The issue of student placement quality has received considerable attention from health professions in Australia over the past decade (Ferns and Pegden, 2012; Siggins Miller Consultants, 2012; Australian Health Ministers' Advisory Council (AHMAC), 2017). In line with training for other professions, paramedic students and universities are more frequently exploring international placements and non-traditional (or non-frontline ambulance) overseas workplace learning experiences as part of undergraduate paramedicine courses (Ashton et al, 2013; Lord et al, 2013).
Academics involved in international placements need to consider objectives and ask if students will:
- Be able to (under supervision) practise vital sign measurements in patients with common conditions and assist with their management
- Have the opportunity to experience emergency healthcare systems in the host country and, be placed in a hospital emergency department
- Travel on the local ambulance service
- Have an opportunity to experience local culture
- Realise that the Australian healthcare system is highly effective in comparison with that in many other countries.
The current study investigated whether a university-organised overseas trip provided a useful clinical and cultural learning experience for undergraduate paramedic students.
Placements and accrediting bodies
In the paramedic and other health professions in Australia, guidance from accrediting bodies about the elements that comprise a quality placement can be limited, as can detail on how learning objectives during placements should be achieved and demonstrated (Siggins Miller Consultants, 2012; AHMAC, 2017).
For example, the accreditation guidelines of the Council of Ambulance Authorities (CAA)—the Australian and New Zealand accrediting body for university paramedicine courses—only generalise about how clinical placements should be administered, while noting that universities should ‘recognise the limited capacity nationally to offer clinical placements' (CAA, 2014: 25).
For other professions, accreditation standards for student placements may be too stringent (Nash et al, 2015; AHMAC, 2017), as the Division of Tropical Health and Medicine (DTHM) at James Cook University noted:
‘Accreditation requirements often restrict DTHM's capacity to administer clinical placements in strategic locations, including in areas relevant to students' future practice where there is high health workforce need. Highly prescriptive requirements about the experience of clinical supervisors, types of settings and quality of facilities in some specific disciplines limit the University's ability to offer students ‘accredited’ professional experience placements, particularly in rural, remote and international settings. The barriers relate to limited provision for inter-professional supervision, including strict “who, what, where” guidelines.’
(AHMAC, 2017: 83)
Attempting to strike a balance that mandates minimum standards of quality in placements without stymieing institutional innovation and responsiveness to emerging workforce needs, a recent AHMAC draft report has proposed that student placements for all registered Australian health professions:
‘… occur in a variety of settings, geographical locations and communities with a focus on emerging workforce priorities and service reform’.
(AHMAC, 2017: 85)
Outside health professions, a major study that comprehensively reviewed student placement and work-integrated learning (WIL) practices at 13 Australian universities concluded that high-quality WIL programmes:
- Are provided in various settings
- Recognise the centrality of relationships
- Are offered to and are meaningful to all students
- Are well organised by the university in terms of resourcing, supervision, industry and institutional champions, and links to learning outcomes, among other matters (Sachs et al, 2016).
Similarly, a major paramedic study in Australia and New Zealand highlighted the importance of defining the purpose of student placements, delivering them in diverse settings and providing continuity—particularly between preceptor and student (O'Meara et al, 2014).
Other quality frameworks for paramedic student placements have been identified (Pink et al, 2016; Health and Care Professions Council (HCPC), 2017). However, none can be identified that specifically address the key factors that comprise quality in overseas placement experiences for student paramedics.
Clinical and cultural aspects of overseas student placements
While the clinical skill acquisition aspects of student placements are well recognised in the Australian paramedic profession, the social and cultural dimensions of placements are sometimes less conspicuous (Willis et al, 2010; Devenish, 2014) despite being of critical importance to the profession, as Carver (2016: 17) notes:
‘These challenges for the novice paramedic are more complex than psychomotor skills … [Consider the] personal side of the paramedic role. Learning to communicate with patients and other health care professionals, building trust and rapport, and overcoming language barriers.’
The cultural and social elements of placement must therefore be considered to be of equal importance as the clinical skills components (Willis et al, 2010). Although perhaps under-recognised in paramedicine, this is not a new idea. On a theoretical level, concepts of experiential learning and learning through social activity were championed by educational theorist and reformer, John Dewey, more than a century ago and have been comprehensively expanded upon since (Ferns and Pedge, 2012).
In a more recent practical example, a large Canadian study notes a dynamic, diverse practice setting is one of the four defining features of modern paramedicine (Bowles et al, 2017). This further supports the equal importance of the clinical and sociocultural aspects of overseas student placements in paramedicine.
Design of the programme
Sixteen students were confirmed to take part in a 2-week clinical and cultural learning experience in Cebu in the Philippines. This was not a clinical placement within the paramedicine degree, but a clinical experience as part of a 2-week tour with the Charles Sturt University (CSU) Global programme.
Many programmes organised by CSU Global allow students to gain experience internationally in disciplines that relate to their field of study. The Philippines tour was chosen for evaluation because of the discourse surrounding workplace learning and WIL for the health professions.
To encourage engagement with both the clinical and cultural aspects of the trip, the 16 participants were separated into two equal groups. For the initial week, the first group undertook a clinically intensive component of hospital, ambulance operations and management, while the second group completed a more culturally-immersive public health medical mission component. The groups switched activities in the second week.
Clinical and cultural components
The hospital, ambulance operations and management tour took place in a hospital in the north of the province of Cebu within reach of remote ambulance stations and ambulance operations centres.
The activities for this part of the trip included assisting doctors and nurses with patient assessment and treatment (vital signs measurement, wound sutures, intravenous insertions, medication preparation and administration, newborn care, minor surgical assistance, sanitation housekeeping (personal health and hygiene), and tooth extractions), as well as assisting in the emergency room, the general patient ward, the delivery room and outpatient and dental departments. Students were also able to join remote ambulance crews to observe care provision and become acquainted with the Philippine ambulance operations system during any down time.
For the public health medical mission tour, student paramedics were partnered with local staff who travelled to remote villages where they worked in numerous public health settings, as well as visiting private homes. This part of the programme included an overview of rural health services in northern Cebu, a family health community mapping campaign (which comprised house-to-house health screenings, and nutritional and lifestyle education), food preparation and cooking demonstrations, a visit to a local medical mission facility (which focuses on screening, consultation, dental and optical services), observing and assisting at a physical rehabilitation centre, and assisting in a public health ‘blood-letting’ campaign (local term used for various types of medical blood testing).
Both parts of the programme included debriefing sessions; cultural-social activities with local people and other international students who were in the region in various capacities; a weekend away to Batanyan Island for relaxation; student presentations to local health workers on medical topics encountered (mainly patients with hypertension and diabetes); and a community fellowship night, which included all participants affiliated with cultural exchanges in the region at the time.
A 60-item questionnaire was designed for this study. This consisted of mostly quantifiable questions designed to draw general conclusions about the students' experiences on this trip. These questions ranged from those requiring simple ‘yes’ or ‘no’ answers to those needing graded ‘strongly agree’ to ‘strongly disagree’ responses. The survey also included a few qualitative open-ended questions to allow students to expand on and express their impressions, opinions and views on their experiences more freely.
The questionnaire was administered immediately upon the return of students to Australia, using online survey platform, SurveyMonkey. When students had completed the questionnaire, the response data were downloaded and cleaned by a statistician associated with the university using data-cleaning protocols.
Data analysis was undertaken using the predictive analytic software Statistics Package for Social Sciences (SPSS) for Windows (SPSS Inc, Chicago, IL). SPSS was used to analyse both continuous and categorical data. Normality tests were undertaken to determine the appropriate parametric and non-parametric tests. Χ2 analysis was used to determine if differences existed between categorical variables and correlations, t-tests and ANOVAs; regression was used to determine if relationships and differences existed between continuous variables. Equivalent non-parametric tests were used if data were not normally distributed.
Ethics were applied in compliance with relevant laws and institutional guidelines. The CSU Faculty of Science Human Research Ethics Committee gave ethical approval for this study.
There were seven respondents to the survey, all of whom completed it fully. Of these, 57.1% were female; 85.7% were aged under 25 years old (the remaining respondents selected ‘prefer not to disclose’); 71.4% were in their second year of study of the undergraduate paramedicine degree, with the remaining 28.6% in their third year.
The hospital, ambulance operations and management tour was conducted at Bogo City Hospital and the emergency medical services centres in the San Remigio and Medellin municipalities.
More than half of the students (57.1%) said this was their first ‘clinical experience’ in a workplace learning setting. When asked if they believed their university course work and clinical learning had prepared them well for what they saw and experienced during their clinical time in the Philippines, 85.8% indicated they agreed (42.9%) or strongly agreed (42.9%)—a result that was also supported in free-text answers.
Figures 1–4. Fire service demonstration (top left and right); delivery room care (bottom left); Inside San Remigio Ambulance (bottom right).
About three-quarters (71.5%) felt they had been given enough opportunities to participate in hands-on care during clinical experiences (strongly agree 28.6%, agree 42.9%) and 100% either strongly agreed (71.4%) or agreed (28.6%) that they were exposed to patient cases that reinforced their clinical learning objectives or skills within their university subjects.
Of the clinical experiences encountered during the tour, 57.1% liked the emergency room the most while the other 42.9% liked the delivery room experience the most. In free-text answers, the themes of childbirth, delivery, intravenous cannulation and blood draws featured strongly as the most positive clinical aspects of the learning experience.
However, when asked if they were satisfied with the number of clinical cases attended and their level of clinical involvement, only 28.6% were satisfied (strongly agree 14.3%, agree 14.3%) and 57.2% were not satisfied (disagree 28.6%, strongly disagree 28.6%). Supporting this suboptimal result, only 57.2% believed their clinical exposure during this trip had improved their ability to assess, treat and manage patients (strongly agree 28.6%, agree 28.6%), while 28.6% believed the tour had not improved their abilities in these areas. The desire for more clinical time (by extending the trip) or more exposure (by undertaking the trip at a busier hospital) featured strongly in the free-text answers, which further supports the results above.
All (100%) either strongly agreed (85.7%) or agreed (14.3%) that the learning environment and preceptors during the clinical experience were very supportive, and 85.7% either strongly agreed (57.1%) or agreed (28.6%) that the local preceptors in the Philippines were well-prepared to supervise them.
While no students mentioned an ambulance-related activity as their most-liked clinical experience, 42.9% would have preferred more time riding alongside ambulance crews (strongly agree 28.6%, agree 14.3%).
All students (100%) believed that the Cebu ambulance attendants were trained/operating at below the level of second-year Australian undergraduate paramedics.
The public health medical mission tour took place in the community of Purok Caimito in Barangay Tacup, San Remigio; healthy cooking demonstrations were also conducted at the Felipe Verallo Foundation College (FVFC) in Bago City.
More than half of the students (57.1%) indicated that their main reason for undertaking this trip was to ‘better prepare [themselves] for working as a paramedic within a culturally diverse community’. Moreover, 71.5% believed that their cultural experience on this trip would help them interact with ‘patients of diverse cultural groups when [they] become a paramedic in Australia’ (strongly agree 42.9%, agree 28.6%).
Making home visits during the public health training was the best overall cultural experience, according to 57.1% of participants.
The majority of students (71.5%; strongly agree 28.6%, agree 42.9%) said that the international trip and had made them more employable as a paramedic. The same proportion (71.5%; strongly agree 28.6%, agree 42.9%) said a valuable part of this experience was creating professional links and improving paramedic services by sharing ideas, knowledge and experiences.
When questioned on what they felt was the greatest benefit of this trip, all students mentioned cultural diversity and cultural immersion. While students felt ‘clinically prepared’ for the trip, the free-text answers suggested that basic language training, greater information on the clinical and cultural matters that would be encountered and even selection interviews would ensure a cultural preparedness across the group. It was encouraging that students identified these non-clinical elements as being so important.
In the weeks before the trip, the media had reported on terrorist events in the south of the Philippines where martial law had just been declared (ABC News, 2017). All students (100%; strongly agree 57.1%, agree 42.9%) felt fully confident in the university's ability to provide immediate evacuation assistance to students in the event of a terrorist incident or attack, and 85.7% percent (strongly agree 71.4%, agree 14.3%) indicated they were not at all worried about terrorism threats while they were in this area. Other data indicated that students were able to identify trusted Australian government sources to inform them about international security situations.
None of the students had undertaken a university-organised international trip similar to this one, nor had they studied abroad before.
The majority (71.4%) would recommend a trip like this one to other students (strongly agree 57.1%, agree 14.3%) and 57.2% believed the cost of this programme provided good value for money for the clinical and cultural experiences it provided (strongly agree 28.6%, agree 28.6%). Most participants (85.7%) said they believed the university should continue to promote these types of international learning experiences (strongly agree 57.1%, agree 28.6%).
Most participants (85.7%; strongly 57.1%, agree 28.6%, neither agree nor disagree 14.3%) appreciated having the opportunity to give feedback on the trip so this information could be used for research and to modify the experience to make it even better for future students.
Over half of them (57.2%, strongly agree 28.6%, agree 28.6%) indicated that this trip and its experiences had sparked their interest in carrying out clinical research and looking deeper into the issues surrounding pre-hospital/paramedic research.
The current study investigated whether a university-organised overseas trip provided useful clinical and cultural learning experiences for undergraduate paramedic students. The survey results indicate that, while the clinical experiences were of a high quality, the amount of clinical exposure was inadequate. On the other hand, the cultural elements of the trip featured positively within the free-text and rating-scale responses of the survey, indicating that cultural diversity and cultural immersion were the most positive elements. Therefore, this university-organised international trip appears to have provided a useful cultural learning experience for students but a suboptimal clinical learning experience; although participants were involved in childbirth, emergency room presentations and blood draws.
A number of findings are similar to those of other studies on international paramedic placements. For example, paramedic students generally feel ‘clinically prepared’ for placements despite relatively limited experience (Hickson et al, 2015), and cultural immersion appears to be a key factor that motivated students to take part in an international trip (Jones et al, 2016).
In terms of quality benchmarks for student placements, there were strong indications that the unique practice setting and cultural elements of the trip presented a valuable and meaningful learning experience (Willis et al, 2010; O'Meara et al, 2014; Sachs et al, 2016). Likewise, it appears that the trip was well-resourced and supported by the university, and was well-supervised through academic and local health staff through professional partnerships with the university and students (O'Meara et al, 2014; Sachs et al, 2016).
Broader questions to consider pertain to how to evaluate overseas paramedic student placements in the future. Key limitations of this study are that: the survey was not validated for a paramedic student population; there were only a small number of respondents (n=7); and this was the first time the survey had been administered. Therefore, an important future initiative would be to develop a validated survey instrument that could be used by universities to evaluate and better understand the dimensions of quality in overseas paramedic student placements.
- Students find cultural aspects of international learning to be of the greatest benefit
- The main professional reason students choose to go on international placements is to better prepare themselves for working as a paramedic in a culturally diverse community
- The majority of students believed that their most valued clinical experiences were labour and delivery, blood draws and intravenous cannulation, and their time spent in the emergency department. However, they were not satisfied with the number of clinical cases attended or their level of involvement during the clinical part of the programme
- The majority of students believed that this international global tour had positive outcomes overall and that the university should continue to make these trips available to students
- Recent terrorist acts in the Philippines did not influence any student's decision to attend the tour
CPD Reflection Questions
- As universities are organising more international paramedic student placements, how can both the quality of their clinical training and the students' overall learning experiences be measured?
- Universities are aware of the well-defined learning needs of undergraduate paramedic students. What should they do to optimise international tours to better meet their students' learning needs?
- Why should a validated survey that can be used by universities to evaluate elements (such as quality) within overseas student paramedic placements be developed; how would you do this?