Words by Steve Whitfield; Shian Watson; Joel Marriott; Cassandra Pokarier; Shelby Hardy; Dean McCort; Nicole Evans.
Presently, graduate paramedics in Australia maintain high levels of clinical knowledge and skills obtained through bachelor programs. However, opportunities for university graduate paramedics in Australian ambulance services is highly competitive.(1) Many graduates find themselves processing lengthy applications and awaiting protracted interview processes. It is during this time that the maintenance and development of clinical skills is paramount. Although simulation can provide genuine and realistic learning, graduate paramedics often find it difficult and challenging to find ongoing access to simulation opportunities following graduation.(1,2) Where learning is a continuous process grounded in experience, this situation for graduate paramedics in Australia presents a challenge.(2,3)
Whilst many ambulance services across the Asia Pacific region rely on a basic life support (BLS) trained ambulance workforce or first aiders, Australian graduate paramedics may be a useful augment in enhancing ambulance delivery in these regions. These ambulance services can also provide means for graduate paramedics to gain real-world experience and further develop their clinical ability in a professional environment. Allowing graduate paramedics to work with experienced local BLS responders can also benefit the skills transfer between the graduate and staff of the local services which increases the capability on both sides.
The Pilot Program
Participants were recruited to work as autonomous BLS responders in the Samoa Fire and Emergency Services Authority (SFESA) during the 2019 Pacific Games. Participants were graduate paramedics who recently obtained registration with the Australian Health Practitioner Regulation Agency. Participants were issued a Certificate to Practice at a pre-determined Basic Life Support (BLS) skills set. They were each partnered with a BLS SFESA officer for the duration of their rotation to respond as a crew. Participants were expected to maintain an open and professional dialogue with the community members, host organisation and clinical stakeholders regarding all aspects of clinical activities including operational resourcing, clinical procedures and emergency response. Due to the limited time constraints in planning the pilot program to support the Pacific Games, the pilot program was a collaborative determination of stakeholders built at short notice. Successful participants were given two weeks to prepare for the rotation.
What is Experiential Learning?
Learning is a continuous process grounded in experience.(3) This process of generating knowledge via the transformation of experience is termed ‘experiential learning’.(3,4) Kolb’s experiential learning cycle remains the “clearest expression” of experiential learning.(3-5) This four-stage cycle depicts four different kinds of abilities - concrete experience (experiencing), reflective observation (reflecting), abstract conceptualisation (thinking), and active experimentation (acting). Concrete experience forms the basis for observations and reflections. Reflections are subsequently assimilated and distilled into abstract concepts, leading to new implications for action. Implications are then actively tested and guide the individual when forming new experiences.(6,7) The individual must travel sequentially through all four stages for effective learning to transpire.(8) If one stage is missed, the entire learning process may become compromised - increasing the risk of the individual making the same mistake.(8-9) Experience based learning is effective because it helps establish long-lasting behaviour change. The entirety of an individual’s learning process is critically reflexive of their experiences and actions.(8-9)
How this applies to paramedic care?
Experiential learning supports the contemporary tradition of ‘learning on the job’, and that a core condition of learning is participation.(10) Recommendations have been made for this to be a compulsory part of paramedic education, as it enhances thinking and deliberation in the paramedic setting, adds depth of understanding to clinical practice, and optimises the recipient's learning.(10,12)
The opportunity to link previous knowledge and simulation to current real world experiences enhances knowledge.(9-10) This develops adaptation and acceptance of new techniques and knowledge, allowing improvement from the previous situation.(10) Furthermore, it develops the ability to recognise information, deliberate assessment, and management skills for a broader range of somatic, and complex psychological conditions.(11-13) The link between theory and practice is deemed as critical.(12,13)
Learning through experience, reduces that gap between clinical theory and practical clinical skills. It facilitates the transition into the paramedical practice.(12) Experiential learning allows graduate paramedics to experience the emotional and physical pressure of the job, whilst utilising their learned skills and knowledge in real time, something that theoretical learning and simulation cannot achieve.(11-14)
Inherently, there is risk involved with graduates who have limited clinical experience working unsupervised but consideration to strategies that mitigate the level of risk, both encourage and display a graduate’s ability.
Cultural differences between the Australian graduates and the Samoan community exist, that if not identified, could be misconceived as inappropriate behaviour or unsafe. To moderate this, participants were provided basic information pertaining to Samoan cultural practice prior to the rotation. Participants were crewed with locally based SFESA officers currently undergoing BLS training and this supported the skills and knowledge transfer, both culturally and clinically.
With limited real-world clinical exposure, the participants were deemed knowledgeable and skilled, yet inexperienced. According to the Australian Health Practitioner Regulation Agency (AHPRA), student development transpires when they are learning how to care for patients and this creates opportunities for learning which improves their clinical practice.(15) However, a recently graduated paramedic still lacks the very exposure and experience required for the role of autonomous advanced clinical work. They still require support and mentoring. The partnering of the graduates with the experienced SFESA officers was further coupled with a predetermined basic life support (BLS) scope of practice for the participants to operate under. Although the BLS scope of practice limited the advanced skills practiced by most graduates, this was a deliberate strategy for minimising the risk of autonomous practice. The opportunity for autonomous clinical decision making and emergency scene management provided a tangible and measured development opportunity whilst relatively controlled and reduced the likelihood of potential patient harm. The controlled nature of this partnership encouraged the inexperience of the graduate and the developing BLS knowledge of the SFESA officer to support each other and permit learning to occur on both sides of the partnership.
Outcomes and feedback
Project outcomes were measured through a Likert scale feedback form distributed to community stakeholders, SFESA representatives and the graduate participants by the host organisation. This information was shared openly with all of the stakeholders. Positive feedback was reported by the community stakeholders and SFESA representatives. This feedback included the professionalism of the graduates, their ability to communicate and cooperate, their clinical ability (at a BLS level), the perceived community benefit and host benefit of the pilot program. Whilst the reported cultural awareness of participants was rated slightly lower on the Likert scale, comments and feedback indicate that the participants self-identified this and were reflective and able to adapt better in the second week. Efforts to communicate in the local language and participate in cultural traditions was positively acknowledged by the community. However, improvement suggested by the community stakeholders identified a lack of awareness in hierarchical conversation (knowing when to speak or not when to speak) regarding community leaders and community meetings.
Overall, the participants were well received by the local SFESA and community stakeholders and it was acknowledged that it would take time for participants to understand cultural principles and a four-week rotation may be of more benefit in the future years.
The graduate paramedic participants reported an overall positive experience. The opportunity to gain real exposure in clinical and operational decision making enhanced their confidence and communication skills. Although limited to BLS, through the application of the participants knowledge and skills, and through the local SFESA mentoring, participants were able to gain significant experience in emergency response, patient management, patient transport and hospital handover. Furthermore, the opportunity to reflect on the daily activities with other participants enabled the sharing of experiences for further discussion, personal growth and development. Repetition of all the aforementioned experiences compounded by an unfamiliar environment had all participants identify that they were outside their comfort zone. However they also noted that this immersive experience built resilience to the individual. Through these varied experiences they all learnt from their successes and failures. Graduate participants also reported positive development in non-clinical aspects of paramedicine that cannot be taught in a classroom such as real-life scene management. Participants considered this aspect of experiential learning and professional growth to be the most beneficial aspect of the pilot program.
Although graduate paramedics are highly trained individuals capable of providing semi-autonomous paramedic care, currently within Australia, the saturation of the profession causes lengthy recruitment delays and a perceived lack of employment opportunities. However, in countries with a sparsity of out-of-hospital health services, such knowledge and skills are extremely sought after. Clinical placement opportunities, as described in this pilot program review, would facilitate the process of experiential learning, ultimately benefiting the graduate, the recipient ambulance service and the local community. As shown in the literature, the importance of experiential learning for medical personnel should not be understated when attempting to foster the abilities of developing clinicians and medical staff. Whilst the management of graduates paramedics working autonomously is delicate, the advantages of developing the capability of a local ambulance service, coupled with gaining real-world clinical experience, remain central to the pilot programs' outcomes.
This pilot program was established to support both the community and the graduate through a shared experience and assist in determining whether it was a case of “sink or swim” for graduates. The best classroom is the real world. Through a carefully managed structure, this program is a proof of concept that there is a real benefit to both the participating graduates and the local ambulance services. This unique approach to experiential learning, clinical practice and collaboration sharpened the graduates skill set, improved their clinical and communication skills and enhanced their employment opportunities.
Conflict of interest
The lead author of this critical reflection is the editor and established the pilot program. The subsequent authors participated in the pilot program.
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