Significant clinical, health system and societal changes over the past three decades have been associated with remarkable developments in the paramedic profession (Williams et al, 2010; Bowles et al, 2017, 2). Frontline paramedics—once expected to rigidly follow clinical protocols—are now required to possess a ‘deep clinical understanding that supports clinical decision-making’ (Brooks et al, 2016). They are required to intervene in lower-acuity, chronic and complex conditions because ‘less serious “undifferentiated” primary care type cases [now dominate] the case mix’ (College of Paramedics 2017, 51). They must also master the supporting sciences in order to effectively care for patients within communities that are increasingly more socially and culturally diverse (Willis et al, 2010; Ford et al, 2014). The importance of the supporting sciences and related attributes has been previously reported upon extensively (e.g. Willis et al, 2010; Williams et al, 2010; Lazarsfeld-Jensen, 2010). In a study aiming to ‘establish which graduate attributes best meet the current and future needs of the Australian paramedic discipline’, Williams et al (2010) identified that the most important graduate attributes were those relating to soft skills, such as being ‘non-judgemental and non-discriminatory … trustworthy, caring, empathetic, self-aware and respectful of others' (Williams et al, 2010; Ford et al, 2014). When discussing the notion of professional practice across multiple professions, Higgs (2016) further highlights the centrality of these attributes:
‘[Professional practices] are manifest through … ethical conduct, professional decision making, client-practitioner communication, consultation and referral, and interdisciplinary team work …’ and, ‘[Professional practice is] ethically informed, committed, and guided by critical reflection on one's own practice and practice traditions …’
These significant developments in paramedicine have challenged modern approaches to paramedic education, not least in the field of work integrated learning (WIL) (Michau et al, 2009; Willis et al, 2010; Ford et al, 2014; O'Meara et al, 2014). The focus on WIL—sometimes referred to as clinical placements in the paramedic discipline—has arisen because quality WIL is considered a valid pedagogy, which contributes to the development of soft skills (Patrick et al, 2008; Helyer and Lee, 2014). Examples include ‘ethical behaviour, teamwork, communication, conflict resolution skills, … critical reflective thinking’ (Hastings, 2013: 2), ‘relational competence’ (Ford et al, 2014), ‘professional socialisation … [and] learning professional etiquette’ (Michau et al, 2009).
The challenge to develop soft skills among paramedic students calls for comprehensive, high-quality and well-evaluated WIL programmes, which immerse students in a diverse range of professionally relevant experiences. Here, diversity of experience appears to be paramount (Siggins Miller Consultants, 2012; O'Meara et al, 2014; Sachs et al, 2016; Australian Health Ministers Advisory Council, 2017). The search for high-quality, professionally-relevant, but also diverse, WIL experiences has been a key factor in driving the rise of non-traditional WIL (Overton et al, 2009; Hastings, 2013: 2).
For paramedicine students, a traditional approach to WIL (or placements) has been to require students to participate in the activities of a frontline emergency ambulance crew, usually in urban settings, and within the local national jurisdiction (Council of Ambulance Authorities (CAA), 2018). Non-traditional WIL activities, on the other hand, promote diversity of experience by providing WIL experiences outside of these traditional settings: such activities may occur with community agencies, other health professions and other emergency services, or in remote areas, diverse cultural settings, or unfamiliar domestic or international jurisdictions. A key aim of non-traditional WIL activities has been to provide diverse experiences, which help participants to develop the soft skills and non-technical capabilities that are essential to operating as well-rounded practitioners.
Another factor that has driven the rise of non-traditional WIL is the shortage of traditional WIL placements, which has ‘required [universities and academics] to develop innovative models that provide sound learning opportunities while addressing placement shortages’ (Hastings, 2013: 2). The challenges of placement shortages in health and social care professions are now prevalent in the paramedic profession (CAA, 2014: 25; Webb et al, 2014). Since 2014, Charles Sturt University (CSU) paramedicine students have undertaken more than a dozen international WIL experiences. Some of these (such as those in the UK) have attracted recognition towards specific WIL placement subjects within the paramedic degree. Others have provided a paramedic-focused clinical and cultural learning experience which the University has been able to financially and administratively support, commonly with the assistance of the New Colombo Plan Scholarship Program (Department of Foreign Affairs and Trade, 2018).
These international WIL experiences provide students with important clinical and cultural exposure which contributes to the development of attributes and capabilities required by modern paramedicine graduates. This paper builds upon previous evaluation activities in order to analyse and assess whether an international WIL experience in Vanuatu, which took place in 2017, provided a useful clinical and cultural learning experience for undergraduate paramedic students.
Methods
Programme design
Nine students were confirmed for attendance on a 4-week clinical and cultural learning experience in Efate, Vanuatu in 2017. During this international WIL experience, students participated in activities that—for the purpose of describing them within this paper—are classified under three headings:
In this WIL placement, participants were teamed up in pairs for the patient-care activities, generally with only one pair undertaking a specific patient-care activity at any time. In contrast, the multi-agency training and recreation activities were conducted as whole-group activities to promote teamwork and group learning. Academic staff members planned, coordinated and attended the Vanuatu WIL programme. The role of the researchers, however, was largely separate to that of the academics who attended the programme; this enabled researchers to focus on evaluating survey results at ‘arm's length’ from the operational programme delivery.
Evaluation procedures
A 60-item questionnaire was used in this study, consisting mostly of quantifiable questions which were designed to draw general conclusions about the students' experiences on this trip. Questions ranged from simple ‘yes’ or ‘no’ responses, to Likert-scale questions (‘strongly agree’ to ‘strongly disagree’) and a small number of questions inviting free-text answers, which provided additional valuable data about the student experience.
The survey instrument used in this study was based upon one used in a similar prior study to evaluate an international WIL experience in the Philippines (Delisle and Ebbs, 2018). As few changes as possible were made to the survey instrument; only geographical names and the details of scheduled activities were updated within the new survey for this Vanuatu WIL study.
The survey was administered immediately upon the return of students to Australia, using the online survey platform Survey Monkey. Only the students who attended this international WIL programme were invited to complete the survey instrument. Upon completion of the survey, response data were downloaded and formatted for analysis within SPSS, which was used to analyse frequencies for both the continuous and categorical data.
Survey response frequencies have been described in this paper, particularly where there is strong uniformity in responses to individual questions. Excerpts from free-text survey responses provide further descriptive detail.
Ethics were applied in compliance with relevant laws and institutional guidelines. The CSU Human Research Ethics Committee provided ethics approval for this study.
Findings
All nine students who attended the WIL experience in Vanuatu were invited to complete the survey. This resulted in six respondents, all of whom fully completed the survey. All attendees were female; five survey participants were less than 25 years old; and four survey participants were in their second year of study in the undergraduate paramedicine degree, with all others in their third year.
This international WIL trip appeared to be a unique experience for attendees as all students stated they had never undertaken a similar ‘university organised global trip’, and all but one student stated they had never ‘undertaken formal international studies’ in the past.
Clinical perspectives
Five respondents indicated that they felt clinically well prepared for what they saw and experienced during their time in Vanuatu as a result of prior coursework and other training (agree=4, strongly agree=1). While this level of confidence from students may be difficult to understand, this phenomena has been reported elsewhere (Hickson et al, 2015).
When asked to respond to the statement ‘I was satisfied with the number of clinical cases I attended and my level of involvement during these [cases]’, four students agreed (strongly agree=3, agree=1), while one student disagreed, and one student neither agreed nor disagreed. Four participants felt they had been given enough opportunity to participate in actual, hands-on patient care during their clinical experiences (strongly agree=1, agree=3).
In terms of relevance to their clinical learning and practice, all students indicated their exposure to cases which reinforced clinical learning objectives or clinical skills within their university subjects (strongly agree=4, agree=2). This result is further reinforced by all participants reporting that the clinical activities undertaken during this trip had improved their ability to assess, treat and manage patients (strongly agree=4, agree=2). All participants reported having learned at least one new skill while undertaking this international WIL experience: examples included ‘[intravenous] cannulation’, ‘blood draws’, ‘communication skills’ and ‘wound care’.
Participants were asked to nominate their most enjoyed clinical experience, and articulate why. Responses provide insight into the challenging nature of the experiences, as well as indicating growth in clinical and sociocultural capabilities:
‘The doctors and nurses were more than happy to let me treat and assess, and actively called for me to help. This may not have been as true if I didn't put the effort in early on my shift to be actively involved and ask to do things, however because I did I reaped the rewards. I was able to do many of the skills within my scope, and interacting with patients who spoke another language was a challenge I greatly enjoyed.’
‘Although my ultimate goal is to work in the paramedic profession, throughout the Vanuatu trip I feel the emergency department (ED) shift at the hospital was where I gained the most experience. … I was pushed to think clinically, make appropriate decisions, and overall step out of my comfort zone. … [In] the ED we attend many more local patients [which] challenged my communication skills, an area I felt I needed to most improve on … I also was exposed at times to a more busy environment, challenging my ability to work under stress, a skill I will be able to directly correlate into my future work as a paramedic.’
Five participants indicated that the learning environment and preceptors during this clinical experience were very supportive (strongly agree=1, agree=4), and the same number of participants indicated that the local preceptors in Vanuatu were well prepared to supervise them clinically as students (strongly agree=1, agree=4). Paramedic preceptors were described as ‘amazing paramedics … very knowledgeable [and] great at mentoring’. Four students indicated that they would have preferred more time riding alongside ambulance crews (strongly agree=2, agree=2, neither agree nor disagree=2).
All participants disagreed with the survey statement, ‘There was a lot of unproductive downtime during the clinical [experiences in] Vanuatu’ (disagree=4, strongly disagree=2); yet when asked about their ‘least liked’ experience during their time in Vanuatu, participants referred to the locations or times when there were low patient workloads. This suggests a strong desire towards participation and further learning, also reinforced by the following comment:
‘… exposure exposure exposure—can never have enough.’
Cultural perspectives
Three students indicated that they were motivated to attend this international WIL experience because of a desire to ‘better prepare [themselves] for working as a paramedic in a culturally diverse community’, while all others indicated they were motivated by a desire to ‘develop [their] global perspectives on paramedicine’. All participants indicated that they felt their cultural experience on this trip would help them to interact with patients of diverse cultural groups when they become a paramedic in Australia (strongly agree=4, agree=2).
When asked to nominate their most liked cultural experiences, three students indicated that this occurred ‘while working in clinical settings’, such as at the local private and public clinics, while two students indicated this to have occurred during their time off to ‘interact with local culture’.
The importance of the supporting sciences, and development of soft skills within culturally diverse clinical environments was strongly evident when students were asked to recount their ‘top clinical experience [that] challenged [them] the most’:
‘[This particular case] tested me clinically as well as my emotional and personal skills in dealing with patients' families… It was a challenge being confronted with a life or death situation… trying to do CPR … and being confronted with the family's grief [and] especially the different cultural approaches to death and grieving than what it would be in Australia. [This] was the experience that challenged me the most, and the one I learnt the most from.’
‘Obtaining a history was very challenging as the patient and all ten of his family members did not speak English. It was quite a hectic scene with many frantic family members [and] a very unwell patient …’
The penultimate survey question asked participants to describe what they considered to be the greatest benefit of the international WIL experience. Many responses related to cultural awareness, cultural respect, and global citizenship:
‘To be indulged in a different culture, language and land, and still be able to practise [para]medicine.’
‘working in an environment that is challenging though beneficial, rewarding and humbling.’
‘A better knowledge of the world and paramedics in general.’
This was further reinforced by one student when asked if they had any ideas for future research:
‘What can be done to intervene in a culturally appropriate manner that will further educate and benefit the community in regards to appropriate treatment plans.’
In this response, the participant has (probably unknowingly) acknowledged the interrelationship between the actions of the profession (to ‘intervene’ with ‘treatment plans’) and the supporting sciences that allow those actions to be appropriate and beneficial within a culturally diverse community.
Other notable responses
All respondents indicated that the daily schedule of the programme was well paced overall, and all would recommend that other students undertake a global trip similar to this one (strongly agree=5, agree=1). All participants stated they believed the university should continue to promote these types of international learning experiences (strongly agree=4, agree=2). In relation to safety, five students (strongly agree=1, agree=4) were fully confident in the University's ability to provide immediate evacuation assistance to students in the event of a terrorist incident or attack. One student strongly disagreed with this statement; however, further detail exploring this perception was not elicited by the survey instrument. All participants indicated they were not at all worried about terrorism threats while in Vanuatu (strongly agree=4, agree=2). When asked to nominate the source of information they would rely upon to make decisions in the event of a terrorist threat (e.g. information from the university, local media, Australian government, US government, or gut feeling), all six respondents indicated that they would rely on Australian government information.
Each of these items appears to be positive. However, a consistent and strongly negative response within the survey related to the cost of this international WIL experience which, on this occasion, was not funded through the New Colombo Plan Scholarship Program; these funds are only provided by the Australian Government when the programme has been successful through a competitive grant process. When reflecting on the cost of this international WIL experience, all students stated they did not believe the cost of this programme was in line with the clinical and cultural experiences they had received. In a separate section of the survey, two free-text responses provided further insight into this concern, specifically indicating that better communication and itemisation of costs would be beneficial to future students. These concerns may also highlight the importance of the New Colombo Plan and related global mobility scholarship grants.
Discussion
The purpose of this study was to evaluate whether an international WIL experience in Vanuatu provided a useful clinical and cultural learning experience for undergraduate paramedic students. According to these survey results, it appears that this international WIL programme in Vanuatu in 2017 delivered a high-quality clinical and cultural learning experience for attendees. For example, at least two-thirds of students consistently reported their satisfaction with the number of clinical cases attended; their level of participation in those cases; and the quality of their clinical preceptors. Participants particularly highlighted strong levels of cultural learning and awareness which demonstrated that students were making links between clinical skills and the sociocultural elements of practice.
Participants demonstrated evidence of developing professional soft skills such as communication, interdisciplinary teamwork, and adjusting care to different cultural groups. Furthermore, the respectful references to ‘different cultural approaches’, ‘languages and land’, and providing treatments ‘in a culturally appropriate manner’, suggest that students were learning to integrate the supporting sciences into their practice. When one considers the recommendation by Willis et al (2010: 2) for ‘a more solid integration between clinical theory, skills and the supporting sciences’, it might be suggested that international WIL experiences (such as this one) may represent one strategy to help achieve this aim within undergraduate paramedicine programmes.
The present study highlights key areas for further review and consideration. For example, an analysis and comparison of content and themes which have emerged in this and other similar surveys may contribute to a better understanding of the way in which these international WIL experiences contribute to undergraduate paramedic student learning. Secondly, while this international WIL experience seems to have provided a useful clinical and cultural learning experience for paramedicine students, mechanisms may need to be established to enable such endeavours to be examined in light of defined learning outcomes and accreditation requirements. The perspectives of academics who attend and supervise such international programmes would also be informative.
Further research would clarify the impact of these programmes on citizens, practitioners and patients who live in the host country. Do these programmes provide assistance in resource-limited settings, or are they a burden upon local community members and their facilities? Do the hosts feel taken advantage of by students from wealthy countries? What does the local community get out of a visit by international paramedicine students? These are important questions for universities with paramedicine programmes if consideration is to be given to the expansion of international WIL.
One limitation of this study is that the survey instrument has not been validated for a paramedic student population, and there were only a small number of respondents (n=6). Therefore, a related consideration is the development of a validated survey instrument which can be used to evaluate the quality of these non-traditional WIL programmes. Challenges in this area include, among other things, the formulation of survey questions that are applicable to the wide range of non-traditional WIL activities currently used in undergraduate paramedic programmes.