The issue of high-quality student placements has received considerable attention across health professions in Australia over the past decade (Ferns and Pegden, 2012; Siggins Miller, 2012; Australian Health Ministers' Advisory Council (AHMAC), 2017). This has coincided with an increasing interest from students and universities in exploring overseas student placements and other international learning experiences (Nash et al, 2015; Jones et al, 2016). Similar issues of quality have been explored within the paramedic profession, although researchers have noted the need for further collaborative actions and research (Michau et al, 2009; O'Meara et al, 2014; Hickson et al, 2015). Like other professions, paramedic students and universities are also more frequently exploring international placements and non-traditional (or non-frontline ambulance) overseas workplace learning experiences as part of undergraduate paramedicine courses (Ashton et al, 2013; Lord et al, 2013).
For academics who support these international placements, necessary considerations have been, ‘Are these international student placements appropriate?’, and, ‘Do these alternative overseas learning experiences meet course learning objectives and accreditation requirements?’ The purpose of this article is to investigate whether a university-organised overseas trip provided a useful clinical and cultural learning experience for undergraduate paramedic students.
Placements and accrediting bodies
In the paramedic and other health professions in Australia, there is sometimes limited guidance from accrediting bodies about the necessary elements comprising a quality placement, or limited detail about how learning objectives during placements should be demonstrated and achieved (Siggins Miller, 2012; AHMAC, 2017). For example, the accreditation guidelines of the Council of Ambulance Authorities (CAA)—the current Australian and New Zealand accrediting body for university paramedicine courses—only generalise about how clinical placements should be administered, while also noting that universities should ‘recognise the limited capacity nationally to offer clinical placements’ (CAA, 2014: 25).
For other professions, accreditation standards for student placements may be too stringent (Nash et al, 2015; AHMAC, 2017), as articulated by the Division of Tropical Health and Medicine (DTHM) at James Cook University:
‘Accreditation requirements often restrict DTHM's capacity to administer clinical placements in strategic locations, including in areas relevant to students' future practice where there is high health workforce need. Highly prescriptive requirements about the experience of clinical supervisors, types of settings and quality of facilities in some specific disciplines limit the University's ability to offer students “accredited” professional experience placements, particularly in rural, remote and international settings. The barriers relate to limited provision for inter-professional supervision, including strict “who, what, where” guidelines.’
(AHMAC, 2017: 83)
In trying to strike a balance that mandates minimum standards of quality in student placements for the health professions without stymieing institutional innovation and responsiveness to emerging workforce needs, a recent AHMAC draft report has proposed that placements for all registered Australian health professions ‘occur in a variety of settings, geographical locations and communities with a focus on emerging workforce priorities and service reform’ (AHMAC, 2017: 85).
Outside of the health professions, a major study which comprehensively reviewed student placement and work-integrated learning (WIL) practices across 13 Australian universities concluded that quality WIL programmes were those that:
Occur across various settings
Recognise the centrality of relationships
Are accessible and meaningful to all students
Are well organised by the university in terms of resourcing, supervision, industry and institutional champions, and linkages to learning outcomes, among other items (Sachs et al, 2016).
Similarly, a major paramedic study in Australia and New Zealand highlighted the importance of defining the purpose of student placements, delivering the placements in diverse settings, and providing continuity of placement—particularly between preceptor and student (O'Meara et al, 2014). Other quality frameworks for paramedic student placements are noted (Pink et al, 2016; Health and Care Professions Council (HCPC), 2017) although none can be identified which specifically address the key factors comprising quality in overseas placement experiences for student paramedics.
Clinical and cultural aspects of overseas student placements
While the clinical skill acquisition aspects of student placements are well recognised in the Australian paramedic profession, the social and cultural dimensions of placements are sometimes less conspicuous (Willis et al, 2010; Devenish, 2014) despite being of critical importance to the profession, as Carver (2016: 17) notes:
‘These challenges for the novice paramedic are more complex than psychomotor skills… [Consider the] personal side of the paramedic role. Learning to communicate with patients and other health care professionals, building trust and rapport, and overcoming language barriers.’
The cultural and social elements of student placements must therefore be considered of equal importance as the clinical skills components of placement (Willis et al, 2010). Although perhaps under-recognised in paramedicine, this is not a new idea. On a theoretical level, concepts of experiential learning and learning through social activity were championed by John Dewey more than a century ago and have been comprehensively expanded upon since (Ferns and Pedge, 2012). In a more recent practical example, a large Canadian study notes the dynamic, diverse practice setting as one of the four defining features of modern paramedicine (Bowles et al, 2017). This further supports the equal importance of the clinical and the sociocultural aspects of overseas student placements in paramedicine.
Design of the programme
Sixteen students were confirmed for attendance on a 2-week clinical and cultural learning experience in Cebu, Philippines. It is important to note that this trip was not classed as ‘clinical placement’ within the relevant paramedicine degree, but rather was delivered as part of the separate Charles Sturt University (CSU) Global programme, which allows students to participate in international settings that may relate to their studies.
While this programme was not considered a clinical placement for the purposes of the paramedic degree, it is considered highly appropriate to evaluate the programme given the current discourse surrounding workplace learning and WIL in the health professions.
To ensure immersion in clinical and cultural aspects of the trip, it was determined that the 16 participants would be separated into two groups with one group undertaking the clinically focused Hospital, Ambulance Operations and Management component of the trip in the first week, while the other group would complete the more culturally immersive Public Health Medical Mission tour. The groups would then swap to the alternate activity in their second (and final) week.
Clinical and cultural components of the tour
The Hospital, Ambulance Operations and Management Tour was structured within a northern Cebu hospital. They were within reach of remote ambulance stations and ambulance operations centres. The itinerary for this component of the trip included assisting doctors and nurses with patient assessments and treatments (e.g. vital signs, wound sutures, intravenous insertions, medication preparations and administrations, newborn care, minor surgical assistance, sanitation housekeeping, tooth extractions), as well as assisting in the emergency room, general patient ward, delivery room, outpatient and dental departments. Students were also able to partner with remote ambulance crews to observe the provision of care and to become acquainted with the Philippine ambulance operations system during any down time.
For the Public Health Medical Mission tour, student paramedics were partnered with local staff who travelled to, and worked within, numerous remote village public health settings as well as visiting private residences in these areas. The subject matter for this itinerary included an overview of rural health services in northern Cebu, a family health community mapping campaign (which comprised house-to-house health screenings, nutritional and lifestyle education), food preparation and cooking demonstrations, a visit to a local medical mission facility (which focuses on screening, consultation, dental and optical services), observing and assisting at a physical rehabilitation centre, and assisting in a public health ‘blood-letting’ campaign (blood-letting is the local term used for various forms of medical blood testing).
Also included in the itineraries of both groups were debriefing sessions, cultural-social activities with locals and other international students functioning in various capacities in the region, a weekend away to Batanyan Island for relaxation, student presentations to local health workers on medical topics encountered (chiefly, patients with diabetes and hypertension), and a community fellowship night including all participants affiliated with cultural exchanges in the region at the time.
Figure 1. Images a–d: View from hostel (a); school clinic (b); inside a San Remigio ambulance (c, d). Cebu Philippines, June 2017
A 60-item questionnaire was created for this study, consisting mostly of quantifiable questions which were designed to draw general conclusions about the students' experiences on this trip. These questions ranged from simple ‘yes’ or ‘no’ responses, to agreement grading (Likert scale) questions ranging from ‘strongly agree’ to ‘strongly disagree’. Additionally, the survey consisted of a few qualitative open-ended questions to allow the students to expand upon and express more freely their impressions, opinions and views of their recent experience.
The questionnaire was administered immediately on the return of students to Australia, using the online survey platform Survey Monkey. Upon student completion of the survey, response data were downloaded and cleaned by a statistician associated with the university using data cleaning protocols.
Data analysis was undertaken using the predictive analytic software Statistics Package for Social Sciences (SPSS) for Windows (SPSS Inc., Chicago IL). SPSS was used to analyse both the continuous and categorical data. Normality tests were undertaken to determine the appropriate parametric and non-parametric tests. Chi-Square analysis was used to determine if differences exist between categorical variables and correlations; while t-tests, ANOVAs and regression were used to determine if relationships and differences exist between continuous variables. Equivalent non-parametric tests were used if the data were not normally distributed. Ethics were applied in compliance with relevant laws and institutional guidelines. The Charles Sturt University Faculty of Science Human Research Ethics Committee provided ethics approval for this study.
There were seven respondents, all of whom fully completed the survey. More than half (57.1%) were female; 85.7% were under 25 years old (the remaining respondents selected ‘prefer not to disclose’); and 71.4% were in their second year of study in the undergraduate paramedicine degree, with the remaining 28.6% in their third year.
The Hospital, Ambulance Operations and Management Tour was conducted at the Bogo City Hospital and the Emergency Medical Services Centres in the municipalities of San Remigio and Medellin. More than half of the students (57.1%) indicated this was their first ‘clinical experience’ in a workplace learning setting. When asked if they believed their university coursework and clinical learning had prepared them well for what they saw and experienced during their clinical time in the Philippines, 85.8% indicated they agreed (42.9%) or strongly agreed (42.9%)—a result which was also supported in free-text answers.
Almost three-quarters (71.5%) felt they had been given enough opportunity to participate in actual, hands-on patient care during their clinical experiences (strongly agree 28.6%; agree 42.9%). All students either strongly agreed (71.4%) or agreed (28.6%) that they were exposed to patient cases that reinforced their clinical learning objectives or skills within their university subjects.
Of the clinical experiences encountered during the tour, 57.1% stated that the emergency room was their most liked experience while 42.9% believed the delivery room was their most liked experience. In free-text answers, the themes of childbirth, delivery, intravenous cannulation and blood-draws also featured strongly among the most positive clinical aspects of the learning experience.
However, when asked if they were satisfied with the number of clinical cases attended and their level of clinical involvement, only just over a quarter (28.6%) were satisfied (strongly agree 14.3%; agree 14.3%) and 57.2% were not satisfied (disagree 28.6%; strongly disagree 28.6%). Supporting this sub-optimal result, only 57.2% believed their clinical exposure during this trip had improved their ability to assess, treat and manage patients (strongly agree 28.6%; agree 28.6%), while 28.6% believed the tour did not improve their abilities in these areas. The desire for more clinical time (by extending the trip) or more exposure (by undertaking the trip at a busier hospital) also featured strongly in the free-text answers, further supporting the results.
All (100%) either strongly agreed (85.7%) or agreed (14.3%) that the learning environment and preceptors during this clinical experience were very supportive, and 85.7% either strongly agreed (57.1%) or agreed (28.6%) that the local preceptors in the Philippines were well prepared to supervise them clinically as a student. While no students mentioned an ambulance-related activity as their most liked clinical experience, 42.9% of students would have preferred more time riding alongside ambulance crews (strongly agree 28.6%; agree 14.3%). Of interest, 100% of students believed that the Cebu Ambulance attendants were trained/operating at below the level of second-year Australian undergraduate students.
The Public Health Medical Mission tour was conducted in the community of Purok Caimito, Barangay Tacup, San Remigio, along with health demonstrations being conducted at the Felipe Verallo Foundation College (FVFC) in Bago City.
More than half of the students (57.1%) indicated that their main reason for undertaking this trip was to ‘better prepare [themselves] for working as a paramedic within a culturally diverse community.’ Moreover, 71.5% believed their cultural experience on this trip would help them interact with ‘patients of diverse cultural groups when [they] become a paramedic in Australia’ (strongly agree 42.9%; agree 28.6%). More than half (57.1%) said that going to individual houses during the public health training provided the best overall cultural experience; and 71.5% stated that the international trip and had made them more employable as a paramedic (strongly agree 28.6%; agree 42.9%). Almost three-quarters (71.5% (strongly agree 28.6%; agree 42.9%)) stated that a valuable part of this experience was creating professional links and improving paramedic services by sharing ideas, knowledge and experiences.
When questioned on what they felt was the greatest benefit of this trip, all the students responded with references to cultural diversity and cultural immersion. Interestingly, while students felt ‘clinically prepared’ for the trip, free-text answers suggested that basic language training, greater information on the type of things that would be encountered, and even selection interviews would ensure a greater level of cultural preparedness across the group. It was encouraging that students identified these non-clinical elements as being so important.
In the weeks prior to the commencement of the trip, there was heightened media reporting of terrorist events in the Philippines' south, where Martial Law had just been declared (ABC News, 2017). One-hundred per cent felt fully confident in the university's ability to provide immediate evacuation assistance to students in the event of a terrorist incident or attack (strongly agree 57.1%; agree 42.9%), and 85.7% indicated that they were not at all worried about terrorism threats while at this location in the Philippines (strongly agree 71.4%; agree 14.3%). Other data indicated that the students had become proficient in identifying trusted Australian government sources to inform them on international security situations.
One-hundred per cent of students stated that they had never undertaken a university-organised global trip similar to this before and had never carried out prior international studies. Many (71.4%) would recommend to other students that they undertake a global trip similar to this one (strongly agree 57.1%; agree 14.3%), and over half (57.2%) believed the cost of this programme was in line with the clinical and cultural experiences they received (good value for cost) (strongly agree 28.6%; agree 28.6%). A majority (85.7%) stated they believe the university should continue to promote these types of international learning experiences (strongly agree 57.1%; agree 28.6%).
Importantly, 85.7% stated they appreciated having the opportunity to provide their feedback on this global trip so that their information can be used for research and modifications (strongly 57.1%; agree 28.6%; neither agree nor disagree 14.3%), thus making it an even better experience for future students. Encouragingly, 57.2% indicated that this trip and its experiences had sparked an interest in them to want to do clinical research and to look deeper into the issues surrounding pre-hospital/paramedic research (strongly agree 28.6%; agree 28.6%).
The aim of the current study was to investigate whether a university-organised overseas trip provided a useful clinical and cultural learning experience for undergraduate paramedic students. The survey results indicate that while the clinical experiences were of a high quality, the quantity of clinical exposure was inadequate. On the other hand, the cultural elements of the trip featured quite positively within the free-text and rating-scale responses within the survey, indicating that cultural diversity and cultural immersion were the most positive elements of this international trip. This university-organised international trip appears to have provided a very useful cultural learning experience for students, but a sub-optimal clinical learning experience (even despite child births, emergency room presentations and blood-draws).
A number of findings in the present study are similar to those of other studies relating to international paramedic placements. For example, it has been observed that paramedic students generally felt ‘clinically prepared’ for placements despite relatively limited experience (Hickson et al, 2015), and that cultural immersion appeared to be a key factor that motivated students' participation in the international trip (Jones et al, 2016).
In terms of quality benchmarks for student placements, there were strong indications that the unique practice setting and cultural elements of the trip presented a valuable and meaningful learning experience (Willis et al, 2010; O'Meara et al, 2014; Sachs et al, 2016). Likewise, it appears that the trip was well resourced and supported by the University, and was well supervised through academic and local health staff through professional partnerships with the university and students (O'Meara et al, 2014; Sachs et al, 2016).
There are also broader questions, however, to consider about how to effectively evaluate overseas paramedic student placements in the future. It is noted that the key limitations of the current study were that the survey was not validated for a paramedic student population; there were only a small number of respondents (n=7); and this was the first time the survey had been administered. Therefore, an important future initiative would be to develop a validated survey instrument which could be used for other overseas placements, and by other universities, to evaluate and better understand the dimensions of quality in overseas paramedic student placements.
Cultural aspects of the trip were designated by several students as having the greatest benefit
The main professional reason students chose to go on this global trip was to better prepare themselves for working as a paramedic in a culturally diverse community
The majority of students believed that their most valued clinical experiences were labour and delivery; blood draws and intravenous cannulations; and the emergency department (however students were not satisfied with the number of clinical cases attended or their level of involvement during clinical training)
The majority of students believed that this international global tour had positive outcomes overall and that the university should continue to make these trips available to students
For the majority of students, the recent terrorist acts in the Philippines did not influence their decision to attend the tour
CPD Reflection Questions
International paramedic-student placements are becoming an increasingly popular feature of undergraduate paramedicine university programmes; how are the quality of these international placements and overseas learning experiences being measured and what can be done to improve this?
What are the clinical and cultural benefits of these international learning experiences? How can we optimise these tours to better cater to these (and other) defined learning needs of the undergraduate paramedic?
Explore in a reflection whether it would it be possible and useful to develop a validated survey that can be used across various paramedic universities to evaluate elements of quality in overseas student-paramedic placements and learning experiences.