The adrenaline rush: nursing students’ experiences with the Northern Ireland Ambulance Service

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  • ISSUES AND INNOVATIONS IN NURSING EDUCATION

    The adrenaline rush: nursing students experiences with the Northern

    Ireland Ambulance Service

    Vidar Melby MPhil BSc RGN RNT

    Lecturer in Nursing, Centre for Nursing Research, University of Ulster, Coleraine, UK

    Submitted for publication 20 July 2000

    Accepted for publication 23 February 2001

    Introduction and rationale

    To most of us an emergency ambulance is a large van with

    blaring sirens and flashing lights that flies down the road to

    an emergency of some kind. We dont know much about the

    inside of the vehicle, nor do we generally know what training

    is required to navigate this vehicle at such harrowing speed.

    We know less again about what ambulance personnel

    actually do when they arrive at the scene of an emergency.

    Nursing students and qualified staff may feel equally

    ignorant about these issues. The only contact students often

    have with the prehospital emergency service is within a

    hospital environment and is associated with admissions,

    discharges and transfers of patients. In general, prehospital

    emergency care appears to have a low priority in nursing

    curricula. The Department of Nursing at the University of

    Ulster introduced a formal placement for its preregistration

    degree students with the Northern Ireland Ambulance

    Service in 1992. Since then, students experiences have been

    monitored. This appears to be the first research study

    investigating nursing students experiences in prehospital

    emergency care in the United Kingdom (UK).

    Literature review

    A review of the literature was carried out using Medline,

    BIDS and PsycInfo covering the period 19851999, using the

    following search words and strings: ambulance service,

    prehospital emergency care, experiential learning, nurses,

    nurse training and education, and trauma. Eighty-two articles

    were found to be relevant (Table 1), and helped to clarify the

    categories identified in the research.

    2001 Blackwell Science Ltd 727

    Correspondence:

    Vidar Melby,

    School of Health Sciences,

    University of Ulster,

    Coleraine BT52 1SA,

    UK.

    E-mail: v.melby@ulst.ac.uk

    M E L B YM E L B Y V . ( 20 01 )V . ( 20 0 1 ) Journal of Advanced Nursing 34(6), 727736

    The adrenaline rush: nursing students experiences with the Northern Ireland

    Ambulance Service

    Aim. The aim of this project was to explore nursing students experiences whilst on

    placement with the Northern Ireland Ambulance Service.

    Background. The literature suggests that experiential learning can enhance under-

    standing, knowledge and skills and has the potential for reducing the theory

    practice gap.

    Design. A qualitative approach was utilized, employing diaries and focus group

    interviews to gather data. One hundred and fifty-four nursing students submitted

    diaries, producing a response rate of 69%, while 190 students partook in interviews

    (86%).

    Findings. Content analysis indicated that the students gained a new appreciation of

    the concept of holistic care, and that increased interprofessional understanding

    provides the foundation for improved quality of patient care.

    Keywords: prehospital emergency, ambulance, paramedics, experiential learning,

    holistic care, nurse education, quality of care, interprofessional collaboration

  • Collaboration in prehospital emergency care

    A guiding principle in nursing is the enhancement of the

    quality of care through interdisciplinary collaboration.

    Members of the health care team collaborate on patient

    issues in an attempt to achieve the most favourable outcome

    of patient care and treatment (Timby et al. 1999). Nursing

    students are challenged to consider the importance of

    subscribing to a multidisciplinary approach to care involving

    nurses, doctors, dieticians, physiotherapists and other health

    professionals and nonprofessionals.

    In emergency settings teamwork is seen as vital for treat-

    ment to be effective and for clients to have a successful

    recovery (Bosworth 1997, Richardson 1998). Dickinson

    (1994) recommended that trauma nurses should receive

    regular training with ambulance personnel. In the UK there

    is little evidence of such collaboration in the area of pre-

    hospital emergency care. There is minimal medical and

    nursing input into prehospital practice, and limited commu-

    nication between the hospital and the prehospital team

    (Driscoll 1994). King and James (2000), when evaluating

    the Accident & Emergency Units response to a major incident

    in 1997 at the Central Middlesex Hospital in England,

    reported that few nurses had the relevant prehospital experi-

    ence and skills to nurse effectively in the prehospital situation.

    Subsequently the hospital developed a 5-day prehospital

    trauma awareness programme for nurses. Evaluations indi-

    cated that nurses had enhanced confidence and had learned

    new skills. The authors failed to locate any other prehospital

    training programme for nurses elsewhere in the UK.

    In other countries, such as Holland, Sweden and Australia

    the involvement of experienced and specially trained nurses

    in the prehospital team is seen as an essential element in the

    quality assurance process (Berden et al. 1993, Hendricks

    et al. 1996, Suserud & Haljamae 1997). The lack of

    involvement of nurses in prehospital emergency practice in

    the UK is mirrored by insufficient emphasis on prehospital

    emergency care in nurse education. The indispensable link

    between the community and the hospital Accident &

    Emergency (A & E) Unit or Emergency Room (ER) provided

    by the ambulance service is thus overlooked (Richardson

    1998).

    Learning during placement

    The placement facilitated experiential learning, reflected in

    powerful narrations of students personal and professional

    experiences. While it may be difficult to achieve a universally

    accepted definition of experiential learning (Green &

    Holloway 1997), in its generic form the term simply means:

    derived from, or pertaining to, experience or observation (The

    Shorter Oxford English Dictionary 1983, p. 705).

    Benefits of experiential learning

    Utilizing this definition allows the researcher to capture all

    learning episodes whether they relate to hands-on or concep-

    tual learning, and students will realize that learning occurs

    from positive as well as negative experiences (Pinsky & Irby

    1997, Stevens 1998). Experiential learning has the potential

    to stimulate independent learning, intuition, critical

    reasoning and problem-solving skills (Studdy et al. 1994a,

    Kreber 1998), and helps students to appreciate links between

    abstract concepts and the real world of nursing (Studdy et al.

    1994b). Crucially, experiential learning provides the frame-

    work for scientific inquiry (Merritt 1983). Experiential

    learning can increase self-awareness and aid the development

    of interpersonal skills (Burnard 1992a). Smith (1987) inves-

    tigated the link between quality of care and the learning envi-

    ronment, and found that placements viewed as positive by

    students had greater potential for enhancing quality of care.

    Students tend to relate experiential learning to clinical

    learning, more specifically task-learning (Costello 1989).

    Experiential learning is often viewed as fun with students

    indicating that they learn more when working in the clinical

    environment than in other settings (Burnard 1992a, Cavanagh

    & Coffin 1994). Practising skills live is associated with

    enhanced confidence building (Gomez & Gomez 1987). So

    learning is by doing, but interestingly also by seeing (Burnard

    1992b). Important issues for effective and satisfactory clinical

    learning include autonomy, recognition as a potential practi-

    tioner, job satisfaction, clear debriefing sessions, peer support

    and access to positive role models (Hart & Rotem 1994).

    The study

    Aim

    The aim of this project was to explore nursing students

    experiences on placement with the Northern Ireland Ambu-

    lance Service.

    Table 1 Literature search results

    Search words

    Number of

    relevant articles

    Nurses in prehospital emergency care 12

    Nurses and trauma 22

    Experiential learning 31

    Ambulance service and emergency care 17

    Total 82

    V. Melby

    728 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 727736

  • Design and methods

    Methodological approach

    This study employed a qualitative approach. In qualitative

    research, phenomena are studied from the viewpoint of the

    individual, and the focus is on how individuals interpret the

    complex situations in which they find themselves (Parahoo

    1997, Burns 2000). The principal strength of the qualitative

    approach is that the researcher is free to shift his orher focus as the data collection progresses (Bowling 1997,p. 311).

    Methods

    Diaries and focus group interviews were employed to

    collect data. Diaries are appropriate for individual partic-ipants to keep a personal account of daily events, feelings,

    discussions, interactions (Coolican 1995, p. 98) and forrecording reflections on experiences from clinical practice

    (Coutts-Jarman 1993). Diaries are a valuable tool for genera-

    ting ideas from individuals experiences (Burns 2000). Diaries

    usually cover an agreed timespan (Burns 2000); in this project

    this was the length of the placement.

    Focus group interviews were undertaken immediately after

    the practice experience, and typically composed of eight

    students plus the investigator. The primary aim was to

    make use of group dynamics to stimulate discussion, gaininsights and generate ideas (Bowling 1997, p. 352). Thisallowed for consolidation and exploration of issues raised in

    the diaries, and helped to identify, consolidate and refine

    themes. Focus group interviews accommodate reflection-on-

    action through sensitive and facilitative use of listening skills

    (Schon 1987, Edwards 1991), and are highly efficient as

    salient data or categories of data can be identified quickly

    (Polit & Hungler 1999).

    A semi-structured approach helped the students to explore

    and express any aspect of their experiences, adding to the

    richness of data. As data emerged during the interviews it

    was evaluated against themes already identified. This was

    achieved through careful probing and by encouraging and

    challenging students within the group to provide comment.

    The sharing of experiences and feelings has the potential to

    provide valuable insights into the phenomena identified

    (Parahoo 1997).

    Reliability and validity

    Qualitative data are evaluated with reference to terms such as

    credibility, dependability, confirmability and transferability

    (Polit & Hungler 1999).

    Triangulation of methods is important in qualitative

    research to strengthen rigour and enhance the reliability of

    data collection methods. Multiple triangulation methods

    were used in this study and can be a strong indicator of

    reliability and validity of qualitative data. Time triangulation

    was used as data was collected over an 8-year period, and

    space triangulation as multiple sites across Northern Ireland

    were utilized. In addition method triangulation, using focus

    group interviews to consolidate and refine the themes that

    emerged from diaries was also used.

    Sample

    The student numbers participating are presented in Table 2.

    Data analysis

    The data from the diaries and focus group interviews were

    transcribed, and manual content analysis was utilized to

    identify themes. A narrative presentation format was

    employed in order to ensure that the richness of the data

    was preserved (Bowling 1997). In the presentation of

    data, no modifications have been made to the students

    presentations except for the correction of spelling errors. The

    author carried out the complete analysis, identifying issues,

    categories and themes (Table 3).

    Table 2 Sample and response rate

    Year

    No. of

    students in

    year group

    No. of students

    submitting

    diary

    Percentage

    participation

    No. of

    students partaking

    in interviews

    Percentage

    participation

    1992 21 17 81 15 71

    1993 23 22 96 20 87

    1994 32 29 91 28 88

    1996 27 19 70 25 93

    1997 31 18 58 29 94

    1998 31 24 77 27 87

    1999 26 12 46 22 85

    2000 31 13 42 24 77

    Total 222 154 (69%) 190 (86%)

    Issues and innovations in nursing education Nursing students experiences with the ambulance service

    2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 727736 729

  • Results and discussions

    Introduction: grasping the concept of holistic care

    It quickly became apparent that much of the data were

    associated with the issue of holistic care, which generated one

    emerging theme: The Realization of Holistic Care. This

    developmental end-stage was characterized by students brid-

    ging and bringing together fragments of theory and practice

    learnt at other times during their education and personal

    lives, into an overall holistic understanding of caring. While

    students were familiar with the concept of holism prior to

    the placement, this experience cemented the importance of

    incorporating a holistic framework into care. Table 3 shows

    the links between issues and the emerging theme. Each

    category is discussed in detail.

    Learning about the ambulance service and its personnel

    Tour of facilities

    Students received a tour of the facilities in the control centres

    and the depots, and were given a demonstration of the

    equipment in the ambulance. Students learnt about the

    important and complex role carried out by ambulance

    control:

    I feel I gained invaluable knowledge by ambulance control on how

    ambulances are ordered and realized they have a busy schedule. This

    insight will be beneficial in the future[when]I have to order anambulance

    The Waiting Game

    Students were keen to learn from all kinds of experiences,

    however, they found the period of waiting for an emergency

    call boring. They experienced the Waiting Game: sitting

    drinking tea and jumping to attention when the emergency

    call eventually came.

    Equipped with a large luminous coat, it was with some trepidation I

    sat awaiting the first call out on my ambulance day.

    Students almost willed emergencies to happen, but when the

    calls subsequently materialized students felt guilty:

    I also felt guilty since I was disappointed that nothing major was

    wrong with him after receiving an emergency call.

    The excitement when responding to emergency calls was

    palpable:

    I shall never forget the rush of adrenaline as we set off with the sirens

    blaring while cars separated like the Red Sea in front of us.

    Abuse of emergency service

    Misuse, overuse and abuse of ambulance services have been

    recognized in several countries including Ireland (Little &

    Barton 1998), Australia (Clark & Fitzgerald 1999),

    Denmark (Krum-Moller et al. 1999), United States of

    America (USA) (Richards & Ferrall 1999) as well as the

    UK (Palazzo et al. 1998). The students shared the frustra-

    tions and annoyance of the ambulance personnel when

    responding to such calls:

    I have been surprised by the reasons people telephone 999 [emergency

    number], for example a toothache.

    Training and education

    In general students had little knowledge of the training and

    education ambulance personnel undertake. However this was

    dramatically changed during the placement:

    Emerging theme Categories Issues

    Learning about the ambulance Tour of facilities

    service and...

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