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).
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
School of Health Sciences,
University of Ulster,
Coleraine BT52 1SA,
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
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
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
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
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 aim of this project was to explore nursing students
experiences on placement with the Northern Ireland Ambu-
Table 1 Literature search results
Nurses in prehospital emergency care 12
Nurses and trauma 22
Experiential learning 31
Ambulance service and emergency care 17
728 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 727736
Design and methods
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).
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
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.
The student numbers participating are presented in Table 2.
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
No. of students
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
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
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 its personnel Waiting for a call
Abuse of service
Training and education
Skills and abilities
The realization Clinical experience Psychomotor skills
of holistic care Communication and interpersonal skills
Social, political and economic environment
Professional issues Inter-professional awareness
Range of experiences Diversity of calls and experiences
Dealing with the physical environment
Personal and professional Preplacement perceptions and expectations
development Postplacement reflection
Table 3 Theme, categories and issues
730 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 727736
The placement allowed me to understand the different grades within
the ambulance service and about their disputes. It is surprising to find
out how much experience the ambulance crews have and the amount
of knowledge they hold.
Characteristics of ambulance personnel
Ambulance personnel were thought of consistently as good-
natured, caring and skilled. The prevalence of black humour
was extensive, and was perceived by students as a method of
coping and dealing with stress. Such use of black humour by
emergency personnel has been noted elsewhere (Britton et al.
Many of the staff joked about different people who may have died.
I realized that they were not being callous. This was a method of
Students consistently commented on the driving abilities of
the ambulance personnel:
The man driving the ambulance drove like crazy. I think he thought
he was in the Circuit of Ireland rally!
There is some evidence to suggest that ambulance personnel
do not always adhere to regulations while driving the
emergency vehicles. For instance, in the USA there is evidence
of inappropriate use of lights and sirens by ambulance
personnel in as much as 40% of cases (Lacher & Bauscher
1997). However this was not supported by data from the
Skills and abilities
The physical care and diagnostic skills of the ambulance
personnel impressed students immensely. They reported an
impressive ability to work autonomously under difficult and
stressful conditions, and to diagnose and treat quite complex
Away from the patient I felt I got a better idea of who ambulance
men are and how they respond to situations. It is not the nurse who
has to try to resuscitate the 3-year-old child after the fireplace has
fallen on him, or hold the 6-month-old baby in his arms as hes taken
to hospital to be certified as dead. Nor is it the nurse who is at the
scene of the Ormeau Road shooting to bring victims to hospital or be
there after a bomb blast. Were sheltered from all of this.
Students were clearly disappointed and annoyed at the
negative views of hospital nurses towards ambulance
As a nurse I was at times ashamed of the dismissive, even rude
behaviour of nurses towards ambulance crews.
Their own perception of the ambulance personnel was now
my concept of such healthcare professionals was to be changedand strengthened. Experiencing the company of this male dominated
domain of health care, their skills, ups and downs, was an education
that enlightened me to the indispensable service which they provide
to the community.
Occasional appreciation by hospital staff was positively
When the hand-over had been completed, the consultant in charge
thanked us all and congratulated us on a job well done. This was a
nice touch often the contribution of the ambulance crew is
Having positive role models is highly valued by nursing
students (Hart & Rotem 1994), and it has been suggested
that exemplary role modelling can bridge the theorypractice
gap (Walsh et al. 1989). Some students infer parity between
the paramedics skills to those of the Emergency Nurse
Practitioner or Specialist (Whelan 1997). Recognizing the
unique skills of other professionals is essential if collaborative
relationships are to be formed (Scott 1990).
The crews interpersonal skills and psychological care
skills were invariably judged by students as excellent when
dealing with clients, family and relatives, nurses and other
health care workers, the general public and between each
other. It was noted that in an emergency, communication
was highly efficient and effective. The ambulance staffs
ability to deal with children and their parents was also
highly commended. During trauma family members react
differently, and there is no way to predict how a person will
respond. Irrational behaviour including shouting and self-
blame is common, and the whole family is in crisis
(Lenehan 1986, Solursh 1990). Other research has shown
that paramedics are capable of excellent, family orientated
communication during crisis situations (Schmidt &
Harrahill 1995, Macnab et al. 1999).
Many students wanted, anticipated, and obtained experience
in hands-on emergency care, such as cardio-pulmonary
resuscitation (CPR) skills, bandaging and providing oxygen.
It appears that students were able to apply resuscitation skills
learnt previously in the course. In one instance, a student
describes her involvement when dealing with her first cardiac
Issues and innovations in nursing education Nursing students experiences with the ambulance service
2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 727736 731
The doctor applied the electro-cardiograph (ECG) leads and defib
pads, the nurse drew up the required drugs and the paramedic
intubated the patient, while I commenced CPR the first time that I
had done this on an actual person.
Through reflection students were able to appraise physical
care skills in a broader perspective:
I learnt how to react calmly and with common sense, the importance
and difficulty of obtaining a physical history, the importance of signs
One student describes how the initial apprehension of not
being able to cope threatened her status as an effective carer:
As we neared the accident, the initial rush of adrenaline heightened
my fear of what was before me and whether I would be able to cope
followed by irrational reluctance to leave the ambulance.
However, once the student was involved in caring this fear
It was a task that subdued my initial fears and allowed my nursing
instinct to take over, so I was able to feel calm and in control and
hopefully of some use.
Communication and interpersonal skills
There was clear appreciation of the importance of involving
and caring for the relatives of the injured, and students
perceived a role for themselves as nurses in emotional
I continued to stay with the mother and sister-in-law and again
explained to the best of my knowledge all that was happening and
told them to expect a lot of leads; throughout the mother held the
Recognition that emotional support demands a sustained
effort embracing a multitude of skills was evident in one
student who, when attending a child in a road traffic accident
was caring for the childs mother:
Comforting and calming his mother took all my interpersonal skills
and then some more!
Recognizing needs of family members of clients in crisis is
exceedingly important (Manley 1988). Students can develop
and consolidate their skills in dealing with fraught relatives
in prehospital emergency care. Family-orientated care
recognizes the need for partnership and promotes honest
and open communication between relatives and the profes-
sionals who care for their family member (Macnab et al.
1999). Care that does not embrace such an approach is
likely to add to relatives distress, anxiety and feelings of
The social, political and economic environment
Many nursing students were blatantly ignorant of economic
and social hardship in Northern Ireland.
the 92-year-old woman who fell down the stairs was living alone
and had no telephone, so had been lying at the end of the stairs in
pain until she felt able enough in the morning to hobble next door to
her neighbour who then called the ambulance.
Observing and experiencing social poverty for the first time
can be hard to cope with, but having experienced it, learning
takes place, and important links between physical, psycho-
logical and social well-being are made, associations that were
previously only known about on a theoretical level:
During some of the callsI observed poverty which I didnt realize[existedand]when social and psychological problems are left
unattended they can cause serious physical problems.
Northern Ireland has a long history of political strife and civil
unrest. Popularly referred to as the Troubles, attempts at
achieving a peaceful solution intensified in the mid-nineties,
resulting in loyalist and republican paramilitary organiza-
tions calling a cease-fire to military activities in 1996. From
the data it was evident that students had little experience of
the Troubles, either personally or professionally. As a
substantial fraction of the sample undertook their placement
during the cease-fires the opportunities for experiencing the
direct effects of terrorism were greatly reduced. However
some students did experience first hand the effects of
terrorism and sectarianism, resulting in deep-founded reflec-
tions on their experiences. Students reflections combine the
physical, emotional, security and human rights aspects of
the situations. When arriving at the scene of a punishment
shooting, one student commented:
The back street alley was crowded with hysterical women forming
a ring around the young man who was sprawled on the ground,
slouched against the wall. I began to get gamgee padding and
bandages organized whilst the crew cut away the trouser leg, leaving
exposed the wound site on the upper leg. Police arrived on the scene
and tried to restore some sort of order. Barriers were put up. An exit
wound indicated that the bullet was somewhere on the ground and
the police diverted all their attentions to finding this.
In another call a student attended a case in which a 17-year-
old girl sustained severe injuries in a punishment beating:
How six men could brutally beat another human being, never mind a
defenceless 17-year-old girl, and leave her alone broken and bruised
in a field is beyond me!
Some students attempted to interpret their experiences within
the wider Northern Ireland arena:
732 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 727736
It was during a time of heightened political awareness in Northern
Ireland when I undertook my ambulance experience. En route to the
scene of an road traffic accident, the combined effort of the drivers
to make way for the emergency ambulance as if to hasten it on its
way demonstrated to me the unity of the people despite their political
differences when someones life was at stake.
It became clear that ambulance personnel extended their
strong professional relationships to include the students, and
this was positively acknowledged by students.
The ambulance crews were very friendly towards me and accepted
and valued me as part of the team. They involved me in all
conversations; never made me feel left out, I was treated as another
member of staff.
This friendship was further emphasized when students were
able to identify and describe feelings that they had experi-
enced with ambulance personnel:
We also talked about the many conflicting emotions and feelings
that can occur, increased adrenaline leading to highs and lows, fear,
anger, sadness, humour, sometimes even a feeling of uselessness and
Teamwork in emergency care is essential. During a major
incident the prehospital emergency team will comprise a
multitude of professionals, and without effective teamwork
and clear leadership care will lack co-ordination, be frag-
mented and ultimately ineffective. In fact the concept of
prehospital emergency care is based upon the team approach
(Kilner 2000), recognizing the unique skills and knowledge
held by various professionals. The importance of being
involved and regarded as a team-member is crucial:
Prior to arriving at the scene of the emergency I was concerned that I
would be a hindrance rather than a help. However, these feelings of
inadequacy soon diminished as I was sent to attend to one of the
individuals involved in the RTA [road traffic accident] who had
sustained minor injuries. This gave me a sense of purpose and
Range of experiences
Diversity of calls and experiences
Students valued the diversity of calls that they attended. This
included calls with the flying squad, cardiac ambulance, and
trauma ambulance as well as routine and emergency transfers.
Emergency calls included a range of experiences from
nonemergency incidents to serious trauma. Some of these calls
confronted students with social and psychological trauma
situations they had never experienced before, such as domestic
violence, child abuse, street violence and terrorist offences.
Students were challenged to appraise their own values and
beliefs towards patients who are often viewed negatively and
unsympathetically by staff, such as parasuicide patients.
Over the years nurses have developed negative attitudes towards
suicide attempts, quickly condemning the individual involved. Nurses
rarely consider the appalling living conditions of some of these
individuals, their social background, psychological status and other
issues which may have predisposed the suicide attempt.
Dealing with the physical environment of the emergency
Students soon realized that the prehospital environment
could be unpredictable, violent and pose a threat to personal
safety. While students were normally used to the professional
and personal security provided in the hospital environment,
they were now faced with complex and challenging situations
that required creativity and imagination in addition to their
usual clinical and interpersonal skills:
The fact that ambulance crews often find themselves in highly volatile
and dangerous situations is little acknowledged and seldom recog-
nized. I came to realize that, as well as dealing with a patient with a
possibly life-threatening condition, ambulance crews also played an
invaluable role in controlling the environment in which they found
themselves whether it was one of hysteria, aggression or violence.
One student highlighted the added threat to physical integrity
within the Northern Ireland situation:
x (paramedic) told me to stay with the ambulance while he went to
check the car in case it was booby-trapped.
Personal and professional development
Preplacement perceptions and expectations
Students looked forward to the placement with a mixture of
feelings and expectations, and many expected emergencies to
happen all the time. One student said:
I thought I would be attending people following car crashes, gunshots
and fire and bomb victims, especially since I was in the Belfast area.
But wanting to experience emergencies and functioning well
during the emergencies was not the same thing:
The ambulance men acted efficiently and calmly whilst I stood
initially in shock. I was the nurse, but I felt useless without the
clinical setting and a medical back up team.
Issues and innovations in nursing education Nursing students experiences with the ambulance service
2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 727736 733
Through reflection students were able to appraise the benefits
of a placement in the prehospital emergency setting. Overall
the placement was viewed as a valuable, enjoyable, and a
beneficial learning experience contributing to personal and
professional growth. Students viewed the ambulance service
as unique and vital, but undervalued. The placement was
exciting, but also challenged students tremendously in terms
of their physical, psychological and interpersonal skills. Job
satisfaction was clearly present.
Overall an absolutely excellent experience. I was overwhelmed by
exhilaration and the constant rush of adrenaline never knowing
what the next call would be.
Another student said:
The experiencewidened my nursing experience and personally Iachieved so much from the day; on a professional manner it will aid
my experience, and in many ways it changes your outlook and
deepens awareness about the importance of this unique service.
Seeing the totality of the process of emergency care was
It was beneficial to see the extended role of the emergency services
and the initial care and interventions carried out before the patient
was actually admitted to hospital or casualty.
Finally, knowing that they had experienced a unique place-
ment, students wanted other nursing students to share in this
I also believe it would be interesting for all student nurses to undergo
this placement; not only was it great fun, exciting and frightening, it
was also very educational.
New dimensions are added to the concept of ethics in
qualitative research (Streubert & Carpenter 1999), in that the
researcher may be confronted with ethical dilemmas in the
midst of data collection, for example a participant may break
down while discussing an emotional issue. However the six
main ethical principles (Parahoo 1997, Polit & Hungler
1999) and four rights of subjects (Parahoo 1997) are central
guiding principles and were adhered to in this study. No
harm occurred as a result of the study, participation in the
study was entirely voluntary, and the students could, if they
so wished, submit their diaries in anonymous format and
decide not to take part in focus group interviews. Confiden-
tiality was assured at all times, and all students were
informed in detail about the aim of the research, its methods
and how the findings would be reported. The moderator, who
is a qualified nurse with considerable experience, would
suspend the focus group interview if a participant displayed
emotional overload, and emotional support could have been
provided as appropriate.
Fortunately this was not necessary. While participants
were encouraged to volunteer their experiences and feelings,
no pressure was put upon participants to do so. Finally,
respondent validation was assured during the focus group
interviews when participants were asked to match their
experiences with those of previous participants.
Diaries are subjective representations of individuals experi-
ences, and there is potential for participants wanting to
inflate their experiences to impress the reader, who was
the course leader, and fellow students. However as the
student group was homogenous and students shared their
experiences within the student body willingly, this limita-
tion is not thought to have influenced findings much in this
research. Students were often allocated to ambulance
depots in pairs, and learning experiences were thus easily
Students obtained varied and diverse learning experiences
that hopefully will produce practitioners who are more
holistic in their approach to care (Sword et al. 1994), and
graduates possessing new and different perspectives that will
enhance practice (MacLeod & Farrell 1994).
The placement approach was entirely experiential. Experi-
ential learning strengthens analytical skills (Parilla & Hesser
1998). Students enter higher education with differing know-
ledge, understanding and experiences of equality issues
within the community, and may be unaware of differences
related to class, gender or race (Dewar & Isaac 1998). The
importance of experiencing economic and social deprivation
adds new dimensions to the concept of holistic care.
Reflection is seen as an invaluable part of experiential
learning (Green & Holloway 1997), and encouraging reflec-
tion helps students to identify what they have learnt (Attree
et al. 1994). The sharing of knowledge between individuals
from nursing and other professions is part of the reflective
process (Walker 1996). This aids students in applying
knowledge and understanding to their role as professionals,
and they can subsequently act as catalysts for change
(Driscoll 1994). Reflection is a dynamic tool for the enhance-
ment of professional practice through critical inquiry of
734 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 727736
practice; it stimulates reflective knowledge (new knowledge
learnt from the experience) as well as reflective skills (new
skills learnt from the experience) (Jarvis 1992). Clinical
learning, incorporating physical and interpersonal skills, has
a powerful influence on the development of competence
(Davis 1990, Laschinger 1992).
Without exception all students seemed to have enjoyed the
experience. This is attributed to positive relations with staff,
feeling accepted, being autonomous, the need to belong,
being busy and immersed in the culture (Baillie 1993, Hart &
In conclusion, there was a realization that holistic care is a
fundamental approach to care, underlined by an under-
standing of the complete process of care from the time the
emergency service is alerted until discharge of the patient. To
accomplish holistic care students must involve family in care
and ensure appropriate and effective communication within
a caring and sympathetic framework. Increased comprehen-
sion of the prehospital emergency team and prehospital
emergency care has created the basis for enhanced interpro-
fessional relationships and collaboration, the ultimate bene-
ficiary being the patient.
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