Implications of Online Pedagogy in Paramedicine

· Clinical Education

Words By Hannah Gray 

Pedagogy is defined as a relationship between learning methodology and techniques, and the active practice towards the learning and teaching process (1). There are five main pedagogical approaches; collaborative, reflective, integrative, constructivist and inquiry-based learning (2). These approaches collectively relate to the pedagogical methodologies within the delivery of content and the sharing of knowledge between learner’s and teachers (2). Research by E. Champagne and A. D. Granja (2021) found that the prevalence of online pedagogy has significantly increased, secondary to the global Novel Coronavirus (COVID-19) pandemic, with the wide majority of institutions moving away from face-to-face learning, and towards online content delivery.   

Pedagogy can be learner or teacher focused, which fixates on the knowledge of the teacher, and the potential impact it will have on the development of the learner (3). Pedagogy within education incorporates the different learning styles of students which are taken into consideration by educators to ensure that all students are exposed to equal learning opportunities (4). As research by J. Wink (1997) demonstrates, this allows for educators to have a further understanding of the strengths and weaknesses of the learner and areas that may require more attention to detail. Teacher-centred pedagogy focuses on the professional development of the educator and their ability to effectively deliver course content, in conjunction with the utilisation of engaging tools and activities (3). Student-centred pedagogy focuses on the learner’s active participation in the learning process. Within this focus, the teacher is to act as a role model, mentor and coach rather than an educator (3).  These focuses can be easily adapted to suit online learning environments; however, facilitators need to ensure that the standard of content delivery is not reduced by changing from traditional face-to-face delivery methods (Seymour-Walsh et al., 2020). Underlying theories of adult learning assist in the understanding of how tertiary level students, such as paramedicine students, learn and develop as professionals and as individuals.  

“Adult learning theories play a pivotal role in the design and implementation of education programs, including healthcare” (5). Adult learning theory consists of three components: andragogy, transformative theory and experiential learning theory, that influence the performance and behaviour of educational practice. These components of adult learning theory, in conjunction with constructivist and reflection theories provide the conceptual framework for the delivery of knowledge and skills, as demonstrated in research completed by A. Taylor (2019). 

Andragogy utilises a self-directive approach to education, highly influenced by the responsibility and motivation of the learner, allowing facilitators to mentor rather than teach (important to note for paramedicine) (6). Transformative and the experiential learning theory are both heavily reliant on the learner’s ability to critically reflect on previous experiences, leading to retention of new information and development of patterns of thinking, promoting professional development and achievement of professional/personal goals as research by Mezirow suggests (2009) (7). 

The constructivist theory is a paradigm which is also utilised within online pedagogy and relates to learner’s constructing their own knowledge and understanding based off experiences and reflective practice (8). As demonstrated in research by S. Fernando (2017), constructivism is centred around the concept that learning is “constructed” and built upon based on the learner’s foundational knowledge and enhances ones logical and conceptual growth. Utilising a constructivist approach allows for the development of learning partnerships to be formed between learners, colleagues and mentors and a strong emphasis is placed on collaborative learning through observation or direct interaction, such as facilitated group discussions and activities (9).  

Reflection theory allows the learner to evaluate their performance and progression towards goal completion and is an ongoing process that utilises the revisitation of experiences, similar to andragogy, to identify past emotions, behaviours, beliefs and assumptions (10). J. A. Moon (2013) demonstrates through study that this process allows for the non-judgmental evaluation of  experiences, allowing for growth and clarity.  

Collectively, these theories are utilised within paramedicine curriculum to allow paramedic students to examine how they are currently performing, and the actions required to be able to achieve progress towards professional/personal goal completion (11). Students are encouraged to recognise the way in which they communicate and behave in a clinical environment, and are provided with the opportunity to be involved in mentoring and coaching relationships (11). The mentoring of paramedic students aims to assist them in becoming empathic, dignified and respectful clinicians, capable of delivering high quality health care, in accordance with regulatory requirements (12). Paramedicine mentors are to act as a role model for their students, and are encouraged to guide the student in their decision making and thought processes (13). Utilising tools and teaching models within these learning theories provides mentors with the framework to be able to provide students with opportunities for self-reflection and professional development (11).   

As demonstrated in studies by Seymour-Walsh et al., (14) COVID-19 has significantly reduced the capacity for tertiary and health professional education (HPE) institutions to deliver face-to-face learning. HPE closely relies on learners developing a sense of professional identity, through interactive activities such as facilitated discussions, tutorial lessons and clinical skill sessions. As researched by Seymour-Walsh et al., (14) the absence of these interactive sessions leads to significant delays in the development of knowledge, understanding and professional/personal confidence in aspiring student clinicians. These changes proved significantly challenging for HPE facilitators to ensure that students were still receiving high quality and engaging content. Providing lectures and tutorials online causes already highly self-directed learning in a tertiary setting to require an even greater dependence on individual learners’ initiative and motivation from the learner (Seymour-Walsh et al., 2020).  

Some students learning in online Zoom sessions were found to have “… the camera disabled and microphone muted, while other distracting home tasks are performed” (Seymour-Walsh et al., 2020) taking their attention away from the course work or online discussions. Seymour-Walsh’s findings also mentioned that software such as Zoom only allows a certain number of participants screens to be viewed at any one time, leaving others attendees unheard or excluded, creating an environment similar to that of a facilitated lecture, rather than an interactive tutorial (Seymour-Walsh et al., 2020). Sessions involving dense visual PowerPoint slides lead to students focusing on the visual information presented as opposed to what the facilitator was discussing, taking away from the potential learning to be gained from the facilitator’s knowledge and experience (Seymour-Walsh et al., 2020).  

In order to learn new psychomotor skills and be able to perform them competently with confidence, conventionally health students are required to have a deep understanding of the performance principles, indications, contraindications and pathological reasoning for the skill. Actively performing the skill allows the development of efferent (motor) neuron pathways. In conjunction with afferent (sensory) neuronal development, these lead to the ability for the learner to perceive and interpret sensations of the performance (16). Repeated performance further leads to myoplastic and neuroplastic development, allowing the learner to build corporeal literacy and competently perform the skill (16). When learning online, this is not always possible, as the opportunity for sensory feedback from performing the physical skill is linked or not available at all.  

The recent shift in the way HPE is delivered has required facilitators to find new ways for students to build on these psychomotor skills in the absence of physically performing the skill. As studies by T. Smith (17) expressed, videos demonstrating how to perform the skill and having the student watching the action of the skill and listening to the description, leads to the activation of mirror neurons, the precursors to motor neurone activation. While these tools are proven to have a positive effect of the development of students performing the skill, the musculoskeletal pathways are still yet to be formed. Smith states that these videos “imply that skills can only be correctly performed one way, thereby neglecting the natural in-practice variation encountered by health professionals” (Smith et al., 2020). When learning practical skills in an online environment, as Smith discussed, the employment of Vygotsky’s principle utilises a step-by-step approach for media delivery, allowing the learner to have ongoing neuronal stimulation and continuously reflect on their performance, while incorporating adaptations and external perspectives into their practice.

Research by S. Dhawan (18) states “… Coronavirus has made institutions to go from offline mode to online mode of pedagogy” and that institutions that were previously “reluctant to change” were faced with the requirement to deliver learning online, no longer an option, but a necessity. For paramedicine students, this has posed as a significant barrier to successful development, impacted by students being unable to attend clinical placements (19). Clinical placements offer students the opportunity to put prior knowledge into practice in an “operational” setting, under the direct supervision of a clinical mentor. Dr Vincent Clarke (20) performed extensive research into the impact that these learning opportunities have in the development of paramedicine students and the underlying “Theory-Practice Relationship” known as the Praxis Model. The model utilises “multiple concepts of theory, practice, knowledge and reflection which may inform the paramedic’s ability to practice as an autonomous health professional” (20).  

As Whitfield et al (2021) discusses, governing bodies for paramedic registration in Australia, require graduating students to demonstrate a specific standard of workplace knowledge and competency. Without the attendance of clinical placement, Whitfield et al (2021) found that students were lacking these skills, leading to ineligibility for registration (19). Much like the rapidly changing unpredictable environment in which paramedics work, COVID-19 required paramedicine facilitators to rapidly develop alternative approaches to teaching students when clinical placements could not be carried out (19).This saw the infiltration of teaching models and tools similar to those used in a coaching environment into paramedicine curriculum. Paramedicine is heavily reliant on a student’s ability to carry out in-depth self-reflection, allowing for identification for improvement, and active involvement in learning plan development and completion (19). The inclusion of these process into students' learning allowed for the identification of areas in which their skills were lacking or required further development, in order to meet eligibility requirements for registration (25).  

Research by B.Williams et al., (2021) discusses that COVID-19 caused the fast-tracking of graduates with the Queensland and Victorian Ambulance services, with the usual 12-month intern programs turning into a 6-month accelerated course, forcing graduates to have reduced clinical hours under direct supervision and reduced driver and safety training. As these programs were carried out throughout 2020, the effects of these fast-tracked graduate programs are not yet known, however S. Whitfield (19) provides the underlying assumption that the effects cannot have been positive on these now qualified graduates.    

Further assessment of the impacts that COVID-19 had on paramedicine students and fast-tracked graduates should be performed. This will allow for the identifications of gaps in the knowledge of new and developing students, to further allow for implementation of methods to overcome limitations. Further investigation in to the impacts of moving towards online learning on education as whole should also be investigated, as like paramedic students, other disciplines may have experienced a similar delay in professional development. As technology continues to advance and new methodologies for effectively delivering content online become available, continuation of research into the strengths and limitations of these methods will allow for improvements, further enabling students to have access to high quality online pedagogy.    

For HPE institutions, the movement towards online learning has presented as a significant challenge. As research demonstrates, students experienced a significant decline in success within their studies secondary to the inability to attend face-to-face learning and practical skill sessions. These sessions are now shown to be vital to the psychomotor development of paramedics. The inability to attend clinical placements for paramedicine students has shown some lacking clinically skills in students and graduates. Collectively this literature supports the premise that online pedagogy alone is not a substitute for face-to-face and hands on learning for undergraduate paramedics.  



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