The seeds of road resilience are sown in the non-clinical dimensions of paramedic education—the supporting sciences. Within these sciences are tools to address practice issues that researchers have labelled ‘wicked problems’ (Mertens et al, 2016), a phrase covering a raft of contemporary issues such as institutional complexity, technologies, inequity, risk, and increasing accountability and governance requirements, as well as interpersonal attitudes unique to those born at the turn of the century. Paramedic work is changing rapidly and diversifying, which is why practice education is moving to universities. Evidence-based, non-clinical subjects develop deep learning and reflective practitioners, providing insights into the self and others.
This discussion draws on the perspectives of educational theorist George Siemens (Siemens, 2004; 2014), who offers insights into the influence of technologies on 21st century teaching and learning. Technology is the first of the wicked problems, because of its impact on the younger generation. Siemens' work has informed educators who found 20th century paradigms were unworkable for producing employment-ready graduates. This is, first, because today's undergraduates will not have a fixed career trajectory and, second, because the social world and needs of the millennial student have been given scant recognition. Skills now have a shorter shelf life.
Technology has subtly changed the way young people work, learn and think (Bennett et al, 2008). Dependence on social media influences the way younger paramedics communicate, as well as emotional sensitivities.
Siemens' insight into contemporary teaching shows the limits of traditional training methods in the digital age, and the need for innovation.
Need for the supporting sciences
The efficacy of any professional training programme depends on educators being able to prepare students for the future. Paramedicine in 2030 will not be the role students sign up for today (Legislative Council Committee, 2008; Skinner, 2012), but they will thrive if they are orientated towards the future, recognising that paramedicine can answer contemporary social needs. Siemens (2014: 5) describes this as ‘the ability to recognise when new information alters the landscape based on decisions made yesterday’.
Emergency medicine dominates curricula in Western nations even though problems associated as ageing are the most common calls on paramedic time; however, the scope of paramedic practice is being rapidly reshaped by socioeconomic demands. New paramedic roles are developing in direct response to urgent trends, such as health services overload, the escalation of mental health issues in the community and ageing populations (Cooper, 2005; Evans et al, 2014; O'Meara et al, 2017; Ross et al, 2018).
The ageing population in Australia, like that of most Western nations, is growing so rapidly that, by mid-century, most paramedic work will be with frail, older people. Ambulance policy, training and priorities are already being shaped by social anxieties about ageing (Legislative Council Committee, 2008). Other factors that are shifting paramedic work away from the emergency focus include stricter industrial safety legislation, and the declining incidence and severity of accidents and reduction in road deaths in Western countries, shaped by technology and innovation (Peden et al, 2004).
Work opportunities are found increasingly remotely and offshore, and employment may require different skills such as health education and the management of long-term health conditions (O'Meara et al, 2012; Acker et al, 2014).
Remote communities have a specific needs for which paramedics may provide innovative solutions, particularly through technologies. Remote, rural and offshore paramedics use telehealth technologies to avoid costly air transport in the case of long-term heath issues, but there is less call on their emergency medicine skills, which is a growing concern as these skills may become weaker (Mendez and Van den Hof, 2013).
Educators are not only dealing with changing social demands but also working with students who are the product of these rapid social shifts. For example, the future needs of ageing populations across the world—with the emphasis on ageing, extreme longevity and the management of long-term conditions—shifts the focus of paramedic practice to primary and public health topics.
It would fit in the paragraph starting “Some paramedic programmes in Australia take an informed biopsychosocial approach”
Students often lack social-emotional competence through a dearth of community contacts because of the fragmented nature of 21st century families (Jennings and Greenberg, 2009; Lazarsfeld-Jensen, 2010). Students who have not known their grandparents may think all older people are alike. They conflate frail, elderly people with retirees of 60 who are decades away from developing age-related somatic conditions. Students sometimes regard long-term conditions associated with ageing as catastrophic and terminal, calling for hospital admission and institutionalisation. The non-clinical aspects of their education must address problems that were less prevalent in the 20th century when families were more cohesive.
Students looking forward to a high-adrenaline career often express disappointment about working with older people. Enhancing empathy, challenging prejudices, provoking social justice, and providing an understanding health care systems and political influences on work practice are all part of the supporting sciences.
Some paramedic programmes in Australia take an informed biopsychosocial approach that prepares and equips students to work with older people and reflect on this constructively (Ross et al, 2018). This recognises the convergence of biological, psychological and social circumstances. However, this type of development is rarely intentional and, more commonly, soft skills are regarded as being embedded in programmes by virtue of the on-road experience of clinical educators. Resistance to deep learning in the social sciences is common among both students and their clinical educators, as evidenced in a recent practitioner doctoral thesis:
‘I was advised repeatedly that I was expecting far too much from my role as a paramedic. The responses from them [superiors] were always the same; I was looking too deeply into the needs of our patients, that our role was to get them to hospital as quickly as possible and move onto the next job at hand.’
Hartley's production of freshwater knowledge—new knowledge based on experience in clinical practice and research—through his dissertation led to support for deeper education in the state of Victoria, where patients are from diverse backgrounds. His research into paramedics' cultural preparedness was fuelled by his surprise at the knowledge of other healthcare professionals, and their concern over the paramedic's lack of broader biopsychosocial knowledge.
The dangers of misunderstandings across cultural and linguistic boundaries were made clear recently in New South Wales, when the paramedics' union issued a public apology to a group of Muslim men who had become involved in an altercation with paramedics at the scene of a patient death.
Unless a university programme has equal dimensions of evidence-based biological, psychological and social theory, the embedded soft skills may only be those of pop psychology, more suited to the Oprah Winfrey show, which are not adequate to address a public cross-cultural altercation or emotional crises in students.
Social psychology
The fictional Jason Crown case (Box 1) provides an insight into the emotional life of a millennial student. Neither Crown nor his cohort would regard his post-traumatic stress disorder (PTSD) as a lack of resilience, but as a problem calling for professional medical intervention. The right to hold specific beliefs is strongly defended in this generation, so it is difficult to help students unpack the ways in which their own beliefs fuel attitudes. Some people may suggest that Crown's main issue would be best addressed by a chaplain, and a more broadly informed psychologist could canvass the issue of moral distress (Corley et al, 2001) rather than PTSD, which has become a baggage term, used to cover emerging descriptions including moral distress and moral injury for anxiety from many sources.
Belief systems influence confidence, fear, empathy, guilt, altruism, prejudice and, ultimately, interpersonal and professional communication, which affect patient safety (Owen et al, 2009). The need for changes in attitude to improve communication skills is acknowledged in emerging educational programmes (Ross et al, 2018) that expose students to patient groups that some might regard as the ‘obnoxious other’, a heuristic term used in sociology to express conflicts of values and lifestyles that cause offence (Taylor and Mettee, 1971). In paramedicine, the less endearing patient groups may be frequent users of services, who become the object of black humour (Filstad, 2010), a coping mechanism that has been well identified although not sufficiently critiqued. Subtle prejudices and fears are best dealt with in an educational setting in an objective way rather than in practice through difficult encounters. These topics require deliberate, challenging conversations.
Social psychology equips health professionals to analyse their own responses to disturbing events, dysfunctional teams, and behavioural and communication issues, and it enhances ethical and informed reflection on practice. Although the clinical focus of many programmes is rightfully intense, burnout, breakdown and PTSD are the commonest saboteurs of a career, and these issues are primarily psychological.
Future-focused paramedic programmes have addressed the time pressure created by including more content and extending education into a four-year honours degree programme (honours degrees in Australia include a year of postgraduate research education). This move responds to needs in paramedic education that were raised almost a decade ago in a national research project into paramedic curricula (Willis et al, 2009; 2010). The broadening scope of educational preparation for emerging roles serves individuals and the healthcare industry in multiple ways, including extending the professional lives of practitioners who cannot continue on the road for any reason. Any paramedic programme that cuts supporting sciences will shrink into a competency-based training system that will be a disservice to the profession.
Although students cannot be made trauma proof, social psychology provides a significant theoretical explanation of key practice issues, including violence and aggression. It leads students to develop their own tools and strategies to de-escalate crowd-fuelled aggression. Social psychology also suggests reasons why people behave in particular ways: why they stay sick, choose poor health behaviours and fail to draw support from friends and family and, perhaps by implication, why poor, homeless and substance-dependent people become frequent (ab) users of ambulance services.
By demonstrating the complex and concentric personal and social problems that keep some people in poverty and despair, social psychology provides some explanations that may ameliorate the frustrations of dealing with demanding patients. While social psychology cannot make anyone more resilient, it can supply students with a deep understanding of the factors that fuel and deplete their emotional energy. In studying their selves, they can learn that not all stressors are equal, and that individuals are not equally affected by similar events.
Enhancing students' natural psychological immunity
Rather than dismiss Crown as lacking resilience and therefore a poor candidate for paramedicine, the author would argue that his future career should not be sabotaged by a mental health diagnosis. His experience provides a platform for reflective learning that could make him more effective as a paramedic. Siemens' (2014) learning theory for the digital age—connectivism—demonstrates that teachability occurs at critical junctures that lead to deeply engaged, transformative learning.
The phenomena of bounceback (Luthar et al, 2000) is used to define resilience and requires an event to recover from. Clompus and Albarran (2016) note the high stress levels among emergency service workers and the lack of research around paramedic responses to stress, and follow Luthar et al (2000) in rejecting resilience as a personal trait. Resilience is ‘a dynamic development construct’ (Luthar et al, 2000: 555), which is neither static nor predictable in those found previously resilient. Teaching resilience as a counter-offensive to PTSD tends to normalise pathological issues, and perhaps heighten student sensitivities and vulnerabilities. The resilience label also creates winners and losers, and is distrusted as victim blaming in some discourses (Joseph, 2013). In contrast, providing generic tools to explore the nature of stressors gives students space to evaluate risk without feeling inadequate.
Crown's exposure to extreme stress and the challenge to his values have the potential of leading him to better self-awareness and greater certainty.
For Crown to process his experience, he needs an educational setting that allows him to be himself at all times and provides adequate structure and support to explore the cognitive and emotional aspects of stress, death, perceived failure and personal values. This is a far cry from the old approach of hiding distress, but it is better attuned to this generation and their professional future.
Road-trained paramedics, many of whom started at a more mature age, often have a robust philosophical approach to themselves and may rightfully believe that people are normally irrepressible, and optimism is a default human response to life. However, the prevalence of exhaustion, burnout and breakdown in paramedicine is rising (Nirel et al, 2008; Clompus and Albarran, 2016; Austin et al, 2018), as the work itself intensifies and diversifies and political pressures lead to institutional constraints such as media vigilance around British ambulance call times (Clompus and Albarran, 2016). There is potential to boost existing strengths and flexibility in undergraduates through rigorously enriching their education with positive strategic approaches to stress.
Second-wave resilience research has shown that bounceback responses to death and loss are normal (Mancini and Bonanno, 2009). The majority of adults do not develop severe psychological distress in response to negative events and situations in their own lives and work (Campbell-Sills et al, 2006). The public perception of inevitable human vulnerability is probably a relic of an era when psychologists, who deal only with abnormal responses, did most of the research (Bonanno, 2004; 2005). Less research has been done with people who are positive deviants—those who are the stuff of self-help books, surviving challenges that have made them strong at the broken places (Chenoweth and Stehlik, 2001; Marsh et al, 2004). Social psychology research leads to a positive rather than a deficit model of student potential. Resilience is an interaction between an individual and a specific stressor, and ‘it cannot be described in the abstract … it is uninformative … to describe someone as having a resilient personality because resilience is defined ex post facto’ (Mancini and Bonanno, 2009: 1806).
Siemens' (2014) widely cited theory of learning enriches our perspective of today's students, who emerge from a highly sensitised, psychologised and socially connected society. Subtle trends that are significant to health education include public reactions to death and suffering. Thirty years ago, a University of Texas academic suggested paramedics could be helped in their response to death by strategies that included educational desensitisation, humour and escape into work (Palmer, 1983); none of these would be acceptable today.
Demonstrative public grief began in the UK with the deaths of the Princess of Wales and other celebrities (Mitchell et al, 2017). Online grief, public mourning and material symbols assembled in public places bear no resemblance to the silence at the end of the First World War, when most families had to settle for a dead son's name on a list on a monument. Older generations may misread the emotional signals of younger people as potent or catastrophic rather than an acceptable level of venting in the 21st century. Student access to counselling services has a positive connotation, and it is easy to encourage both men and women to seek help early because mental health problems have little stigma for this generation; most universities are experiencing this as demand on counselling services even for trivial matters (Randall and Bewick, 2016). Crown's reaction to his first patient death would probably be regarded by his peers as normal, constructive and transient.
Link between confidence and success
There is no doubt that Crown needs to increase his confidence, and this is on the educational agenda because of the correlation between self-esteem and academic performance, shown through a plethora of international research (Feldman and Kubota, 2015; Tangney et al, 2018). However, in the 20th century, attempts to build confidence in schoolchildren led to a proliferation of barely earned stars and stickers, which led to a false sense of entitlement (Katz, 1993).
Discussions on self-esteem have extended to those on other positive attributes such as hope, self-control and goal-directedness, which can be measured with validated instruments. They are correlated with personal behaviours and attitudes by young people, who expose and criticise their own and others' attitudes and behaviours on social media (Andreassen et al, 2017).
However, as students of social psychology quickly learn, correlation is not causation. The self-esteem concept was turned on its head early this century by positive psychologists (Seligman et al, 2005; Lopez et al, 2018), who suggested that genuine academic achievement leads to greater self-esteem and, by default, greater goal-directedness, hope and self-control in working towards tasks that seem achievable. Positive psychologists focus on the elements of living well throughout life, with an emphasis on what is normative and attainable.
Looking through the lens of positive psychology, Crown's self-esteem will increase when he has more successes or when he is able to think through the positive dimensions of his experiences. Deep learning of this nature requires opportunities for educational reflection. It cannot be dispensed in bolt-on classes in resilience, self-esteem or how to cope with a patient death. It is formative, personal and emotive learning (O'Meara and Lazarsfeld Jensen, 2018).
Conclusion
To develop excellent university programmes for paramedics, it will be a case of physician heal thyself. The paramedic of 2030 will be unrecognisable compared to the ambulance driver or medical technician of the last century. To prepare road-resilient graduates, clinical educators need to extend their teaching far beyond personal experience. Paramedics are best qualified to train the next generation, but the effectiveness of university programmes depends on how far clinical educators are willing to extend their own education, challenge their own preconceptions and understand the perspectives of today's undergraduate.
Paramedic educators with postgraduate qualifications in education, psychology, sociology, law, evidence-based practice and research skills can add deep freshwater knowledge to the profession. Because of the dearth of paramedics with doctoral qualifications, supporting sciences are largely taught by career academic subject matter experts, who have doctoral qualifications in one discipline but no practice knowledge. Until paramedic educators become the experts and take on the non-clinical dimensions of a course, the fit between instructors and students will always be poor. Students want to be taught by someone who has done the job they intend to do. Subjects taught at a generic, theoretical level do not engage vocationally oriented students. Paramedics equipped to teach supporting sciences can make these subjects relevant for students; they can better interpret, integrate, adapt and apply contemporary research knowledge to clinical practice education.
Ultimately, paramedic autonomy in managing university teaching programmes and the move away from dependence on career academics, such as has been achieved in nursing, depends on paramedic educators generating their own freshwater knowledge through the marriage of their professional skills with the traditional disciplines of any university degree programme.