Paramedic education
Real engagement improving paramedic attitudes towards the elderly Linda Ross and Brett Williams Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
SUMMARY Background: Negative attitudes adversely impact on patient care and outcomes. Given the aging population in Australia, it is inevitable that paramedic attendance to this demographic of patients will also rise. It is therefore imperative that undergraduate paramedic attitudes towards elderly patients are investigated, along with pedagogical approaches to maintain or enhance them. Methods: Eleven second-year paramedic students enrolled in Monash University’s Bachelor of
Emergency Health (Paramedic) degree, came together with 11 independently living elderly residents from Patterson Lakes Village and participated in an engagement activity. The Aging Semantic Differential (ASD) survey and focus groups were used to analyse the students’ attitudes towards the elderly, before and after the activity. Results: Students showed improved attitudes toward the elderly across two of the three ASD dimensions. Focus group discussions suggested that students found the elderly
participants to be more independent and capable than they had first thought, but were unchanged on their attitude with regard to elderly people being inflexible. Conclusion: Students were presented with an opportunity to actively engage with independently living elderly patients. This experience challenged their preconceived ideas about the elderly and their capabilities, and at a minimum increased awareness, which will assist future paramedics in their interactions and care of these patients.
Negative attitudes adversely impact on patient care and outcomes
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Paramedics begin their undergraduate training with preconceived ideas about elderly people
INTRODUCTION
I
t is widely known that the Australian population is aging at a profound rate. Current projections estimate that the percentage of the population over 65 years of age will double from 20 per cent in 2007 to 38– 42 per cent by 2056.1 Chronic diseases, illness and the multiple morbidities associated with aging will lead to increasing demands on health services.2 This has contributed to a sustained rise in demand for emergency ambulance services over the past 20 years, which will continue into the future.3 Paramedics begin their undergraduate training with preconceived ideas about elderly people based on previous experiences and external influences. They develop lasting attitudes to elderly patient care during their education and training.4 This is facilitated throughout the curriculum by simulations, using actors or peers as patients, in combination with theory-based learning. Students also form attitudes towards the elderly whilst on clinical placement through interaction with patients and by observing qualified paramedics. Preliminary survey results, using the Aging Semantic Differential (ASD), of 56 second-year Monash University paramedic students found that they bore negative attitudes towards the elderly, finding them to be ‘inflexible’ and ‘oldfashioned’. Opportunities to challenge perceptions and develop positive attitudes towards the elderly in the field can be limited by a lack of clinical placements and exposure to this patient group. In addition, students are often focused on clinical assessment and an expectation to make clinical decisions in a timely fashion.5
Attitudes and preconceptions are a key link in the establishment of rapport with patients. Negative attitudes towards
patients have been shown to lead to poor communication between professional and patient, and to an inferior therapeutic relationship.6 Therefore, attitudes towards patients substantially impact on the quality of care.7 Structured engagement with real patients, as opposed to simulated patients or actors, could improve student attitudes towards the elderly. Real patients have been used in medical education for decades in the teaching and learning of physical examinations, clinical skills and communication skills.8 Interactions with real patients are more authentic and meaningful, which results in students developing true emotional relationships rather than the often feigned simulated relationships.9 The purpose of this study was therefore to determine whether active engagement with the elderly results in improved student paramedic attitudes towards the elderly.
METHODS Participants In April 2013, 11 second-year paramedic students enrolled in Monash University’s Bachelor of Emergency Health (Paramedic) came together with 11 independently living elderly residents from Patterson Lakes Village and participated in an engagement activity. During their first year of study students attended
one gerontology lecture and two ambulance observer shifts. Engagement activity During the engagement activity each student paramedic sat opposite an elderly participant. Each pair engaged in a 10–minute conversation. After 10 minutes the paramedic students rotated to the next table and began a new conversation with another elderly participant. Each student engaged in a total of six 10–minute conversations with elderly participants. The students were directed to begin the conversation with a question about the elderly participant’s health, and then to let the conversation progress in any direction from there. The elderly participants were directed to be themselves and only to discuss topics that they were comfortable with. It was decided to keep the conversations as natural as possible, rather than following a typical structured patient interview. It was hoped this would allow the students to form genuine relationships and gain true impressions of the elderly residents without the impedance of trying to gather information. Instruments Prior to the activity and 5 weeks after the activity student paramedics completed the ASD survey. A 5–week period was selected to enable sufficient time for wash-out, but prior to students attending clinical placements and interacting with elderly patients. The ASD, designed by Rosencranz
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and McNevin (1969), is the most widely used instrument to access stereotypical attitudes towards the elderly.10 It uses a seven-point semantic differential scale questionnaire (in which 1 represents the positive end of the spectrum) consisting of 32 polar adjectives and three dimensions. The first dimension, Instrument–Ineffective, is the ‘potency’ factor, e.g. busy–idle, productive–unproductive, etc. It contains nine items and a score range of 9–63. The second dimension, Autonomous– Dependent, is the ‘activity’ factor, e.g. independent–dependent, organised–disorganised, etc., and also has nine items and a score range of 9–63. The third dimension, Personal acceptability– Unacceptability, is the ‘evaluative’ factor, e.g. pleasant–unpleasant, friendly–unfriendly, etc., with 14 items and a score range of 14–98. Two weeks after the engagement activity the student paramedics and elderly residents were invited to participate in two separate focus groups conducted by the lead author. Volunteers were asked questions about their perceptions of the activity. The quantitative and demographic data were analysed with the Statistical Package for the Social Sciences (SPSS 19.0). Results with p < 0.05 were considered to be statistically significant. The qualitative data from the focus groups were transcribed verbatim and analysed by the authors using thematic analysis. The final themes identified for further
[Students’] preconceived notions could stem from their lack of exposure to elderly patients
analysis were agreed upon through a collaborative process. Ethics approval for this project was granted by Monash University Human Ethics Research Committee (MUHREC).
An analysis of the focus groups’ data identified two key themes related to the students’ attitudes towards the elderly participants (flexibility and dependence). Student quotes relevant to these themes are presented in Table 2.
RESULTS DISCUSSION A total of 11 undergraduate paramedic students participated in this pilot study. Of the second-year student participants 63.6 per cent (n = 7) were female. The majority of students were less than 23 years of age (n = 10, 90.9%); the median age was 20 years. Data analysis of the ASD responses showed statistically significant results in the Instrument–Ineffective dimension (p = 0.036). The Autonomous– Dependant, although not statistically significant, trended in a positive direction, and the Personal acceptability–Unacceptability remained unchanged (Table 1).
Paramedic attitudes towards elderly patients are important because of the impact they have on rapport development and overall patient treatment and outcomes. The increase in the Instrument–Ineffective (potency) dimension, which included items such as progressive versus old fashioned, productive versus unproductive, healthy versus unhealthy and strong versus weak is indicative of a change in student perceptions of elderly people as being weak and feeble to a more positive perception of strong and capable individuals. Their preconceived notions could stem from
Table 1. Aging Semantic Differential (ASD) dimension results (n = 11) ASD domains
Pre-activity (M)
Post-activity (M)
Change (M)
p
Instrument–Ineffective
36.7
32.4
–4.3*
0.04
Autonomous–Dependent
29.3
28.8
–0.5*
0.72
Personal acceptability–unacceptability
41.3
41.3
0.0
1.0
M, mean. *Denotes a trend in the positive direction. © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 37–41 39
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The introduction of this type of activity into paramedic training would be logistically and financially challenging
Table 2. Focus group themes and student quotes Flexibility
• They were pretty set in their ways • They are rigid in their thoughts
• He taught himself how to do internet banking, so he was pretty willing to change and learn more
• They have habits where they do things at the same time every day • They have spent 60 or 70 years of doing it one way, why change it? Dependence • She needs a reminder to have a shower • They need emotional support • You can’t say that every elderly person is independent or dependent, it’s purely dependent on the person
• They are happy where they live, and visit family and friends • They travel around in a caravan • I thought most old people were dependent on someone, and that once you get to a certain age you need a carer, but most of them were able to get around their house, go for walks, garden and live pretty well
their lack of exposure to elderly patients up until this point, coupled with the nature of exposure that they have had, i.e. attending sick and frail patients in nursing homes. This highlights the need for variety in exposure to patients as not all elderly people live in high-care aged care facilities. The student attitudes towards the elderly across the Autonomous –Dependant (activity) dimension, which included items such as independent versus dependent, secure versus insecure and self-reliant versus dependent also improved. Again, a lack of exposure to elderly people could have contributed to the students’ stereotypical views of the elderly with regard to independence. The focus group responses indicated the students felt that many of the participants were very independent, whereas others needed some physical or emotional support. They were unwilling to categorise all elderly people at one end of the spectrum or the other, recognising that the level of dependence was determined by multiple factors. Exposure to a cohort of independently living elderly people helps to balance student perceptions. Results across the Personal acceptability–Unacceptability (evaluative) dimension, which included items such as optimistic
versus pessimistic, flexible versus inflexible, friendly versus unfriendly and hopeful versus dejected saw no change in student attitudes. The focus group responses indicated that most students found the elderly participants to be as they expected with regards to flexibility; however, some thought this was warranted. Perhaps some negative stereotypes such as ‘inflexibility’ are warranted, and an awareness of such can be beneficial in the management of patients who present with this challenge. Limitations Although only a pilot, this study was limited by size and
therefore trends could be noted without drawing definitive conclusions. In addition, the study did not account for selection bias, nor were confounding variables such as previous experience with the elderly accounted for. Implications The introduction of this type of activity into paramedic training would be logistically and financially challenging for programmes with large cohorts of students. The activity could potentially be modified using small group interactions rather than the one-on-one model. Alternatives or adjuncts could
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also include evaluating videoed ‘real’ interactions with the elderly. Future research Although this study indicated some improvement in paramedic attitudes towards the elderly, further research is required to determine whether this translates to actual improvements in patient care and whether the standard of care differs from that with younger patients.
CONCLUSION This study proved to be purposeful and presented students with an alternative notion of what elderly people are like and an opportunity to actively engage with this demographic of patients. It is hoped that this balancing of preconceived ideas about the elderly and their capabilities will assist future paramedics in their interactions and care of these patients.
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This study.... presented students with an alternative notion of what elderly people are like
8. Collins JP, Harden RM. AMEE Medical Education Guide No. 13: real patients, simulated patients and simulators in clinical examinations. Med Teach 1998;20:508–521. 9. Clever SL, Dudas RA, Solomon BS, Yeh HC, Levine D, Bertram A, Goldstein M, Shilkofski N, Cofrancesco J Jr. Medical student and faculty perceptions of volunteer outpatients versus simulated patients in communication skills training. Acad Med 2011;86:1437–1442. 10. Gonzales E, Tan J, Morrow-Howell N. Assessment of the refined aging semantic differential: Recommendations for enhancing validity. J Gerontol Soc Work 2010;53:304–318.
Corresponding author’s contact details: Linda Ross, Department of Community Emergency Health & Paramedic Practice, Monash University – Peninsula Campus, PO Box 527, McMahons Road, Frankston, 3199, Victoria, Australia. E-mail:
[email protected]
Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethics approval for this project was granted by Monash University Human Ethics Research Committee (MUHREC). doi: 10.1111/tct.12226
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