Year : 2018 | Volume
| Issue : 4 | Page : 540-547
International internship experience for emergency medical service paramedic students
EMS Department, Prince Sultan Bin Abdulaziz College for EMS, King Saud University; Chair of Saudi Association for Emergency Medical Services, Riyadh, Saudi Arabia
Dr. Daifallah Alrazeeni
Prince Sultan Bin Abdulaziz College for EMS, King Saud University, Riyadh
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||4-Oct-2018|
Introduction: The purpose of this study is to delineate the training activities in the internship program, describe students' clinical and emergency medical service field hours and skills performance, and compare between internship students groups in their skills performance.
Methods: This is a retrospective, descriptive, and analytical study based on an interpretive observational documentary review of internship reports received on internship students.
Results: Three groups of internship students participated in various training activities in 3 years. Students in Group A (2015) completed 4610 h and contact 1600 patients. They completed the following clinical skills: 712 medication administrations, 652 intravenous (IV) access, 174 team leads (TLs), 4 live patient endotracheal intubations, and 13 ventilations. Students in Group B (2016) completed 2424 h and contact 797 patients. They completed several clinical skills including 256 medication administrations, 249 IV access, 16 TLs, 1 live patient endotracheal intubation, and 8 ventilations. Students in Group C (2017) completed 5700 h and contact 1200 patients. They completed several skills including 673 medication administrations, 650 IV access, 198 TLs, 11 live patient endotracheal intubations, and 27 ventilations. The study revealed significant differences and superiority in skills performance in Groups A (2015) and C (2017) over Group B (2016).
Conclusion: Internship students have exposure opportunities to patients and have more opportunities to perform medication administration, IV activities, and serve as TLs. As expected, internship students have few opportunities to perform live tube insertions and ventilation. There are statistical significant differences in skills performance within the group of students in each year and among the three groups of internship students.
Keywords: Clinical skills; emergency medical service; emergency medical service field skills and skills performance; internship; paramedic
|How to cite this article:|
Alrazeeni D. International internship experience for emergency medical service paramedic students. Saudi J Anaesth 2018;12:540-7
| Introduction|| |
The internship program for paramedic students is intended to help them practice medical interventions through exposure to patients in prehospital or hospital settings. It provides opportunities to paramedic students to learn skills, ensuring their competency. Prince Sultan Bin Abdulaziz College for Emergency Medical Service (PSCEMS) realized that some objectives of its paramedic program curriculum were not being achieved through local internship placement.
PSCEMS was established in 2010 at King Saud University (KSU), Riyadh, Saudi Arabia. The EMS Bachelor program curriculum and its objectives and learning outcomes were developed based on the United States (US) national standards curriculum for paramedics while considering Saudi market needs. The course objectives and syllabus were extracted from the main three teaching tools for paramedics (textbooks by Mosby, Brady, and Nancy Coralline). These teaching tools are in harmony with the principles and requirements of the American Ministry of Transportation presented in the EMS ACT published in 1973. Officials at PSCEMS recognized the gap between EMS practice in Saudi Arabia and the themes presented in the paramedic textbooks that needed to be addressed. The gap appears in the clinical practice in which the EMS setting and ideal practice described in textbooks varies from the Saudi EMS system, which confuses students.
Therefore, the idea of a 6-month internship program for PSCEMS students in the US was initiated, which takes place in the second half of students' internship year. KSU approved financial support of 2 million Saudi Riyals (equivalent to 500,000.00 USD) a year for the annual internship program. This covers students' tuition fees, medical insurance, airfare, and living expenses.
KSU and Creighton University (CU) entered into a collaboration to start the internship program by signing a mutual memorandum of understanding. An internship training program was designed to provide paramedic students at PSCEMS with EMS internship experience at US EMS agencies and hospitals in Omaha city, NE. Accordingly, students had the opportunity to gain clinical practicum experiences, a paramedic psychomotor skills review and assessment.
Omaha is the largest city in the state of Nebraska. According to the 2010 census, the population was 408,958 and estimated to increase to 446,970 by 2016. The (2015) National Run Survey revealed that the volume of 911 calls in the city was 48,712, most of which were EMS calls.
Three groups of students completed the internship program. They were groups of 13, 12, and 13 students, respectively. This year (2018), 17 students are currently in the program. For better outcomes of the internship program, PSCEMS implements strict measures to select the best internship student applicants. For instance, a grade point average of 4.0 and International English Language Testing System of 5.5 are required. Furthermore, internship committee interviews are conducted and an academic and behavioral report on the student was prepared. In addition, students must be certified as a provider by the American Heart Association in several courses.
The purpose of this study is to delineate the training activities in the internship program, describe students' clinical and EMS field hours and skills performance, and compare between internship students' groups in their skills performance.
A limited literature review addressed the undergraduate paramedics internship., O'Brien et al. contended that a 4-year bachelor paramedic program could provide students with a strong educational foundation and sufficient hands-on practical experience. Boyle et al. noted that paramedic programs incorporate theoretical knowledge taught alongside experiential clinical practice in emergency and nonemergency ambulances and hospital departments.
In paramedic programs, clinical placement enables the integration of theoretical knowledge gained with real-life exposure to patients (Lord et al., 2009).,,, It enables paramedic graduates with the means to develop their communication skills as well as professional socialization, an interdisciplinary work environment, professional methodology, and an environment in which to practice psychomotor skills. Yorke and Mantz  described work-integrated learning (WIL) as an essential component of paramedic education. It provides opportunities for a learning experience to paramedic students and enables the integration of theory and practice.
However, paramedic programs were criticized as having a limited scope or capacity in terms of the duration of clinical education. The literature implies that insufficient preparation of and support for new paramedics may induce poor outcomes and inadequate preparation for the transition into the workplace. Therefore, studies concluded that most paramedic graduates do not feel they have accumulated adequate experience before beginning their employment in an ambulance.,,
Michau et al. identified a theory-practice gap in paramedic education by investigating the types of cases students were exposed to during clinical placements. The study concluded that paramedic students were able to practice only 50% of the skills they learnt during their clinical internship placements. This gap between knowledge attainment and practical application may hinder professional competence. Factors promoting deficiencies in clinical placement for paramedic students stem from a shortage of training funds, shortage of monitoring staff, limited access to patients, and an increasing number of students at the required sites (Cooper, 2005).
The shortcomings in clinical practice are largely due to scheduling constraints and a high demand for clinical placements. Further shortcomings include inadequate exposure to critically ill or injured patients, a lack of advanced clinical skills among practicing paramedics, and the short duration of clinical experience. Therefore, Boyle et al. reported that many students were not satisfied with their learning experiences during the clinical placement period, which resulted in wasted learning opportunities.
In general, clinical placement for paramedic internship students is completed locally. However, international WIL is becoming increasingly common as it provides students with adequate experience. This study adds to the EMS research knowledge and insights by presenting the experience of PSCEMS in its student internship initiative.
| Methods|| |
This is a retrospective, descriptive, and analytical study based on interpretive observational documentary review of internship reports received from EMS team at CU (the host of internship program led by Dr. Mike Miller) about the internship students. PSCEMS receives regular progress and summary report attached to supplementary Excel sheet data of the students' clinical and field performance. For interpretation and explanation, data were reviewed, analyzed, and presented for each group as it is categorized based on various variables. Moreover, statistics of the anonymous students' skills performance was presented. For data analysis, mean count (X), standard deviation (std. dev.), and standard error (std. error) were calculated. In addition, one-way analysis of variance (ANOVA) is used to examine if there is a statistical significant difference within each group of students and comparison between the groups. To obtain this P value, multiple comparisons and t-test were used using Statistical Package for the Social Sciences (SPSS) Version 11.0 software package.
| Results|| |
Results of the study are organized based on the study objectives stated and are as follows:.
Clinical and Emergency Medical Service field training activities
The highlights regarding internship student activities are provided as follows:
[Table 1] show that the areas of patient care engaged in for internship included field internship-ambulance, emergency room (ER), Children's ER, respiratory therapy (Resp.), catheterization laboratory (Cath. Lab), and Critical care unit (CCU). Some departments were excluded in certain year based on CU requirements. Students in Group A (2015) completed more than 2372 and 2238 clinical and field internship practicum hours, respectively, with more than 4610 of total hours completed. The mean count (X) for each student was 354.6 h. Students in Group B (2016) completed over 1458.7 and 965 clinical and field internship practicum hours, respectively, with total hours completed of more than 2424 (X = 202). Students in Group C (2017) completed over 2,200 and 3,400 clinical and field internship practicum hours, respectively, with total number of hours completed of more than 5700 (X = 476).
|Table 1: The combined clinical and field hours, patient contacts, and skills performed for the three internship groups|
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[Table 1] illustrates that field hours audit for each internship student was at its highest level in Group C (2017) and Group A (2015); however, in Group B (2016), it was at the lowest level. On the other hand, [Figure 1] shows that it is obvious that the time duration consumed for the ER hours audit in each internship student, i.e., in Group A (2015), Group B (2016), and Group C (2017) is high. It shows that the highest number of Intensive Care Unit (ICU)/CCU hours audit and Resp. hours audit was completed at the highest by students in Group C (2017) then Group A (2015) following Group B (2016). This indicates the duration required to spend by students in these department is much less. Cath. Lab audit and Children's ER audit were applied in only 1 year and stopped later.
[Table 1] and [Figure 2] show that students had contact with patients in the clinical and in the EMS field. Students of Group A (2015) had contact with nearly 1600 patients (X = 122), 1048 in the clinical arena and 548 in the EMS field. Students in Group B (2016) had contact with nearly 797 patients (X = 66), 494 in the clinical arena and 303 in the EMS field. Students in Group C (2017) had contact with over 1200 patients (X = 93), 351 in the clinical arena and 863 in the field. It appears that for Group A (2015), the focus was clearly on the patient contact clinical as well as in Group B (2016); however, students in Group C (2017) were more likely to be directed to patient contact in the EMS field work.
[Table 1], [Table 2], [Table 3] and [Figure 3] and [Figure 4] present descriptive statistics for the skills performance variables of the three internship student groups. 5 skills studied are medication administration (M), intravenous (IV) access, live patient endotracheal intubations Life tube (LT), ventilation (V) and EMS call team lead (TL) mean count (X), std. dev. and std. error were calculated.
|Table 3: Descriptive statistics for the skills performance of each internship student|
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Students in Group A (2015) completed the following clinical skills: 712 medication administrations (X = 54.77, std. dev. = 39.42. and std. error = 10.93), 652 IV access (X = 50.15, std. dev. =17.96 and std. error = 4.98), 174 TLs (X = 13, std. dev. = 14.63 and std. error = 4.05), 4 live patient endotracheal intubations (X = 0.3, std. dev. = 0.75 and std. error = 0.20), and 13 ventilations (X = 1, std. dev. =1.52 and std. error = 0.42). The total number of skills practiced by Group A was 1555. Among this Group A, 3 students administered medications more than 100 times, while 3 demonstrated this skill <20 times.
Student in Group B (2016) completed several clinical skills including 256 medication administrations (X = 21.33, Std Dev. = 16.68 and std. error = 4.81), 249 IV access (X = 20.75, std. dev. = 11.15 and std. error = 3.22),16 TLs (X = 1.3, std. dev. = 1.77 and std. error = 0.51), 1 live patient endotracheal intubation (X = 0.08, std. dev. = 0.28 and std. error = 0.08), and 8 ventilations (X = 0.67, std. dev. = 1.07 and std. error = 0.31). The total number of skills practiced by Group B was 530. Among this Group B, the performance of students was low overall. For this Group B, 3 students administered medications <3 times, while the rest varied between 11 and 46 times.
Students in Group C (2017) completed several skills including 673 medication administrations (X = 51.7, std. dev. = 25.51 and std. error = 7.07), 650 IV access (X = 50, std. dev. = 26.39 and std. error = 7.32), 198 TLs (X = 9.92, std. dev. = 11.56 and std. error = 3.20), 11 live patient endotracheal intubations (X = 0.8, std. dev. =18.99 and std. error = 5.26), and 27 ventilations (X = 2.2, std. dev. = 2.42 and std. error = 0.64). The total number of skills practiced by this Group C was 1,559. Among this Group B, only 1 student administered medications more than 100 times, while two students demonstrated this skill 23 times. Most students in this Group B vary between these two figures.
It is apparent that the students in Groups A (2015) and C (2017) share highest level of skills performance while it was significantly decreased among students in Group B (2016). The variation continues between the students' groups regarding IV insertions. Only 1 student in Group C (2017) applied 114 IVs, while 2 students in Group B (2016) performed this skill <10 times. The majority of students had opportunities to practice their IV skills. The opportunity for students to act as team leaders varied significantly and low overall in the three groups. Although 10 students did not have the opportunity to lead the crew in any EMS calls, most did so few times. Live intubation and ventilation skills seem rare since most students never perform these during their internships. However, one student in Group C (2017) performed an LT 4 times and another 3 times. Regarding ventilations, two students in Group C (2017) performed this skill 9 and 4 times (respectively), one student in Group A (2015) five times, and 4 students from all three groups 3 times. All levels of performance are close between Group A (2015) and Group C (2017) while it is significantly low among the Group B (2016) for the 5 skills.
For this study, the 0.05 levels of significance and P > 0.05 were applied to indicate no significant differences between students' skills performance within the groups and P < 0.05 to indicate a significant difference. [Table 4] shows the value of F significance is <0.05 indicating statistical significant differences in the students' performance regarding the 5 skills in each group over the years.
|Table 4: Analysis of variance for the skills performance of each internship student|
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In addition, a multiple comparisons in ANOVA were applied to compare between the students' skills performance between the Groups A (2015), B (2016), and C (2017). [Table 5] illustrates that the value of F significance <0.05, meaning that there are statistically significant differences between students in the groups.
|Table 5: Analysis of variance for the skills performance of each internship student years (2015-2017)|
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Moreover, a t-test at a significance level of 0.05 was used in order to determine which group was better performance. [Table 6] and [Figure 5] show that there are statistically significant differences and superiority in performance in Groups A (2015) and C (2017) over Group B (2016). However, there are no statistically significant differences between the performance of students in Groups A (2015) and C (2017).
|Table 6: Analysis of variance for the skills performance of each internship student years|
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| Discussion|| |
This study presents the KSU-CU internship program experience for 3 groups over three consecutive years. Its focus of the study is to delineate the training activities in the internship program, describe students' clinical and EMS field hours and skills performance, and compare between internship student groups in their skills performance.
The KSU-CU internship program has benefited the EMS program at PSCEMS and has become another area of competition among students. New students join the EMS program and are motivated to work hard to have the opportunity to be one of the students completing their internship in the US. The internship program seems to have added value to PSCEMS students who completed the program.
During the internship program, students participate in various distinguished activities related to the EMS profession that enriches their experience. The results revealed that the internship program helped PSCEMS students accomplish several learning means mentioned in Michau et al. such as communication skills development, professional socialization, an interdisciplinary work environment, a professional methodology, and enables them to practice their psychomotor skills. Internship students integrated with the CU EMS Club, and EMS simulation team utilized the FISDAP software package to enter their training skills.
The literature review identified factors triggering skill deficiencies and a theory-practice gap in paramedic programs. These factors could be attributed to the shortage of training funds, shortage of monitoring staff, students scheduling constraints at required clinical sites, inadequate exposure to patients, and insufficient skills among paramedics. The PSCEMS EMS program regularly faces some of these challenges in local internship clinical placement. However, by implementing the KSU-CU internship program, most have been avoided.
The literature review indicated that a bachelor's paramedic program provides the opportunity to integrate theoretical knowledge and experimental clinical practice by enabling real-life exposure to patients in ambulances and hospitals. The KSU-CU internship program enabled PSCEMS students to practice their clinical skills on an academic level in hospitals and in the EMS field in Omaha, NE, where EMS is implemented in accordance with the procedures outlined in textbooks.
For Group A (2015) students, the CU arranged clinical placement in the departments, namely the ER, Children's ER, ICU and cardiac care units (CCU) and respiratory unit. Paramedic students spend more time in the ER to practice their clinical skills and observe the treatment and management of emergency cases. However, with the Group B (2016), the departments selected in the hospital for practice were modified. The Children's ER was replaced with the Cath. Lab. This change may have been related to the sensitivity of that department and cultural and language differences. Moreover, for Group C (2017), students were dispatched to only three departments for their internships, namely the ER, ICU/CCU, and Respiratory unit. The total number of hours worked by Group A (2015) and Group C (2017) internship groups exceeds 4,600 and 5,700, respectively, while Group B (2016) racked up <2400 h. The mean count of hours students spent at clinical sites was 354, 202, and 476, respectively. This indicates better performance and superiority of Groups A (2015) and C (2017) over Group B (2016).
It seems that internship students in Group B (2016) spent less time than the other two groups in the clinical arena and field. This might be because the educational program the CU prepared for them consumed a great deal of time of practice, which affected the number of skills performed by these students. Nevertheless, the total number of patients seen by Groups A (2015) and C (2017) internship groups exceeds 1,600 and 1,200 patients, while the Group B (2016) dealt with less than 800 patients. The mean count of patients that students were exposed to in the clinical placement was 122, 66, and 93, respectively. It is important to consider that Omaha, NE is not an overly large or crowded city. The volume of 911 calls and visits to the ER are normally low, which affected the exposure of internship students to patients.
The skills focused on included IV access, medication administration, TL, ventilation, and live patient endotracheal intubation. However, again, Group B (2016) completed only one-third of the number of clinical skills completed by the other two groups. Furthermore, the performance of field and clinical skills varies significantly between students, and they are more likely to differ in their levels of confidence and aggressiveness in asking for opportunities. In addition, exposure likely depends on the preceptor at each EMS station or hospital setting and his/her confidence in the student. This might indicate cultural and language barriers and may correspond to the feeling of dissatisfaction paramedic students' feel toward field practice presented in the literature reviewed. Students may need to be educated on how valuable this opportunity for them to utilized successfully.
Furthermore, the number of students might lag and some may not have the encouragement, confidence, and enthusiasm needed to practice skills. This could indicate deficiencies in various skills among some students, shifting the responsibility to the PSCEMS leadership to review practical skills attainment, practice, and assessment for their graduates. An in-depth assessment of students' knowledge and skills is crucial in EMS paramedic education, and the assessment of skills should accurately reflect the achievement of learning outcomes. Moreover, tracking the attainment of practical skills should ensure that students have the opportunity to practice their psychomotor skills before being assessed in an examination. Stricter selection criteria should be set to reliably assess students' proficiency in paramedic skills. The insufficient preparation of paramedics leads to poor outcomes, a lack of confidence, and lack of preparation for the ambulance workplace which was raised in the literature review. Possibly, this is true, as Group B (2016) performed significantly fewer skills than the other two groups, necessitating a skills enhancement program for these students.
The study acknowledges the importance of the impressions, feedback, and perspectives of internship students on their experience as well as the individuals in the EMS team at CU. They will be good source of information to spot the factors associated with the internship experience. Moreover, an in-depth analysis of the cases responded to by each internship student, and their competencies management need to be conducted.
| Conclusion|| |
The study revealed that international cooperation between EMS schools provides many promising educational opportunities to paramedic education. During the internship, students participated in various distinguished activities related to the EMS profession to enrich their experience. Internship students have opportunity to have exposure to patients and have more opportunities to perform medication administration, IV activities, and serve as TLs. There are distinguished differences in skills performance within the group of students in each year and among the three groups of internship students. As expected, internship students have few opportunities to perform live tube insertions and ventilation.
I extend my acknowledgements that this work was supported by PSCEMS, Deanship of Scientific Research, KSU, Riyadh, Saudi Arabia. Moreover, all help received from the data and information prepared by the CU EMS team led by Dr. Miller, Mike G, and the team comprising Jensen, Gail M, AHMED AOJ Chavez, Jairo, Leggio Jr, William J Carritt, Kevin S Cota, Jacquelene S Oviatt, Sheryl L Madvig, Evie Y Renner, and Tami M is appreciated. Thanks are also due to Dr. Mohammed Sami Al Sufi, PSCEMS for scientific assistance in this study. In addition, appreciation should be dedicated to Mr. Alromaih A and Mr. Alenazi F, as well as internship student Alshahrani B for their help during the study. Also, an appreciation for Dr. M. Hakim's effort in data manipulation, interpretation, and analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]