with dementia in the context of an IPL activity. However, they noted the lack of appropriate assessment tools related to people with dementia that they could use while on placement. One student acknowledged this as an issue, stating: ‘another problem we have is that paramedics in general don't really have a lot of geriatric assessment tools’ (AP2018). Mentors also recognised this as a problem for paramedic students, with one mentor reporting how ‘the medical students had their CMAs [comprehensive medical assessments] to do, the nursing students have their functional assessment to do, but the parameds haven't really got a focus…and they do feel a bit lost’ (AMtrL004). Mentors considered that suitable assessment tools would have enabled paramedic students to participate in IPL activities on an equal footing with their nursing and medical student counterparts, and hence this deficiency was a source of frustration for the students.
Relevance to paramedic practice
Students felt there needed to be an increased focus on paramedic issues during the placement. They considered much of the placement was geared towards medical and nursing students and this represented a missed opportunity to provide insights into what paramedics do. As one student argued:
‘[The placement] needs to be not so focused just on nursing and medicine. There could have been a couple of lectures throughout this week on our [paramedic] perspective, so the medical students could benefit from that, whereas it's kind of just been us sitting back not doing a lot, just listening. We should be a multi-disciplinary team and bringing our perspective into this programme as well would benefit [everyone] so much more (AP2016).’
Other students said they struggled to see the relevance of many of the activities they were involved in during the placement to their work as paramedics. Some activities were seen as being outside the paramedic scope of practice:
‘We can't do anything here because…it's not within our scope of practice to hand out any of the medications or anything like that so we can walk around with a nurse doing that but there's not a lot of scope [for us to be directly involved]. We don't do any dressing of wounds and we haven't done a lot of the stuff that the nursing students are able to do (BP2013).’
Mentors reported that some students refused to perform tasks related to personal care, such as showering residents, as they considered this outside their scope of practice. Meanwhile, others were happy to assist with the routine tasks performed by carer staff, considering it an opportunity to learn more about individual residents capabilities and impairments. Some students enjoyed the ‘hands on’ aspects of the placement and welcomed the opportunity to provide personal care to residents; however, a number of students felt this was not appropriate for paramedic students. For example, one student reported that they were ‘not a fan of clothing and bathing; I don't want to be a nurse’ (AP2014). This issue further highlights a need to clarify the paramedic students’ scope of practice.
Discussion
This research analysed a pioneering programme of clinical placements in RACFs for undergraduate paramedic students. It is critical that the difficulties encountered in such innovative endeavours are documented to provide a sound evidence base for future placements. In this way the barriers to effective teaching and learning identified here will serve to inform the further refinement of placements and improve the learning experience of students in RACFs.
It is hoped this translational research may be relevant to other jurisdictions that adopt a similar undergraduate model of training paramedics.
The barriers identified include: the need for a more structured placement with clearly identified learning objectives; a lack of appropriate paramedic clinical supervision while on placement; an overemphasis on classroom learning at the expense of ‘hands on’ clinical skill development; and limited engagement with residents and facility staff.
A key challenge facing the paramedic profession is clearly articulating the relevance of clinical placements in RACFs to students and structuring placements so they have increased opportunities to interact with residents and facility staff. Limited participation in client care has been noted elsewhere as having a negative impact on students’ experience of placements (Michau et al, 2009; Hou et al, 2013). This might be a reflection on the preferred learning style of paramedic students where ‘hands on’ learning appears favoured over theoretical content, particularly while on clinical placements (Michau et al, 2009). Structuring placements so students have more ‘hands on’ experience with clients and less time in classrooms learning theoretical perspectives of ageing and dementia should address some of these issues. Further research into the optimal mix of theoretical and experiential learning while on such placements should be considered.
Additionally, the placements need to be structured in a way that reduces the amount of ‘down time’. Unproductive ‘down time’ has been identified elsewhere as a negative aspect of paramedic students’ clinical placement experience (Boyle et al, 2008; Michau et al, 2009). Feedback from students indicates this was an impediment to their learning and they were often unsure what they should do or where they should be. This sense of being a ‘burden’ has been identified elsewhere as negatively impacting on students’ clinical placement experience (Robinson et al, 2007). At the same time mentors felt students should learn to take responsibility and adopt a self-directed approach to their learning. Structuring placements that keep students fully engaged, while fostering a sense of self-directed professional development, should deliver improved learning outcomes.
Clarifying the scope of practice of paramedics also needs to be addressed. This caused problems for mentors and students. The differing response from students regarding their scope of practice (e.g. providing personal care) caused concern among mentors who became unsure what tasks they could ask students to perform. Clinical educators’ unfamiliarity with paramedic students’ knowledge and skills has been identified elsewhere as negatively impacting on placement experiences (Wray and McCall, 2007). More work needs to be done by the school to communicate what these teaching facilities can reasonably expect paramedic students to do while on placement. It also needs to be clearly communicated to students what the expectations are of them while on placement.
Another finding is the need to clearly articulate expected learning outcomes for students and how these will be assessed. There was confusion around this with both students and mentors identifying it as a problem. It seems this was in part due to a lack of clarification between the school, students and facilities and improved communication regarding this is critical. This also illustrates the emerging status of paramedic practice as a profession and, to date, the discipline's lack of meaningful engagement with the aged care sector.
The lack of appropriate assessment tools that paramedic students could use on placement to demonstrate competencies most likely contributed to this confusion. Lord (2009) has identified a lack of suitable assessment tools available to paramedics and called for further research to address this. Clarifying suitable assessment tools that paramedic students can use while on placement to develop skills and demonstrate competency should be a priority for future placements so students have clear benchmarks against which they can be assessed while on placement. One such tool that might be considered is the Abbey Pain Scale, a tool designed to assess pain in people with cognitive impairments and identified as potentially useful for paramedics (Lord, 2009). This would provide students and preceptors with a tangible tool that would enable students to demonstrate competency and preceptors to assess this competency.
A lack of appropriate support by paramedic tutors was another issue raised by students on placement. This was identified in previous placements as negatively impacting on the learning experience of students and on the mentors within the facilities. A shortage of suitable paramedic clinical instructors has been identified elsewhere as having a negative impact on student placements (Boyle et al, 2008). However, due to structural constraints and growing demand for clinical placements this problem cannot be easily remedied (Joyce et al, 2009; Michau et al, 2009). Securing suitably qualified and experienced paramedic preceptors is likely to become a more competitive process in future years as paramedic education undergoes significant reform (Edwards, 2011; Hou et al, 2013). Education providers must plan for this to ensure they are able to attract and retain high calibre teaching professionals. Finally, education providers need to be sensitive to the structural and resourcing issues that impact on the capacity of aged care facilities to effectively support students on clinical placements (Robinson et al, 2007). In this round of placements the lack of paramedic tutors on site placed an additional burden on the facilities. If this is not addressed the goodwill that exists between RACFs and education providers seeking clinical placements for students may be jeopardised.
Conclusions
Notwithstanding the shortcomings discussed above, these placements provided opportunities for students to develop knowledge and skills that highlight the potential of clinical placements in RACFs for paramedic students. A previous paper analysing the positive aspects of these placements attests to this (Lucas et al, 2013). The placement enabled students to develop their knowledge of dementia and the operations of an aged care facility. With significant increases forecast in the incidence of dementia worldwide (World Health Organization and Alzheimer's Disease International, 2012) it is essential that paramedics understand dementia as a terminal condition with a range of associated complications. Understanding how to effectively assess, engage with and treat people with dementia are important attributes for paramedics. Given the high proportion of residents with dementia in RACFs (Australian Institute of Health and Welfare, 2011) clinical placements in these facilities represent an opportunity to foster the development of these skills. With appropriate support from paramedic clinical liaisons and mentors in these facilities, paramedic students stand to gain invaluable experience that will equip them with an essential skill set for practicing in the changed landscape of a 21st century health care system. This research has shown that the Wicking Teaching Aged Care Facilities Programme has taken the first steps to supporting this endeavour, but there remains a great deal of work to be done.