A simulated wilderness exercise: the development of relational competence in paramedic students

Background

The concept of work-readiness refers to the paramedic graduate's capacity to transfer their entry-level qualifications and job-specific competence to the workforce and to quickly adapt to normal work pressures. Central to paramedic practice is the ability to assess and respond to the patient's condition, to work as a team in gaining control of difficult situations and to communicate effectively with patients, families, the public, the media and emergency and health services (Boyle et al, 2011).

In their research on key attributes for the paramedic discipline, Williams et al (2010) used a self-report questionnaire to scope the opinions of paramedic education and training experts (n=71). Their analysis revealed 10 key attributes, with the most important being ‘personal characteristics’ covering such relational qualities as non-judgement, non-discrimination, trustworthy, caring, empathetic, self-aware and respectful of others. A professional paramedic may have excellent technical and critical thinking competence, but if relational competence is missing, there is a failure to fully contribute to the team's efforts in often high-risk working environments (Von Wyl et al, 2009). Relational competence, also known as soft skills, generic skills and graduate attributes, is an essential competence for a professional paramedic where his/her interface with patients is clinically and personally challenging.

Lazarsfeld-Jensen (2010) notes that the poor development of relational skills in young graduates cannot be blamed wholly on educational pedagogy in the university sector—she notes the impact of contemporary social pressures on young students, where small family size, limited parental shielding from social pressures, immersion in communication technologies and social isolation limit their development of relational skills. Regardless of the reason for this low level of relational competence, it is clear that the university sector needs to do more to offer effective learning opportunities in this field.

Simulated wilderness exercise (SWE) pedagogy

The simulated wilderness exercise (SWE) was developed for senior undergraduate paramedic students at a regional university in Victoria, Australia. Paramedic lecturers, in consultation with practising paramedics from Ambulance Victoria, developed a range of clinical simulations drawn from real cases. In addition to navigation, wilderness response and trauma care skills, a key objective of the simulations was to target the development of students’ relational competence. Simulation, a pedagogical approach that brings the realities of the workplace to the student learning experience (Flowers and Gamble, 2012), falls within the umbrella term of work-integrated learning where theory is transferred to the practice of work (Patrick et al, 2008).

The three-day SWE was a busy, challenging event. Students worked in teams of up to eight and rotated through at least three extended simulations on the first day and up to six smaller simulations on the second day. Students achieved specific learning outcomes using a participatory approach to knowledge building and collaborative learning. Students were encouraged to keep a reflective journal during the event. This approach conforms to Lombardi's key characteristics of authentic learning (2007: 2):

Learning activities closely match the real-world tasks of professionals in the field

Learners undertake challenges that are complex, ambiguous, and multifaceted in nature, requiring sustained investigation

Reflection, self-assessment, and performance review are fully integrated in the learning experience

Teamwork is as essential to the authentic learning experience as it is likely to be in the modern workplace setting.

Methods

Methods

Participants were invited to keep a diary of their personal field exercise experiences. They were instructed to use reflective journaling, that is, to record what they noticed/experienced (discuss feelings and emotions) to make sense (analyse and evaluate) and to make meaning (action plan for future development). De-identified diaries were returned to the research team in a sealed envelope via the school office during the week following the exercise.

Focus groups were conducted approximately one week after the field trip; all were conducted over 60 minutes and addressed a schedule of questions designed to elicit responses on key study objectives (see Box 1). Focus groups enable participants to share their stories through open conversation in an environment where power imbalances between participants and researcher are de-emphasised (Seidman, 2006). This method of data collection has been found to encourage engagement from participants in terms of contributing their attitudes, priorities and framework of understanding in open conversation (Kitzinger, 1994).

Focus group schedule of questions

A maximum of 12 students participated in each focus group, conducted face-to-face on the university campus. All groups were audio-taped and conducted by a member of the research team not involved in the field exercise. To protect participant confidentiality, participants’ names were removed from data during data transcription; otherwise, audio-tapes were transcribed verbatim.

Results

Several themes emerged from the analysis of field diary and focus group data. A particular theme that voiced students’ perception of being challenged on a relational level was broadly termed ‘new understandings’. Statements within this theme were analysed and sub-themes were developed (see Table 1).

The text-based quotes below were taken from the full complement of participants. Minor corrections have been made to the quotes to enhance readability, namely, spelling and punctuation corrections, the addition of filler words (denoted by [ ]) and the omission of side issues (denoted by …).

1. New understandings: interpersonal relating

The three-day SWE was a busy, challenging event. Students worked in teams of up to eight and rotated through at least three extended simulations on the first day and up to six smaller simulations on the second day. An overall view of the challenge is provided by one participant below, along with her/his realisation of the importance of appropriate communication within the team:

‘… so you go out quite far, you use your navigational skills to get to a patient, based on a real scenario, a real occurrence of a patient out in the forest. And then you need to go back to base with the patient, while monitoring and treating [them] on route …. That really puts pressure on people to utilise their correct skills and to communicate… one of our biggest problems was you had half the team up the front [navigating back to base] and the other half carrying the patient out… and they just didn't pass it [information] on… We've got no idea where we're going…’ (Focus Group).

Participants recognised the existence of competitive personalities in teams, the behaviour of whom unsettled interpersonal relating and stymied accurate, reliable decision-making. One participant described this dysfunction in the team as ‘… such big personalities and everybody wanting to lead’ (Focus Group). The excerpts below, however, show the reflective nature of participants’ responses to this ‘chaos’ (Focus Group) in terms of the need for careful interpersonal communication and awareness of their role in team performance/goals. The first excerpt shows a participant's realisation that his/her natural inclination to act competitively and loudly in team decision-making was unproductive. In this simulated incident, the team was faced with a difficult extrication of a sick child (manikin), and the urgency of the clinical situation led the team to argue over exit strategies. In the second excerpt, another participant recognises the importance of appropriate interpersonal communication; in this case, restraint and silence.

‘I have a huge competitive personality and I am loud and everyone knows that but I decided to take a step back. I thought, for this to work I can't be all the way up high… I decided to step back. …then I decided to start picking the points where I was going to have an opinion’ (Field Diary).

‘Silence… um… letting the person… do what they're doing, and stop giving instruction or talking over them… four people standing around you saying 30 different things… And so, yeah, standing still and silence was always a good option’ (Focus Group).

2. New understandings: maturity, respect and tolerance

Participants quite quickly realised that the unfamiliar environment challenged them all equally and they needed to manage their own unease and be sensible and reliable within the team, that is, to demonstrate maturity. The participant below reported her/his decision to speak out with conviction in a situation where s/he would normally remain quiet.

‘… we all had really good communication and really good team work, but we didn't have any strong personalities [in the team] that really stepped up to the lead. We were like, “oh what do you want to do?” and taking a consensus. So I said ‘I'm not sure what everyone else is doing, but I know I can get us out of the bush …I know where we've been and I know how to get home’ (Focus Group).

Teams were occasionally under physical duress during simulations, in such situations some members stepped up to show a level of strength and resilience not previously seen by their teammates. The excerpt below shows a participant's respect and confidence in her team mate, while the second excerpt shows a participant's recognition of her own capability.

‘We had to find a trauma patient. … our team leader at that point knew her navigation really well, but she was challenged by all our opinions about the route back to base. She really held her nerve and that was …pretty good. She just had a clear logical argument, I was just really impressed with that anyway, because you know, it's thinking outside the square, which is what you really need in those situations’ (Field Diary).

‘And I found that, you know, being in the middle of the bush, where you haven't got the luxury of your truck that is filled with all the equipment you could ask for… Um, you really did have to improvise and think outside the square. And for me, it [the experience] gives me greater confidence’ (Focus Group).

Tolerance for, and acceptance of, others in the team is shown in this participant's reflection about teamwork during an arduous extrication of a trauma victim. The participant first reacts with anger to another team member's advice; however, the early frustration is followed by a valuing of the team member's view.

‘She is like “why are you doing that?”. Her … questioning was actually, at times, frustrating as hell because you are just trying to get this patient out in some kind of timely manner. But …what she was doing was actually quite valuable in terms of making me stop and question myself …why am I doing this… am I doing this blind? But yeah at the time it was incredibly frustrating’ (Focus Group).

Participants also expressed a new respect for team members with whom they had little familiarity; a developing awareness of each person's value within the team, and the need to use the full complement of their team's skills and commitment in activities and decision-making. The two excerpts below give voice to these sentiments.

‘It was interesting for me to see how the other people in my team got along with each other in a different environment other than sitting in the classroom… even people that sort of sometimes were left out or aren't so much into like being social… got to become part of the group. It was probably necessary too, like it took all, um, all the team members to get the job done’ (Focus Group).

‘I think it was a completely different environment. Even for people who are comfortable at uni [university], it takes everyone out of their comfort zone in a way. So it puts everyone maybe at the same level’ (Focus Group).

3. New understandings: self-awareness within the team environment

Various participants reflected on how their team developed and re-shaped itself as the experiences and challenges continued throughout the multiple simulations. A growing awareness and respect for teamwork is clear in the following excerpts: first, a participant describes the team as a collective from which various strengths could be rallied, and second, a participant recounts how the diversity of skills and knowledge in the team added to their own learning experience.

‘And yeah, in some shape or form we all, within our own groups, we all got to a point where we delegated roles to each other. We had our strengths and we played to them. Like for example, navigation, I know I found it extremely difficult to begin with but there were other things I knew I was capable of doing in patient treatment. And then accordingly we were matched in our own groups to what our strengths were, which I thought was really good for the team’ (Focus Group).

‘Just to see the different strategies that members of the team used to obtain information [from patients], especially if patients were in multi-conscious states. We all had different approaches and I especially learnt from that. Yeah, I liked that’ (Focus Group).

Participants noted how the SWE stretched them physically, cognitively and emotionally. In the first two excerpts below, participants show a self-awareness of their contribution to the team.

‘Then the next thing was to get out of the bush. Once I've been somewhere I know where I am. So I said to the group “I know I can get us out of the bush.” That was something I was adamant about’ (Field Diary).

‘The night navigation [exercise] showed us that we had learnt something… we remembered most of the track… we counted steps out and recognised different land marks… [in future] we can guide people or we can now be leaders in doing that sort of thing’ (Focus Group).

4. New understandings: belonging and professional identity

The final sub-theme in ‘new understandings’ was participants’ recognition of themselves as belonging to a community of health professionals, and their first steps towards understanding the strength gained from professional identity.

‘For me it kind of felt like we were part of it … we are part of this developing professional community. Especially having ex-paramedics [retired], current paramedics and people from the wider health care setting and military and all that. …even just with the students, it kind of made this little community, which creates a bit more sense of belonging in the profession. I felt like I was contributing to something’ (Focus Group).

In the excerpt below the participant shows an awakening to the professionalism in other team members. Respect and valuing of the calmness and composure of a team-member is clear in the participants’ words.

‘Some people are just calm. He was just so clear on what everyone had to do, there were no issues at all… And he went, “Well have you thought about this?” And you were like, oh, okay maybe I will just wait…’ (Focus Group)

Key features of professional identity are the notions of accountability for your own practice, and responsibility for the welfare of members of your profession. The following excerpts show the emergence of these sentiments.

‘I think it was a shared feeling, but I definitely felt I had a greater accountability and responsibility, not just for myself and for the patient but for all members of my team. Because you're looking out, and you are walking [and] you are carrying that patient who is heavy, and you have maybe 3 km to go. And you know, everyone is feeling it, and you kind of all just band together’ (Focus Group).

Discussion

This study shows that the development of undergraduate paramedic students’ relational competence can be successfully targeted through an authentic learning experience such as that provided in the SWE. These findings support Boyle et al (2007) and Williams and Dousek (2012), who found simulated learning experiences to offer safe learning environments for rehearsal of communication and patient care skills, with Boyle et al (2007) also confirming that skills learned through simulation transfer to real patient care.

The unfamiliar and physically taxing environment was perhaps the most important feature of the SWE; it was this environment that tested participants’ usual relational behavior and caused them to rethink and reprioritise certain traits. Participants in the study reported that poor interpersonal relating, most notably competitive and argumentative behaviour, reduced team cohesion and severely limited their team's performance during time-sensitive simulation exercises. Self-reflection was evident from both ‘dominant’ and ‘passive’ individuals who explained how they changed their usual manner of relating for the good of team performance. Participants’ words gave evidence of maturity in thought and action and a valuing of other team members’ skill, performance, reliability and responsibility. These sentiments are recounted here in one participants’ field diary:

The second key theme in the focus group data was participants’ increased level of awareness of benefits of working in, and belonging to, a team. Participants viewed their team in very complimentary terms; for example, they recognised the benefit of being able to draw on the diverse set of skills and knowledge held within the team, they appreciated the rich learning experiences provided within the team, and finally, they were gratified to be recognised for their own unique contribution to the team. These team benefits also extended to participants’ sense of pride and belonging within the professional group, expressed through admiration for others and their desire to protect the welfare of team members.

In an evaluation of paramedic graduate capability, Willis et al (2010) found senior paramedics in Australia, New Zealand and Great Britain to view graduates as novices in terms of maturity and clinical competence. These authors stressed the need for the university sector to integrate interpersonal skills, counselling, ethical thinking and learnings from other supporting sciences into theoretical and clinical learning. Being able to communicate was seen by Willis and colleagues as essential relational ability in a paramedic, specifically ‘being able to talk and listen appropriately… choose appropriate language and behave appropriately’ (Willis et al, 2010: 7).

Other health disciplines also give priority to teaching relational competence in undergraduate courses. In nursing, Searl et al (2014) found their puppet-based simulation to improve nursing students’ humanistic attributes of being genuine, accepting and empathetic, particularly in relation to paediatric care. In a mixed interdisciplinary health group, Meyer et al (2009) instigated simulation education to target participants’ capability in engaging in difficult discussions in relation to a patient's poor prognosis. After the education, participants reported greater ease in establishing relationships, and better preparation, communication skills and confidence. Bambini et al (2009) found undergraduate nursing students to increase their level of self-efficacy in patient care, particularly communication, confidence and clinical judgment, as a result of a three-hour simulation exercise.

Lazarsfeld-Jensen (2010) suggests educators and lecturers should no longer presume a level of relational competence in young people who enter tertiary programs. She notes that the language of inclusion, tolerance and morality needs to be taught to students who are ‘increasingly isolated by family structure, disembodied friendships and a lack of cohesive communities’ (Lazarsfeld-Jensen, 2010: 370). The term ‘disembodied’ friendships is coined by Lazarsfeld-Jensen to explain friendships formed through social media and other communication activities, activities that present young people with an ‘impersonal, disembodied and easily terminated set of relationships’ (Lazarsfeld-Jensen, 2010: 371). Regardless of the reason for this low level of relational competence, it is clear that the university sector needs to do more to offer effective learning opportunities to undergraduate students in the health sciences.

Conclusions

Contemporary research and opinion stress the need for relational competence, or maturity, competent interpersonal relating and the ability to contribute to a team environment in paramedic work. Our university's simulated wilderness exercise offered paramedic students the opportunity for new learning in relational competence, a competence seen as essential for a positive team result in paramedics’ often high-risk working environment. There is an important practice implication from our study findings, namely, our graduates will transition to on-road paramedic work with greater ease. They will bring a high level of understanding about communication strategies and team cohesion. They will also understand the strength to be gained within the professional team. Importantly, by performing the relational aspects of their role with greater ease, they will find their transition to normal work pressures to be less stressful.