It is well known that, nationally, frontline paramedics are increasingly attending to non-emergency problems or calls that could potentially be managed by a primary care provider (Booker et al, 2017). Therefore, student paramedic training, including both placement and taught elements at university, should reflect this.
However, placement opportunities for student paramedics in primary care settings while they are at university varies across the UK. Student paramedics currently have placements on the ambulance, in the emergency department, in care homes, in maternity, on the hazardous area response team (HART) and in theatre. Considering that urgent care complaints encompass the majority of a contemporary paramedics' workload, with increasing pressures to avoid conveying patients to the emergency department where this is safe and possible, should including placements within general practice be a priority? It can also be argued that exposure to primary care is a crucial aspect of education for paramedics to facilitate interprofessional learning (Health Education England (HEE), 2016).
It is evident that the number of paramedics working in GP surgeries is increasing, which is supported by the recent five-year framework for GP contract reform to implement the NHS Long Term Plan (NHS England, 2019). These paramedic practitioners may be able to provide mentoring in the GP surgery to student paramedics. It is acknowledged that student paramedics attend to non-emergency problems on their ambulance placements; however, the footfall of patients within general practice is far greater; anecdotally, GPs and paramedics in general practice see an average of 35 patients per day, so placements in general practice would increase their exposure to these cases as well as to the advanced knowledge of GPs and paramedic practitioners working in primary care.
Placements are essential element to student learning; in addition to allowing students to apply subject knowledge and technical skills in a professional environment, placements give a helpful insight into organisational discourse, culture, professional socialisation, applied skills and working relationships. Most importantly, placements are valuable for increasing self-confidence and encouraging reflective practice (Norton, 2018).
Both nursing and physician associate students degrees incorporate placement within a general practice setting, but this is not consistent for paramedic degrees. The College of Paramedics (COP, 2017) practice curriculum guidance suggests that universities must demonstrate they provide a range of appropriate, high-quality placements that support students to achieve the learning outcomes of the programme. It does not specify that paramedics should have a placement within general practice; however, it can be argued that a placement in this setting may help to ensure learning outcomes are achieved. Equally, the Health and Care Professions Council (2019) standards for education and training suggest that learners must be able to learn from and with practitioners from other relevant professions, which implies the importance of interprofessional learning.
Some universities have piloted placement in general practice for student paramedics and some continue this as part of their mandatory placements; The North West Placement Development Network worked in partnership with Edge Hill University in Manchester in 2016 to incorporate a rotational placement model in which four weeks was spent in general practice. On evaluation, key outcomes of the placement included the chance to engage with a multidisciplinary team, with an increased opportunity to practise skills, triage, decision making and the management of long-term conditions (HEE, 2016).
Similarly, another study used qualitative interviews to evaluate student paramedic placements in an accredited training general practice in south-east England, and reported that students felt they had acquired greater skills, they were more autonomous and felt they could manage more patients at home following the placement (Ruston and Tavabie, 2011). Importantly, the students valued the high-quality interprofessional learning, which is essential for the modern paramedic. Kaput (2018) suggests that this is imperative, particularly with contemporary teaching practice, that students have more of a voice on facilitating their own learning.
This background informed how the question, aim and objectives of this study were formulated.
Study question
What are student paramedics' views on the importance of including a placement within general practice as part of their degree on their learning and development as an autonomous paramedic?
Aim
To explore student paramedics' views on incorporating a placement within general practice as part of their degree on their learning and development as an autonomous paramedic.
Objectives
The study's objectives were:
Methods
This is a small pedagogic study as part of a postgraduate certificate in academic practice for higher education, providing scoping work to explore student paramedics' views on including placement within general practice on their learning and development. The methodology used was a case study with a qualitative approach, using face-to-face, semi-structured interviews and thematic analysis.
Ten students agreed to participate. Four withdrew so interviews were conducted with six participants; there was no scope for these to be rearranged. Each interview lasted approximately 30 minutes and was audio-recorded. The interviews were conducted by a senior lecturer who is also an advanced paramedic practitioner in a GP surgery. Purposive convenience sampling ensured personal experience of the situation being explored, and the inclusion criterion was that participants had to be third-year paramedic science students (Aveyard, 2014). The first 10 participants to volunteer were selected. All interviews took place on the university campus and refreshments were provided.
Third-year student paramedics were approached by the researcher during a lecture and the proposed study was explained to the class. The researcher then distributed participant information sheets and consent forms for the students to read, sign and return if they wished to take part in the study. The consent forms were returned over a period of two weeks and students were given an opportunity to ask any questions. The researcher then contacted the first 10 participants via university email to organise a date and time for interview. In developing the interview questions, Patton's (1990) technique of open-ended, conversational questioning was used.
The data obtained from the audio recordings of the interviews were transcribed by an independent transcriber, and themes were generated from the data to unify concepts. Having another individual studying the data and generating themes reduced bias, increasing the validity and plausibility of the study (Khalke, 2014). Thematic analysis can be seen as a foundational method for qualitative approaches; a well-established iterative process of data reduction, constant comparison, organisation and understanding through thematic analysis was used and consensus of themes was reached (Braun and Clarke, 2006). This involved familiarisation with the data, assigning preliminary codes to describe the content, searching for patterns in the codes, reviewing the themes and then defining them.
Ethical considerations
All procedures were performed in compliance with relevant laws and institutional guidelines with appropriate committee approval. Approval was provided by the University of the West of England research ethics committee.
Findings
Description of participants
The six participants interviewed were third-year paramedic science students, in the 20-40 years age range. There were four women and two men.
Thematic analysis
Three themes were identified:
Theme 1. Positive reasons for placement in general practice
All students felt that a placement in general practice as part of their degree would largely benefit them as an autonomous paramedic.
SP4: None [negatives]. I can't think of any reason. I don't think it could ever do any harm, especially as it's a service that we liaise with so often – the insight would never be a bad thing.
The students spoke about the importance of adapting to the changing role of the paramedic and the need for additional knowledge and confidence to manage non-emergency complaints.
SP1: We are lacking in certain areas for the contemporary side of things. On my ambulance placement, with my mentor who is very good and modern, sometimes he is uncomfortable with doing the full contemporary assessment. Therefore, I sometimes don't get to do it. If we were to do these new skills like the full assessment of cardiovascular etc, in an area we can do it on a real patient, I think this will be beneficial.
SP1: To be honest, primary care problems are my least favourite thing [but] I really want to know more and I like learning about the medical stuff. But the complex cases – I feel I have limited tools in my kit to help. I would love to know more about how decisions are made, just to safely make them.
SP3: I feel less confident managing patients with primary care problems than critically ill patients or patients who obviously need [the emergency department]. I suppose at the moment I have a low threshold for admittance. If in doubt, I call a GP.
Students acknowledged they worked with GPs on almost every shift in some way, whether this was to make a referral or ask a GP to visit, to ask for advice or to ask about a patient's medical history.
SP6: My mentor is really proactive with keeping patients at home, but we use the GP a lot.
Some of the students felt that the most important benefit of having a placement in general practice would be to build a better understanding of the role of GPs, and to develop the relationship between paramedics and GPs.
SP1: I think it would be really good to understand their decision making. I may say to a patient to contact the GP, but I don't know what their plan of action or care/treatment would be thereafter. Being able to advise the patient what [the GP would do] would be really beneficial.
SP2: In terms of a more holistic approach, I think it gives you a better view of what GPs can do.
SP3: Seeing what they do, what they find and that's the key thing really. We've got all this information, so what happens next?
Students were often specifically concerned about when and what they should refer to the GP, and therefore felt strongly that a placement in general practice would give them a better idea of what GPs expect from them as paramedics.
SP4: I think it would help massively, because a lot of the complaints we go to would otherwise be seen by the GP, so I think seeing the way they deal with things, what they look for, their red flags when they're concerned, but also their opinions from the other side, when they would expect us to refer to them and what they would do – none of us have actually had a GP placement.
SP6: Definitely, I'd love one [a placement in general practice] because I think knowing what the GPs want off you and giving the right information to the GP, you can see what they expect of us.
Another key factor that many students expressed as a reason for having a placement in general practice was to focus their assessments. This would result in shorter on-scene times and better decision making.
SP1: I can see where they [GPs] focus their assessment, they just don't have that time, whereas as paramedics, you may be unsure of a diagnosis so you do everything, which would not happen in a GP surgery – they will focus their assessment and will make a decision based on that.
SP3: I think it would definitely help. A lot of patients we see are non-critical and their management is based around taking history, using the medical model, doing a physical assessment and that's what doctors do. Having a good few days with a GP would definitely help me do a more thorough assessment.
SP5: We'll stay for around 45 minutes to an hour whereas if patients go the GP surgery, they're in there for 5-10 minutes. I think: what are we doing? Are we doing something wrong on the ambulance? Are we taking so long to identify what's wrong or is not wrong? Is there a quicker way to deal with the patient to turn over? Yeah, definitely learn a more focused assessment.
Students discussed the importance of having a placement on general practice in terms of progression in their career and learning about opportunities within this setting.
SP2: Paramedics are starting to go into GP surgeries now, so it might be good if they have a paramedic in their surgery, it would be really handy to work with someone. If you could do a master's and then go into general practice, that is a realistic goal.
SP4: I think it will be a good insight for people who think that they may want to branch off into primary care later down their career. That's where, at the moment, I think that I'd like to go. I'd like to [go on a GP placement] – even if it is a week or so – just get an insight to see if you can see yourself doing this.
Students spoke about the opportunity a placement in general practice would offer in terms of interprofessional learning and knowledge of alternative care pathways:
SP3: You've got lots of roles within a surgery too, nurses and paramedics, so you could spend time with them as well, because that's another alternative care pathway, isn't it? So you can see who can deal with what.
This demonstrates the importance of interprofessional learning from a student's point of view, and how it is essential to understand how staff within general practice work so they can work better together.
Many of the students thought of the GP practice as the ‘gateway’ or ‘hub’ to all alternative care pathways and often, while on the ambulance, they know the patient does not need hospital admission but are unsure of the referral options available.
SP4: We've been guilty of taking people in [to hospital] because we haven't known what other resources are around for them.
Theme 2. Negative reasons for placement in general practice
When the students were asked whether they foresaw any negatives of having a placement in general practice, half thought there were no negatives and half had some concerns.
Some students felt that if the presenting complaint was too complex, then the patient would see the GP anyway, questioning the point about learning how to carry out a more in-depth patient assessment.
SP2: In terms of assessment, it probably won't help, based on they [GPs] having 5-10 minute windows to assess someone. We're quite lucky and can take our time. If we need to go really in depth, then doctors can do that.
Many of the students felt that even when they did a full assessment and referred to the GP, their decision was not supported and they ended up conveying the patient to hospital anyway. Additionally, they felt they did not have the equipment or authority while on the ambulance to use their knowledge.
SP1: If you call out-of-hours they say ‘too complex’ and we end up taking them in [patient to hospital], which is frustrating.
SP1: The consensus among some crew mates and paramedics is that it won't change our diagnosis/going to hospital, so why do it [advanced assessment]?
SP1: We have limited tools and authority on the ambulance.
SP2: With personal experience, if you mention the observations, they [GPs] will pick something and say ‘no, I want him in hospital’.
Theme 3. Challenges/logistics
Students discussed factors that could be challenging with incorporating placement in general practice. One student identified a concern of ensuring paramedics knew their own limitations. They felt that a placement with GPs may blur the line between urgent and emergency care further, leading to unsafe decisions as paramedics would be unsure of what they can and cannot do. Moreover, students believed that their placement on the ambulance should always be the priority.
SP1: The only negative I can think of is that paramedics are not sure what they can and can't do.
SP2: Needs to be a suitable proportion of our placement hours, so the priority needs to be working on the ambulance because that is what we are doing.
The students were keen to discuss the logistics around when the placement in general practice would be. All students felt that one week would be enough and that they would like the placement to take place in their final year, so that they could use their skills.
SP6: I think year three because you've got all your physical assessment and clinical reasoning done.
SP3: It's all about assessment of non-critical patients, so it would fit in quite nicely with year three.
Students also said they thought a placement with an out-of-hours GP would be beneficial, as they found management of patients to be different from in office hours.
SP1: A placement with an out-of-hours GP because sometimes you feel that if you have spoken to a particular out-of-hours GP, you always get a sigh of relief because they quite happily say, ‘It's OK I'll send someone round’, but there might be locums who have no idea and are less willing to try.’
Discussion
Findings show that student paramedics view a placement within general practice to be enormously beneficial to their learning and development as an autonomous paramedic.
The results demonstrate that, above all, students felt that observing GPs may help to develop the relationship between paramedics and GPs, increasing understanding of expectations and essentially who does what. This is reflected in a study by Burns (2018), who wrote that in a time of very high expectations, GP services require interaction with other health professionals to evaluate gaps in the urgent and primary care arena.
The placement may lead to more appropriate referrals to GPs and paramedics feeling confident to make decisions. This is further echoed by Djalali et al (2017), who identified that an increase in practitioners' confidence regarding primary care provision can lead to an improvement in their professional organisation and examination skills after vocational training. Student paramedics do not feel they have the skill set so their confidence is reduced when referring to the GP. Students often insinuated that GPs do not always accept their referrals. While there are many reasons for this, building relationships between paramedics and GPs may help to address the problem. A placement in general practice at an early stage of a paramedics' career may therefore be of benefit in this situation.
Another popular opinion was that student paramedics felt that a placement in general practice would focus and improve their patient assessment. Student paramedics commonly queried how GPs could consult with a patient in 10 minutes. The complexity of the prehospital environment means that 10-minute on-scene times would be particularly difficult (Levitan et al, 2018). Paramedics do not often have access to notes and the patient's medical history, which is just one factor playing a part in extended on scene times. Student paramedics believe that having a more focused assessment will improve decision making and on-scene times. Observing GPs and paramedic practitioners doing this regularly may be of great benefit to students for this reason.
Student paramedics clearly recognised the changing role of the paramedic and frequently identified that they were attending to more and more non-emergency problems on the ambulance. Subsequently, they understood the importance of utilising alternative care pathways to reduce unnecessary conveyance to the emergency department. They felt that placement within a GP surgery would be pivotal in helping them to understand the processes of what happens when they refer a patient to the GP, and to learn about the alternative care pathways available.
Students also mentioned that working as part of a multidisciplinary team within a GP setting would help to establish links and learn how different practitioners work, which is particularly important to reduce emergency department admissions for patients with complex long-term medical problems, who paramedics attend to frequently (NHS England, 2014).
The main concern student paramedics had regarding having a placement in general practice was that they would not be able to use the additional skills and knowledge learned in this setting. This is primarily because they do not have the equipment required, such as urinalysis, pregnancy tests and otoscopes.
It was clear from the interviews that students struggle with their confidence to make decisions about non-conveyance. They consistently reported that they felt more confident to manage patients with a ‘life-threatening’ condition or ‘patients who definitely require admission to hospital’ than those with ‘primary care sensitive’ problems.
The educational structure is pivotal to student paramedics' ability to make decisions (Perona et al, 2019). Furthermore, O'Hara et al (2015) conclude that training and knowledge of access to alternative options to emergency department conveyance are important issues in paramedic decision making. Both placement in a primary care environment with the use of problem-based learning could improve student paramedics' confidence and decision making skills, which will in turn have a positive effect on the health service.
Students reported that they would prefer to have the placement in their final year of university, as they would have the greatest amount of knowledge by this point. The first and second years are more focused on trauma and communication and practical skills than on patient assessment and clinical reasoning, so it was felt that the final year would be the most beneficial time.
Limitations
The findings outlined in this article are not generalisable, as the views from six students do not provide a true reflection of the wider population.
Additionally, the interviewer is a senior lecturer who also works as an advanced paramedic practitioner in a GP surgery, giving rise to internal bias. Despite this, every effort was made to reduce this bias by having an independent reviewer and transcriber.
Conclusion
This study provides a foundation and scoping work to explore the importance and influence of incorporating a placement within general practice as part of a student paramedic science degree programme.
Overall, student paramedics feel that having a placement in general practice will significantly help in their learning and development as an autonomous paramedic. Specifically, they feel it: will help them to understand the role of the GP and what the GP expects of them; will help them to focus their assessments, which could result in less ‘on scene time’; may lead to an improved knowledge of alternative care pathways because of working with multidisciplinary teams in general practice; may improve the confidence of student paramedics not to convey patients when this is safe and possible; and, finally, may provide an insight into the role of the paramedic in general practice as a future career opportunity.
There are a few reservations about whether the students would be able to use the new skills and knowledge they learn in this setting, as they feel they do not have access to the tools or the authority on the frontline ambulance. Students would prefer to have a placement in a GP surgery in the final year of their university degree, lasting one week.
Although this is a small, pedagogic study and cannot be generalised to the whole population, the findings clearly suggest it is important for universities to incorporate a placement in a GP surgery within paramedic science degree programmes for final-year students, and the benefits this may lead to. This is particularly pertinent with the changing role of the contemporary paramedic who attends to non-emergency problems.
Future, larger research should investigate students' experiences of placement in general practice and the benefits and problems involved. Perhaps all newly qualified paramedics would benefit from a primary care experience once they have consolidated their emergency care practice.