This study indicates that for some student's clinical placements is not providing theory consolidation or skills practice appropriate for their scope or level of education. While students were satisfied with the number of cases during placements and believed clinical placements sufficiently reinforced learning objectives, the exercise of matching learning objectives to case exposure and skills practised for education level revealed contradictory findings.
Second year and third year responses were analysed separately to link learning objectives to clinical placement cases. This study was conducted when second year students had completed foundation subjects such as anatomy and physiology and had undertaken reduced clinical placement hours compared with the third years. Their role during these placements was to gain an introduction to life on the road as a paramedic by having an observer role only. This study has shown second year students were participating at an appropriate level by mainly assisting with equipment or observing the paramedic crew undertake case management. In some instances students were participating at a level higher than an observer role. This was also found by Melby (2000) where nursing students undertaking observer shifts with the ambulance were provided with hands on experiences conducting cardiopulmonary resuscitation, oxygen therapy and bandaging [31
]. Anecdotally from a university perspective students are encouraged, if appropriate and under supervision, to complete skills not yet learnt at university. This was occurring for over half of BEH students and indicates observing students are being provided with skill practise during clinical placement despite not yet studying these skills at university.
At the time of completing the survey, third year students had covered cardiac, respiratory, trauma and some cases in the 'other' category including pregnancy/birth, pain relief, some aspects of paediatrics patients, unconscious by an unknown cause and drug overdose. Correlating learning objectives to clinical placements cases, the majority had at least one cardiac and one respiratory case during clinical placements. However limited exposure to trauma cases was reported by third year students with in some cases 40% of students not encountering a trauma case. This also reflects the low number of trauma cases seen by paramedics in Victoria [27
]. The lack of practising trauma management skills is pertinent throughout Victorian ambulance practice and is not unique to the current study [8
]. Additionally, aside from pain relief where two thirds of students had exposure, only half of students had exposure to cases in the 'other' category that had been learnt at university. This study shows that students are not receiving adequate case expose that link to theoretical concepts and additional theoretical reinforcement may be needed during clinical placement to meet learning objectives, particularly for trauma cases. Alternative educational approaches should be considered in bridging this gap; these alternatives might include DVD simulations, virtual simulation wards, teleconference/Internet videoconferencing ward rounds and integration of e-portfolios.
Discrepancies in the case type/number seen by second and third year students can be attributed to the number of hours of placement completed by each student year level. Not surprising, the greater the number of placements the more cases students were exposed to (40 hours for second year students compared to 280 hours for third year students). Consequently, an obvious solution of increasing case exposure would be to increase clinical placement time; however this is not feasible considering the Victorian ambulance services are already unable to support the increasing number of undergraduate students [8
]. Further, from 2009 the ambulance services have reduced clinical placement hours from 600 hours to 380 hours per student in the BEH course. (Lord B 2008, personal communication, July 7)
Skill praxis was also suboptimal for third year students. Less than 50% of learnt skills were practised during clinical placements. These findings are similar to an evaluation completed on undergraduate surgical students where 70% of students failed to complete a procedure that linked to their level of education [7
]. This raises the concern that students are not receiving adequate skills practice during clinical placement and a review of supplemental skills practice needs to be considered by the university and the ambulance services. This begs the question; does the problem lie with the university or the paramedic industry itself? Is the university curriculum meeting the contemporary needs of the paramedic environment, or is the industry complicated by other issues such as industrial reforms and enterprise bargaining disputes? Without national standardisation of the paramedic curriculum, or standardised graduate attributes, it would seem blame rests with both parties at this present time. Perhaps skill practice sessions during clinical placement down time could be a possible solution, or consideration of increasing patient simulation during academic semesters. This is particularly applicable for rural placements as students reported on average 4 hours/shift of down time. In addition, students were highly receptive to additional activities during down time to supplement learning. This reception to attaining greater professional knowledge perhaps offers an opportunity for further examination.
Skill practice during clinical placement is not just dependant on the frequency and diversity of cases. The student's level of involvement also plays an integral part of whether skills are practised. The majority of third year students had hands on experience with managing cases, yet 30% of third year students were not engaging in patient management. This shows that not all students are participating at the expected level and raises questions surrounding the notion of job-readiness, work-readiness and ongoing ambulance employability.
Barriers to participation were also explored in this study and several themes were identified including factors relating to the student, case nature and paramedic supervisor. For student factors their skill level, motivation and confidence were all identified as variables inhibiting participation in patient care. As expected, life threatening cases also prevented skills practice. There is a delicate balance of providing students with skills practice and compromising patient outcome. Furthermore, paramedic students perceived that supervising paramedics were not always aware of the student's role during clinical placements. This may have limited student participation either due to the paramedic not actively inviting student involvement or the student not feeling supervised during the placement. Supervision during clinical placement has a profound effect on clinical learning and can shape clinical competence [32
]. Simply providing clinical placement does not automatically ensure learning will occur [34
] and these barriers to student participation should be addressed to enhance clinical placement learning. The notion of clinical placement learning provides an opportunity for future examination and pedagogical/curriculum integration. While students currently complete reflective journals during placements, theoretical explanation of i) reflection models, and ii) how reflection can improve learning and metacognition during placements has room for improvement for both universities and industry partners. Simply put, students/educators can not afford to miss any learning opportunities given the current placement shortages and changes to population health.
This study had several limitations. Firstly the results were conducted at one university with a limited sample size and therefore are only representative of BEH students indicating caution should be exercised when generalising these results. Secondly, when exploring themes for level of participation, barriers to participation and activities during down time students were provided with a series of answers to select from and even though students could add additional concepts, designing the retrospective questionnaire in this manner may have biased student responses. Finally, while the questionnaire largely investigated clinical skills whilst on clinical placements, we acknowledge that many other skills beyond psychomotor proficiencies are offered to students during placements, such as attitudes, values and professional socialisation.