Huellas espaciales de la violencia en Rincón del Mar

As discussed previously paramedic preceptors are required to have two sets of capabilities to operate in their profession, they need to be a capable paramedic to deliver the best care to their patients and to be a capable preceptor to enable the learner to progress. This translates into a duality of purpose when working with

159 learners; while they have a responsibility to support the learner, their primary

responsibility is to the patient and their needs. Participants in this study reported this as an important factor in the performance of their role in working with learners from several different perspectives. These included knowing what level a learner is at, or allowed to practice at; making a decision on ‘how much room’ you give a learner in their clinical practice before intervening; recognising the need to intervene where it appears the learner is moving toward an error in clinical practice; and taking over clinical care without allowing the learner to practice where the clinical severity of the patient precludes learner involvement.

Participants reported concerns that they often do not have, or a not provided with a clear indication of where the learner is in the clinical scope of their education and therefore what the learner can or cannot do. These concerns align with prior

commentary (see Chapter 7, Section 7.2.3) on the lack of opportunity to meet with and plan with the learner or coordinating educators prior to the learners’ arrival for shift. Managing the overall expectations of the learner was reported to be a challenge to paramedics, as Simon explained.

I know the students want to do everything, but they don't know how to do it, but there are legal or ethical issues associated. (Simon)

Julie provided further clarification on the need to have a degree of planning and prior information on what the level of clinical scope will be for the learner and what the expectations are:

if I knew I was getting, for example, a level one [vocational learner]

coming out on road with me, I would make sure I knew what they were learning… so we could focus on those things and developing those skills at their level, rather than raving on about things like colloid

160 osmotic pressure and complicated things that they're not at that

stage… (Julie)

Participants demonstrated an appreciation of the value in meeting with their learners, planning and setting boundaries for scope, role and communications strategies as Tanya explained:

I think it’s really important to sit down and talk with someone of what, how are we going to do this, what do you want to get out of it so you just, you know where you’re at and there’s no, like anything

unexpected that one of you might have been hoping the other one would do or say and then things don’t happen, then you get awkward. (Tanya)

The opportunity to plan with a learner prior to, or on their arrival for their shift, was inconsistent across participants however. Ira outlined past experiences when working with learners undertaking the ICP course in his ambulance service where he was able to plan out the objectives for the period he was working with the learner:

when I had an intensive care trainee, I'd sit down, I'd look at all of our core clinical guidelines, all of our skills that go into being an intensive care paramedic, divvy them up in some sort of logical way over the 14 weeks or the 9 weeks or the 10 weeks that I had with the person… (Ira) Of note, however, is that what Ira described is not necessarily aligned to where the learner was in their course, but simply a breakdown of the overall scope of a qualified ICP. Of additional note is that it still fell to Ira to plan this element of curriculum, rather than it being a structured element in the professional experience placement, supported with resources.

161 Roger reported that in his experience the capacity for this level of planning is a factor that improves the experiences of paramedics working with learners, potentially impacting on their willingness to undertake the role:

the best experience is not a particular instance but a period of time that I was mentoring where I felt that I knew what they needed to do, I had a clear vision of what they needed and I had some clear goals... (Roger)

Planning of this nature provides the space for the paramedic and learner to get to know each other, setting the foundations for a positive working relationship. Participants consistently reported their desire for a positive relationship with their learner, as Richard explained:

you need to have also individual connections with people… Getting to know the person if you can - it's always good to get to know the people because then you realize you get some personal connection and you get that buy in. (Richard)

Interestingly there is a small degree of inconsistency in the data on the point of making connections with and meeting the learner. Roger described more recent experiences in his career in which he has found a greater degree of structure in this regard:

Ordinarily when you go into a mentoring situation you have a meeting with the clinical support officer and you sit down and you’re given a learning package. This came in sort of the latter half of my career, before that it was a little less structured but generally speaking what happens now is you will sit down with a document that says here are the learning outcomes, here is some examples of how we want you to

162 go about it and here is the structure about it so there is a little bit of a

frame work given there and we will sit down and discuss it with the clinical support officer. (Roger)

Roger’s experience is not necessarily one shared by some other participants including those from the same local area as Roger, indicating a level of inconsistency in the data.

What the preceptor decides to allow the learner to do in dealing with patient care reflects the dual function of paramedics in taking both the responsibility for the patient and the learner. The preceptor is often faced with three possible options: deciding when to intervene and provide guidance; deciding when to take over completely; and deciding when to exclude the learner from the delivery of care, all of which are based around the needs of the patient. Participants spoke in detail about the need to decide when to step in and provide guidance or take over care. What is evident in the data was the lack of a clear understanding or basis for making these decisions. Newer paramedics exhibited greater variability in their decision making, with some being willing to give more room for error than others, and it was noted that paramedics gained increased confidence in making such decisions as their experience grew.

Chris was one of the less experienced paramedics in this study, with three and a half years’ experience in the profession; he outlined how over time he has changed his approach to intervening in the clinical care being provided by a learner:

I think when I first started, I gave them a lot of trust that they can handle… things, because I generally like to… let them try and do things their own way just to see how they go… I think that now… I'm more aware of… where things can go wrong so I recognize where they're in trouble a lot earlier whereas before I was sort of just assuming that

163 they've got it… so I stepped in later when I first started working with

students. Then now, I'll step in a lot earlier... (Chris)

Conversely, Samantha reflected that people with more experience are less likely to step in and intervene than those with less experience:

[with experience] you can stand back more and sort of not let them drown but let them sink a little to gain that experience whereas sort of I think people that have got minimal experience would probably jump in sooner because they don’t see the sort of clinical pattern that a more experienced person would see. (Samantha)

My own experiences and observations as a paramedic align with Samantha’s comment, in that there is a tendency for more experienced paramedics to stand back and give the learner more room. As has been discussed in chapters 6 and 7, in order to perform the role effectively, there is a need for paramedic preceptors to have experience and confidence as a paramedic which brings with it a greater confidence in being able to intervene where required without overriding the learning opportunity.

Beyond the intervention to re-direct care and guide the learner, there is also the occasion where the learner may make clinical decisions that are not in the best interest of the patient. It is at this time that the paramedic preceptor needs to step in rather than guide, and take over the clinical care of the patient. Tracy provided an example of this experience:

on one occasion he [the learner] took some aspirin out of the bag for a query CVA [stroke] patient, for their headache and went to administer it and I said "I think we will have a think about what our course of action is going to be we will just do a few more checks" and started to

164 try and take over to engage the patient in a different manner rather

than cut him down in front of the patient and he said "I have already decided my course of action, this is what we are going to do" so at that point I had to say “excuse me we are just going to grab a few things out of the ambulance" I said that to the patient and then persuaded him to leave the house come outside with me and

unfortunately had to say "look we are going to stop this now, it is not the course of action we are going to take, because it is inappropriate management and you need to consult together before we do things like that" so then I had to go back in and take over. (Tracy)

Participants reported a need to restrict the exposure of the learner in clinical care, due to either the clinical acuity of the patient, or the capacity of the learner to contribute at the level required. Given the degree of evidence in the data from this study that paramedics often do not know the level of the learner at the outset of the professional experience placement, it is reasonable to propose that the learner may be removed from, or prevented from, delivering care more often than is needed. Lisa explained the prioritisation of clinical care, whilst also outlining how there may still be some learning opportunities for the learner:

Sometimes when all your brain is focused on doing the clinical tasks because the person that you're with can't do them, the preceptor role gets put on the backburner… Sometimes you can do both. Sometimes you get that little snapshot of time where you can say, "let's look at what's going on here." But clinical care has to come first… I'm not going to let someone who doesn't know what they're doing kill someone so I can teach them…(Lisa)

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