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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 ¯ashing lights that ¯ies down the road to

an emergency of some kind. We don't 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 quali®ed 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 ®rst 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 1985±1999, 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 identi®ed in the research.

Ó 2001 Blackwell Science Ltd 727

Correspondence:

Vidar Melby,

School of Health Sciences,

University of Ulster,

Coleraine BT52 1SA,

UK.

E-mail: [email protected]

M E L B YM E L B Y V . ( 20 01 )V . ( 20 0 1 ) Journal of Advanced Nursing 34(6), 727±736

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 ®fty-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 Unit's 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 con®dence 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 & HaljamaÈe 1997). The lack of

involvement of nurses in prehospital emergency practice in

the UK is mirrored by insuf®cient 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, re¯ected in

powerful narrations of students' personal and professional

experiences. While it may be dif®cult to achieve a universally

accepted de®nition of experiential learning (Green &

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

¼derived from, or pertaining to, experience or observation (The

Shorter Oxford English Dictionary 1983, p. 705).

Bene®ts of experiential learning

Utilizing this de®nition 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 scienti®c 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 speci®cally 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

& Cof®n 1994). Practising skills `live' is associated with

enhanced con®dence 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 debrie®ng 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 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 727±736

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 ®nd themselves (Parahoo

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

approach is that the researcher is `¼free to shift his or

her focus as the data collection progresses¼' (Bowling 1997,

p. 311).

Methods

Diaries and focus group interviews were employed to

collect data. Diaries are appropriate for `¼individual partic-

ipants to keep a personal account of daily events, feelings,

discussions, interactions¼' (Coolican 1995, p. 98) and for

recording re¯ections 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

`¼make use of group dynamics to stimulate discussion, gain

insights and generate ideas¼' (Bowling 1997, p. 352). This

allowed for consolidation and exploration of issues raised in

the diaries, and helped to identify, consolidate and re®ne

themes. Focus group interviews accommodate re¯ection-on-

action through sensitive and facilitative use of listening skills

(SchoÈn 1987, Edwards 1991), and are highly ef®cient as

salient data or categories of data can be identi®ed 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 identi®ed. 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 identi®ed

(Parahoo 1997).

Reliability and validity

Qualitative data are evaluated with reference to terms such as

credibility, dependability, con®rmability 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 re®ne 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 modi®cations 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

Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 34(6), 727±736 729

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 bene®cial in the future¼[when]¼I have to order an

ambulance¼

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 ®rst call out on my àmbulance 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-MoÈ ller 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]¼, 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

Teamwork

Range of experiences Diversity of calls and experiences

Dealing with the physical environment

Personal and professional Preplacement perceptions and expectations

development Postplacement re¯ection

Table 3 Theme, categories and issues

V. Melby


The placement allowed me to understand the different grades within

the ambulance service and about their disputes. It is surprising to ®nd

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.

1994).

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 dif®cult 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 àmbulance

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 ®replace has

fallen on him, or hold the 6-month-old baby in his arms as he's taken

to hospital to be certi®ed 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. We're sheltered from all of this.

Students were clearly disappointed and annoyed at the

negative views of hospital nurses towards ambulance

personnel:

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:

¼my concept of such healthcare professionals was to be changed

and 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

received:

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

overlooked.

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 theory±practice

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 ef®cient and effective. The ambulance staff's

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 ®rst cardiac

arrest situation:



The doctor applied the electro-cardiograph (ECG) leads and de®b

pads, the nurse drew up the required drugs and the paramedic

intubated the patient, while I commenced CPR ± the ®rst time that I

had done this on an actual person.

Through re¯ection 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 dif®culty of obtaining a physical history, the importance of signs

and symptoms¼

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

subsided:

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

support.

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

child's 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 traf®c accident

was caring for the child's 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

inadequacy.

The social, political and economic environment

Many nursing students were blatantly ignorant of economic

and social hardship in Northern Ireland.

¼the 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 ®rst 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 calls¼I observed poverty which I didn't realize

[existed¼and]¼when 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 intensi®ed in the mid-nineties,

resulting in loyalist and republican paramilitary organiza-

tions calling a cease-®re 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-®res the opportunities for experiencing the

direct effects of terrorism were greatly reduced. However

some students did experience ®rst hand the effects of

terrorism and sectarianism, resulting in deep-founded re¯ec-

tions on their experiences. Students' re¯ections 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 ®nding 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 ®eld is beyond me!

Some students attempted to interpret their experiences within

the wider Northern Ireland arena:

V. Melby


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 traf®c 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 someone's 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 con¯icting emotions and feelings

that can occur, increased adrenaline leading to highs and lows, fear,

anger, sadness, humour, sometimes even a feeling of uselessness and

inadequacy.

Teamwork

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 traf®c accident] who had

sustained minor injuries. This gave me a sense of purpose and

belonging.

Range of experiences

Diversity of calls and experiences

Students valued the diversity of calls that they attended. This

included calls with the ¯ying 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 ®nd 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 ®re 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 ef®ciently 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.



Postplacement re¯ections

Through re¯ection students were able to appraise the bene®ts

of a placement in the prehospital emergency setting. Overall

the placement was viewed as a valuable, enjoyable, and a

bene®cial 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 experience¼widened my nursing experience and personally I

achieved 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

noted:

It was bene®cial 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

learning:

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. Con®den-

tiality was assured at all times, and all students were

informed in detail about the aim of the research, its methods

and how the ®ndings would be reported. The moderator, who

is a quali®ed 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

in¯ate their experiences to ìmpress' 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 in¯uenced ®ndings much in this

research. Students were often allocated to ambulance

depots in pairs, and learning experiences were thus easily

corroborated.

Conclusions

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.

Re¯ection is seen as an invaluable part of experiential

learning (Green & Holloway 1997), and encouraging re¯ec-

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 re¯ective

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). Re¯ection is a dynamic tool for the enhance-

ment of professional practice through critical inquiry of

V. Melby


practice; it stimulates re¯ective knowledge (new knowledge

learnt from the experience) as well as re¯ective skills (new

skills learnt from the experience) (Jarvis 1992). Clinical

learning, incorporating physical and interpersonal skills, has

a powerful in¯uence 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 &

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-

®ciary being the patient.

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