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

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    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


    Vidar Melby,

    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

    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


    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 study


    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).


    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.


    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


    No. of

    students in

    year group

    No. of students





    No. of

    students partaking

    in interviews



    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

    Personality characteristics

    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

    V. Melby

    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

    stress relief.

    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

    present study.

    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

    emergencies rapidly:

    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

    so different:

    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).

    Clinical experience

    Psychomotor skills

    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

    arrest situation:

    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

    and symptoms

    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

    childs hand.

    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:

    V. Melby

    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.

    Professional issues

    Inter-professional awareness

    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

  • Postplacement reflections

    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.

    Ethical considerations

    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.

    Study limitations

    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

    V. Melby

    734 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 727736

  • practice; it stimulates reflective knowledge (new knowledge

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    (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 &

    Rotem 1994).

    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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