Traditionally paramedicine has been considered a vocational career (College of Paramedics (CoP), 2008); however, contemporary discussion supports the need for ambulance service education to be exclusively higher education institute (HEI) based (Department of Health (DH), 2005; CoP, 2008; Association of Ambulance Chief Executives, 2011).
Paramedics trained via the traditional Institute of Healthcare and Development (IHCD) route are often sceptical of the move toward university education (Cooper, 2005); during focus groups conducted in Cooper’s qualitative study, participants questioned the need for academic qualifications, suggesting that ambulance service clinicians relied more on ‘life’ experience; this may be due to feeling more comfortable with the traditional ‘working’ route to paramedic registration, joining an ambulance service in a non–emergency capacity and progressing through various ranks to that of a paramedic.
Undergraduate student paramedics come from a wide age range and varied backgrounds to study paramedicine; HEI students are expected to undertake a minimum of 1 500 hours supervised clinical placement to gain eligibility for the Health and Care Professions Council (HCPC) register as paramedics (CoP, 2008). Within the programme where this study was completed placement time is carried out in a supernumerary capacity, practising under the supervision of a named mentor the student is formatively and summatively assessed. Active and comprehensive engagement is therefore vital during placement, this includes understanding of the specific placement area, the importance of learning contracts and making the most of every learning opportunity. Successful engagement in placement will allow the student to achieve a set of mandatory summative learning outcomes as well as individually agreed personal learning contract objectives.
The author aims to explore the enablers and barriers to engagement in practice placements, specifically;
This will be done by exploring the views of groups of students’ from two backgrounds. For the purpose of this study, the comparison to be made is between mature students, defined as over 25 years old and students under 25 with uninterrupted academic careers.
Methodology
Ethical approval was given by Plymouth University for the study.
The population for sample group selection comprised first year undergraduate paramedic students. Criteria were developed in order to select two sample groups. These were defined as follows:
It was hoped by the author that extension of the traditional mature student definition (21 years old) would facilitate further life experience and leave a more defined gap between them and students who have stayed in full time education. Essentially this would allow comparison of student experiences between those in the ‘fow’ of learning currently and those that are returning to education following a break but have a different set of experiences that they are able to call upon during their studies/placements.
An e-mail was sent to the year group (n=41)describing the project and inviting them to volunteer. They were offered a rationale as to why the author was undertaking the project and also offered an opportunity to answer any questions potential participants might have. Attached to the e-mail was a copy of the project proposal and ethical clearance form.
The gender split in the cohort overall was 66/34 % (n=27/14) female/male and the mature/ direct entry student split 39/61 % (n=16/25). Replies to the invitation to participate were received from 56 % (n=9) of the mature students and 28 % (n=6) of the direct entry students. A second e-mail was sent to try and secure additional participation but without success. The overall gender split was similarly refected in each of the sample groups which were made up of four mature and four direct entry students.
The average age of the mature group was twenty seven and ranged from 25–31. The direct entry group ranged from nineteen to twenty one giving an average age of 20 years and a difference of seven years between the groups.
Dates and times were then agreed with participants to carry out semi-structured interviews. Informed consent was gained, all involved were given a copy of the project proposal and ethical clearance forms, provided they were satisfied with the content/process they were asked to return them signed at interview; the right to withdraw was highlighted in these forms and again verbally during the interview.
Data collection was carried out through semi-structured interviews. A focus group comprising lecturers from the programme allowed for triangulation of the data and therefore cross-validation of concepts and experiences (Tarling and Crofts, 2003). A random selection of four candidates from each of the student sample groups were interviewed, both student groups were asked the same questions (Box 1).
Interviews were recorded then transcribed verbatim by the author, following this the data was thematically analysed through a series of coding that identified repeated concepts/experiences.
Results/findings
During analysis of the collected data five themes emerged and were developed.
Organisational
Students from both groups mentioned that some existing staff who felt they no longer had a route of progression; or those currently on a different route of progression to become a paramedic were initially slightly unreceptive to their placement needs:
‘I felt uncomfortable with some of the staff on station who went for their paramedic tests and then the system changed and they kind of hold a grudge towards you. It’s not my fault I have to go through this way (via an HEI) and it’s not their fault that it’s changed, but they have been friendlier now.’ (Participant B1).
The mature sample discussed the importance of working with mentors,
‘If I am working with my mentor, I am more confident because I know he knows my ability. If I was to go out with somebody else they wouldn’t know what I could and couldn’t do.’
The net potential effect of which is that engagement in placement and therefore placement experience/performance can be negatively affected. Direct entry students made no mention of this.
Among the direct entry sample staff feelings about the HEI route to paramedic registration were discussed, they seemed to suggest there was a significant lack of understanding about what it aimed to achieve:
‘ I don’t think they understand some of the more academic aspects…He (mentor) is happy with me clinically but doesn’t understand why I have to do two weeks on clinical governance…Why do I need to know about auditing.’ (Participant B4).
These sorts of issues may also be caused by reluctance to acknowledge a new system for education by existing staff.
Personality and people skills
Both sample groups commented on, in their words, the importance of being good people, communicating well and having the focus to achieve the necessary programme/HPC requirements.
The direct entry sample specifically placed considerable emphasis on general attributes considered important for paramedics. This was done in isolation of any linking to previous experiences:
‘I have always thought I am a nice bloke, nice enough so I can always get on with people if they want to get on with me. Even with a complete clash of personalities I can still have that bare thread of communication with them.’ (Participant B4).
The other commonly mentioned characteristic within the direct entry group was the importance of getting involved:
‘I engaged pretty well with getting to know everyone on station…Building a relationship with people and just getting stuck in, if they asked me to do something I wouldn’t mind doing it, mopping the vehicle and stuff like that.’ (Participant B1).
The mature student sample group displayed similar ideologies; however, they made links with attributes to age and previous experiences in relation to practice engagement:
‘With my old job I needed to be able to go into a whole new group of people, just take it easy and work out who was who. So I never felt awkward, you just take your time to see where you ft in.’
There was a trend within the mature students for reporting problems with confidence on placement; specifically this seemed to be linked to making mistakes and feeling like they had let themselves down:
‘I think I am scared of making a mistake and looking silly, particularly if there are other clinicians around.’
The same sample commented about this programme being the last chance to achieve goals due to financial constraints and age:
‘For us (mature students), coming back, this is what we actually want to do. There is a lot more riding on it. You are paying your own fees and everything else because it is something you really want to do. If you didn’t you wouldn’t be here.’
The focus group discussion reiterated this, pointing out that mature students may potentially have exhausted funding if they have already been through some form of higher education.
Life experience
This was discussed within the context of two paradigms; engagement in placement and credibility with staff in placement areas. There was variation between the groups in how they thought about and discussed life experience. The direct entry sample displayed some significant life experiences such as, living in a foreign country, experience of alcohol misuse, drugs and social issues and teaching disabled children.
The programme team focus group reiterated this making specific comment that some direct entry students could have incredibly valuable life experiences, within this focus group there was also suggestion that a young individual with the above experiences could ‘unsettle’ existing ambulance service staff:
‘We can get direct entry students who have a great deal of experience and maturity in their lives and that also unsettles the ambulance service staff.’ (Participant FG).
The direct entry sample generally did not mention these varied and valuable life experiences until they were asked during their interviews. This left the author to wonder if they understood the value of them. In contrast the mature students linked life experience to their engagement in practice, without prompting. When asked what had allowed a particular student to engage well in practice they said:
‘I think my background [army] really, working in big groups with different people.’
Within the mature sample group all students had experiences directly relevant to the role of a paramedic; this included previous exposure to medical environments, armed forces, and retained non-medical emergency services. This is reflective of many of the people applying for a place on paramedicine programmes and within paramedic practice, Pajonk et al (2010) makes mention of this in a study about the personality traits of emergency care clinicians where common personality types are found within emergency care.
Learning and education
This appeared in both sample groups as well as the focus group. Once again there was variation between the two student samples. Direct entry students discussed learning during placement if they came across something that they had not previously seen, or did not understand:
‘If we go to an incident and I struggle a bit, when we are back on station they will go through things with me using books and help to teach me.’ (Participant B3).
Several of the mature students’ acknowledged that as a result being out of full–time education for several years they felt disadvantaged and ill prepared for some aspects of the programme/ placement. One participant felt it would have been easier if they had gone straight from college to university. The same student made the following comment:
‘While on placement you are enjoying it but in the back of your head you are thinking I need to be doing this research, once I have finished that I need to be doing this essay on refection.’
This feeling was common within the mature student group. These findings are again reinforced by the programme team focus group:
‘The direct students are more keen, eager and willing to express their need to learn rather than to do, whereas the mature students in the clinical environment are more focused on doing the job.’ (Participant FG).
Age
The mature student sample indicated they had settled into placement far sooner than the direct entry students, the focus group touched on this in discussion about life experiences:
‘Mature students are likely to have been in the working world and will have got used to the idea of working.’ (Participant FG).
Similarly, most participants said their placement experience had been affected by their age. However, there was a significant split between both sample groups; mature students felt this had been positive and the direct entry sample that their age had been a negative factor. Comment was made by the direct entry students was that they had all, at some stage experienced some negative interaction from colleagues or patients commenting on their age:
‘They (patients) always say: “Oh, you are young; you look too young to be doing this.”‘ (Participant B3).
One direct entry student did however make the point that age and experience do not necessarily go hand-in-hand:
‘You could get someone who is thirty that’s never had anything happen to them in their life and you could get someone my age (20) that’s had loads of stuff that relates really well.’ (Participant B2).
The mature student group talked more about the positive aspects of their age, in fact they were protective of the fact; it is evident they feel this, in conjunction with life experience offers them credibility with staff:
‘I think people tend to look at you and feel that they have a little bit more in common with you as someone who is a bit older.’
The focus group discussed this in relation to the danger mature students might look more experienced and therefore may have unfair expectations levelled at them by staff and patients.
A common aspect to both sample groups was being ignored by a patient when working with older clinicians, even in a scenario where they are asking questions but answers are directed back to the older clinician:
‘I have been asking the questions but they [patient] will direct the answers back to the older person in the room. That is not even my paramedic because the ECA at the time was older than the paramedic.’
Discussion
In this study the mature student sample specifically commented on the importance of spending enough time with the named mentors; they felt engagement in placement was negatively affected when this was not possible. The NHS Knowledge Skills Framework places responsibility on staff to contribute to the development of others (Agenda for Change Project Team, 2004).
Pollard (2009) identified variations in student placement experience, influenced by factors such as doctors, professional cultures, mentors and student confidence. The same study further suggested that a lack of placement support negatively effects confidence and engagement. This has potentially worrying connotations for engagement as the mature student sample also reported concerns about looking foolish if they made mistakes; this could be the result of feeling that this is their last chance to achieve goals and begin their chosen career.
Specific guidance for paramedic mentors from either the professional or regulatory body is not available; however, within nursing there are stringent standards for mentors set by their regulatory body (Nursing and Midwifery Council (NMC), 2008). The current shift towards HEI paramedic education encourages deep learning and understanding, quality mentoring is central to both this and paramedic student development (Armitage, 2010). In order to achieve the full potential of mentees/mentors one suggestion could be to match students with paramedic mentors based on age. However, research proposes this has minimal effect on the formal mentoring relationship (Lankau et al, 2005). Given the direct entry student group felt their age to be a negative factor during placement it would seem that in a perfect world matching mentee to mentors age could be a positive step for the future. This ideology is sound but the reality of achieving it in a placement setting, where there are potentially limited numbers of qualified mentors with multiple demands on their time is unrealistic (Mursell and Sibson, 2010). A qualitative study looking at physiotherapy placement education by Kell and Owen (2009) surmises that students’ learning during placement can be affected by the student/mentor ratio. Although, physiotherapy is a separate profession, there are similarities to be drawn in the area of clinical placement requirements. This highlights the benefit of a one to one system, as exists within the local ambulance trust/university area that this research was conducted.
Participants from both groups mentioned a general lack of understanding among ambulance service staff of the developing model of education for paramedics. In partnership, the local ambulance service trust and university make considerable efforts to ensure staff/ students are suitably informed about what is expected of them. This is done through mentor meetings, tripartite meetings (mentor/mentee/
‘…mature students in this incidence were seemingly able to link their learning and knowledge of the profession with a more extensive range of life experience
Annual mentor/tripartite meetings allow discussion about student progress as well as other issues such as procedural details. This achieves vital contact and communication that allows collaboration between lecturers and mentors (Papp et al, 2003).
The importance of a quality placement is highlighted by an Australian study that discusses the need for supportive placements offering openness, opportunity and tolerance of inter-generational differences (Newton et al, 2009). This is particularly relevant in light of some initial animosity mentioned by both sample groups due to a lack of traditional progression routes for existing ambulance staff. Since completion of this research, specific time to prepare paramedic students for their placement is now provided during induction to the programme/university, thus benefitting placement engagement by informing them of social, cultural and political aspects of contemporary ambulance services. Curtis (2007) concluded that similar workshops for mental health nursing students had been helpful in preparing them for placement.
In relation to personality and people skills there was a distinct difference between the two sample groups; the direct entry students generally aligned themselves to what they considered the desirable attributes of a paramedic such as communication, decision making and the ability to get on well with others. The mature student sample took this further by linking attributes with their life experiences when talking about engagement in placement. Much of this experience bore comparison to aspects of the paramedic role such as medical exposure and careers within armed forces or other emergency services. This draws attention to an obvious link with research by Orland-Barak and Wilhelem (2005) that suggested that prior experience, knowledge and beliefs must play a positive part in clinical practice placements. The mature students in this incidence were seemingly able to link their learning and knowledge of the profession with a more extensive range of life experience. During placement this may allow them to settle in quickly and gain acceptance from existing staff, as was suggested in comments made by the mature student sample.
The subject of attributes and previous experience highlights the importance of providing and maintaining an infrastructure suitable for the provision of clinical placements; in particular a supportive environment that is tolerant of age, thus preventing discrimination against younger students (CoP, 2008; Newton, 2009; Billett and Ockerby, 2009; Association of Chief Ambulance Officers, 2011; HCPC, 2012). The majority of the direct entry participants suggested age had precipitated a negative effect at some point on their placement. Similarly, in the authors experience within the ambulance service there is concern among clinical staff over the age at which some HEI students will be eligible to join the HPC register and practice as paramedics; this seems to be around the ability of the younger graduate paramedic to manage complex social, ethical and moral situations. This reinforces the notion that paramedicine is often considered a vocational career and therefore better suited to those with more life experience (Cooper, 2005; CoP, 2008) who have also travelled the traditional ambulance service route to paramedic registration through a ‘working’ education over a period of several years.
The potential ability for mature students to settle in to placement quickly may be cancelled out or levelled in some manner by data from both the semi–structured interviews and focus group regarding capacity for learning. This suggested direct entry students were in the habit of learning and therefore had a clearer understanding of what they were trying to achieve on placement. Longer term, this may help direct entry students, who are ‘learning aware’ and recently familiar with education engage more due to their ability to link theory to practice; in particular, activities such as refection and the completion of learning contracts (Chartered Society of Physiotherapy, 2005). The same group may also be able to take advantage of the ‘hidden curriculum’ and ‘unintentional learning’ in placement as they do not have to exclusively concentrate on programme learning outcomes and programme requirements (Billett, 2004). This was demonstrated in comments made by the direct entry sample; the comments suggested if this student group are unsure about an incident, when they get back to the ambulance station they can review it with their mentor. Several of the mature student group specifically suggested that this was difficult for them as they were always thinking about the next essay or refection that they needed to be working on.
The concept of ‘unintentional learning’ also has potential to benefit the mentor and in turn LAT through re-invigoration of experienced clinicians that commit to mentoring students. This dialogue between mentee and mentor facilitates review and dissemination of knowledge (Clarke and Copeland, 2003; Andrew et al, 2008). Staff are regularly exposed to contemporary ideas/research by students who are encouraged to question and explore concepts, not historically something that paramedics have been encouraged to do until recently, as a result of higher education (Armitage, 2010).
Limitations
The author acknowledges this study would benefit from increasing in sample size; this could be done by including the second and third year paramedic students. In addition mentors could be included in future as it is these clinicians that have the experience of working alongside paramedic students from all backgrounds and age groups.
Conclusions
This study has shown that engagement in placement is a complex subject that is influenced by many factors. We must harness all the experiences of our students in order to allow them to make the most of their time in education. For example, an 18-year-old student brought up in an abusive household around drugs and alcohol will have regrettable but significant experiences to draw on in a career as a paramedic. Conversely a 30-year-old student may have limited experience of such issues but may have other life skills that can enhance their university/placement experience. The process required students to harness experiences and turn them into positive learning will be different for various individuals which presents a challenge for HEIs and LATs;
‘…an 18-year-old student brought up in an abusive household around drugs and alcohol will have regrettable but significant experiences to draw on in a career as a paramedic’
A recurring theme in this research was that of quality mentoring. As undergraduate paramedics embark on their educational journey they must be met by mentors with patience and understanding of an individuals’ background. Similarly mentors must be shown that they are valued and supported. Any friction within the process will likely be short lived as HEI programmes become more established and understood. Increasing numbers of graduate paramedics, with first-hand experience of HEI programmes will eventually begin mentoring students, providing what they see as a condition of their paramedic registration. This will in turn provide further support for existing mentors that have committed to the HEI education route for paramedic training.
There is no magic ‘bullet’ for solving or improving this situation overnight, it requires gentle nudging and culture change over a period of time, in addition to a level of understanding that all staff and students have travelled a different route to this point in time and therefore have different strengths and challenges. HEIs, in partnership with LATs and the CoP must continue to educate staff and students about what their aims and visions of the future are, this will facilitate promotion of the role they play in the future of paramedic education.