How caring assessment is learnt – reflective writing on the examination of Specialist Ambulance...

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How caring assessment is learnt –reflective writing on the examinationof Specialist Ambulance Nurses inSwedenBirgitta Wireklint Sundström a & Margaretha Ekebergh ba School of Health Sciences, Research Centre PreHospen ,University of Borås,The Prehospital Research Centre of WesternSweden , Swedenb School of Health Sciences , University of Borås , SwedenPublished online: 30 Oct 2012.

To cite this article: Birgitta Wireklint Sundstrm & Margaretha Ekebergh (2013) How caringassessment is learnt – reflective writing on the examination of Specialist Ambulance Nurses inSweden, Reflective Practice: International and Multidisciplinary Perspectives, 14:2, 271-287, DOI:10.1080/14623943.2012.732944

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How caring assessment is learnt – reflective writing on theexamination of Specialist Ambulance Nurses in Sweden

Birgitta Wireklint Sundströma* and Margaretha Ekeberghb

aSchool of Health Sciences, Research Centre PreHospen, University of Borås,ThePrehospital Research Centre of Western Sweden, Sweden; bSchool of Health Sciences,University of Borås, Sweden

This paper presents a research study that aims to describe and analyse how car-ing assessment is learnt in the Specialist Nursing, Prehospital Care Programmefor educating specialist ambulance nurses. The study is based on a contextualand didactic model for learning. The focus was on the final course, PrehospitalEmergency Care, with clinical studies and clinical practice amounting to 15credits, plus one of two theoretical examinations. We are testing the model toexplore what characterises the students’ learning when the model is applied.The informants were 37 students (registered nurses). Written data from all 37examinations were analysed by means of the phenomenological Reflective life-world research approach. The results stress the significance of a didactic modelconstructed according to the specific circumstances prevailing in the learningcontext. With the help of the model an attitude of reflective awareness isadopted, showing that knowledge in caring science and medical science areequally valuable and, are applied simultaneously. Furthermore, the model gener-ates knowledge that underlines the significance of the encounter with the patientin the care-giving context of the prehospital environment, in order for thestudent to be able to develop understanding and to learn caring assessment inprehospital emergency care. Thus the result reveals that it is the encounter withthe patient that is most effective for the student’s learning process.

Keywords: didactic model; reflections; reflective awareness; specialistambulance nurses; nursing training

Introduction

Since 2007, courses have been available to Registered Nurses (RN) in Sweden toacquire deeper knowledge in Prehospital Emergency Care, leading to a one-yearMaster’s Degree and a postgraduate Diploma in Specialist Nursing. The Master’sDegree is obtained after the student has completed course requirements worth 60credits including at least 30 credits with in-depth studies in Caring Science(University of Borås, 2011) (Table 1). The criterion for entering this programme isa Bachelor of Science including a specialisation in Caring Science/Nursing. Itshould be noted that this programme is aimed at nurses who – apart from praxis asspecialist ambulance nurses – also have the ability to confront and seek solutions toresearch problems and to develop methods for improving quality in praxis. In

*Corresponding author. Email: [email protected]

Reflective Practice, 2013Vol. 14, No. 2, 271–287, http://dx.doi.org/10.1080/14623943.2012.732944

� 2012 Taylor & Francis

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addition, this programme can be complemented with a further year’s study resultingin a two-year Master’s Degree in the subject.

Specialist ambulance nurses constitute a rather new profession in the SwedishEmergency Medical Services (EMS), and the discipline of Prehospital EmergencyCare is becoming established and recognised as an important part of the patient’stotal care (Suserud, 2005; Wireklint Sundström & Dahlberg, 2011). Many studieshave focused on resuscitation skills and out-of-hospital survival (Axelsson,Axelsson, Svensson, & Herlitz, 2007; Berdowski et al., 2011; Shin, Ahn, Song,Park, & Lee, 2011). However, very little attention has been paid to how specialistambulance nurses learn to integrate a caring science approach with all the medicalknowledge needed in everyday work in prehospital emergency practice. Thisquestion is of crucial importance in the EMS where there is a movement towards amore flexible guidelines approach involving reflective practice, and away from thetraditional approach of training for and following strict protocols.

This paper presents a research study that is carried out within a caring scienceapproach (Dahlberg & Segesten, 2010) and aims to describe and analyse howcaring assessment is learnt in the Specialist Nursing, Prehospital Care Programme.

The process of learning caring assessment

The specialist ambulance nurse needs a broad knowledge base and skills to applyto the care of patients in different settings (Suserud, 2005) with support from bothcaring science and medical science. That the two perspectives should complementeach other is stressed by Wireklint Sundström and Dahlberg (2011). It has beenshown that care-givers’ openness to patients’ lifeworlds is an essential part ofassessment in prehospital emergency care. Assessments that are based on anencounter and dialogue between patient and care-giver are characterised by invitingthe patient to participate. This approach is caring assessment which adds furtherdimensions to the objective data. The inclusion of the patient perspective relieves

Table 1. Contents in the Specialist Nursing, Prehospital Emergency Care Programme, 60Credits

Courses Theory/practice Credits

CaringScience,

40 creditsCaring Assessment in PrehospitalEmergency Care

Theoretical studies 10

Prehospital Emergency Care Clinical studies andclinical practice

15

Master’s Degree Project, PrehospitalCare

15

MedicalScience,

20 creditsEmergency Theoretical 12Medicine studiesPrehospital Care of patients withTrauma

Theoretical and clinicalstudies

8

272 B. Wireklint Sundström and M. Ekebergh

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suffering and leads to greater accuracy and safety in decision-making. Comparedwith the work of paramedics this everyday work has been described as unrecogn-ised and silent until Campeau (2008) developed the space-control theory anddescribed how paramedics establish social control at a scene through interaction.Hubble, Paschal and Sanders (2000) wrote that looking for the best solution forpatient’s care needs is one of paramedics’ skills of practicing. However, the issue isstill how students can learn this caring science approach.

Thus, it is unclear how the students’ academic and clinical learning in prepara-tion for specialist nursing in the EMS can best be achieved. The difficulty is toknow what kind of support they need for this learning. The process of learningcaring assessment in prehospital emergency care is preceded by giving the studentthe opportunity of problematising the information from the emergency medical dis-patch centre. Problematisation involves a discussion between the student and her/hissupervisor concerning what the assignment may bring with it, before meeting thepatient. After the assignment has been completed, the student can evaluate her/hisnewly acquired knowledge in relation to the assignment and its actual results. Thesupervisor’s experience thus meets the student’s less experienced lifeworld.

Reflection is frequently mentioned as a complement to protocols, and guidelines(Jones, 2008) and Ekebergh (2009) underline the necessity of recognising the stu-dents’ lifeworlds in the supervision process. Gustafsson, Asp and Fagerberg (2007),in their meta-synthesis study of qualitative research in nursing, conclude thatassumptions about reflective practice are predominantly based on theory. However,there is still a demand for conceptualising reflective practice in clinical contexts(Gustafsson et al., 2007) based on the urgent requirement for discipline-specificresearch (Jones, 2008; Campeau, 2008; Wireklint Sundström & Dahlberg, 2011).

Jones (2008) highlights the need of adapting programmes for paramedic studentsto the right educational level and to have a clear conceptual and contextual focusfor reflective practice. The lack of critical thinking has been demonstrated, and alsothat paramedic students emphasise ‘technical reflection’ grounded in practical prob-lem-solving. These results agree with Wireklint Sundström (2005) on EMS, andalso with Elmqvist, Brunt, Fridlund and Ekebergh (2009) using the concept of‘doing’ when describing care in acute contexts, that should be understood ascarrying out a systematic course of actions. We underline the risk that the patients’lifeworlds can be forgotten in practice with such a treatment-orientated approach.Therefore studies are lacking on how the integration of the caring science approachin the area of Specialist Nursing could be developed and learnt. Consequently wecall for didactic research focusing on reflective practice for continuing professionaldevelopment in the EMS with increased requirements for reflective thinking anddecisions when it comes to the care of individual patients. Ekebergh (2007) wrotethat the lifeworld perspective allows a new and deeper understanding of the role ofreflection in nursing students’ learning processes and also in students’ abilities tointegrate caring with caring practice.

A previous study (Wireklint Sundström, 2005) based on Ekebergh (2001)presents a didactic model for the EMS, which is intended for the supervision of stu-dents at different educational levels, both for RN and paramedics, during clinicalstudies. In this model both students and other care-givers are seen as learningpersons, i.e. they are under constant and continuous development and therefore“growing”. As its starting point, the didactic1 model takes the prehospital care

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context and the unique conditions prevailing for the learning process in thePrehospital Emergency Care Programme.

The didactic model for prehospital emergency care

The didactic model for prehospital emergency care is presented in the form of threedidactic ideas, i.e. as a structure for students’ learning processes to develop areflective awareness, which overlap each other, as follows:

Didactic idea 1. To recognise the interdependence of caring science knowledge andmedical knowledge.

Caring science constitutes the basis of the didactic model. Thus supervision andother teaching activities take as their starting-point an approach where the patient isalways understood to be an integrated part of the whole caring context. Caringscience clarifies for that reason how prehospital emergency care and its didacticscan develop, grounded in a patient perspective that recognises an interdependenceof caring science knowledge with medical knowledge.

Didactic idea 2. To prepare to be unprepared with the help of open didactic reflection.

In order for students to be able to assimilate the knowledge that is needed to carryout prehospital emergency care, it is necessary for the supervision to emphasisereflection and its importance for preparing the encounter with the patient’s individ-ual care needs. The overall purpose of reflection is to prepare for keeping an openmind in the face of the unknown and the uncertain, in each new assignment. Theaim of didactics in this respect is to guide the student towards an attitude involvingnever really knowing what the next assignment or care situation will be like, whichis the actual situation for care-givers in the EMS.

Didactic idea 3. To recognise the changing and vulnerable nature of caring and at thesame time create a balance with the need for control.

To be able to relate to prehospital emergency care in a didactic way also entails rec-ognising a highly variable caring context that leaves the care-giver with a sense ofvulnerability. The didactics must therefore include the care-giver’s need to create asense of temporary stability and control in the mobile care given in the EMS wherethe care-giver also has to create his/her own care environment and make space forcaring on each occasion. Didactics that give prominence to flexibility can help toclarify but also problematise the tension that exists between being sensitive to whatis unique and for example using standardised assessment forms.

The present study is based on this contextual and didactic model (Figure 1). Weare testing the model in the Specialist Nursing, Prehospital Emergency CareProgramme to explore what characterises the students’ learning when the model isapplied. The research questions were as follows:

• How are students learning caring assessment?• How is their learning process formed?• What characterises their reflection?


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Methods

This study design is based on a reflective lifeworld approach within the caring sci-ence context (Dahlberg, Dahlberg, & Nyström, 2008; Dahlberg, Todres, & Galvin,2009) and reflective practice in nursing education (Ekebergh, 2007; 2009).Reflective lifeworld research (RLR) is characterised by its search for meaning. Inorder to make this approach possible we need to adopt a reflective stance to ourusual attitudes and things we take for granted in everyday life, i.e. the EMS in rela-tion to the learning process, and describe the phenomenon as it is experienced. Thephenomenon referred to is how the students experience the learning of caringassessment with its focus on the ability to meet the patient in need of prehospitalemergency care.

The method refers to Husserl’s philosophy (1973) and is founded on his conceptof lifeworld theory. The starting-point of the method is a lifeworld-based under-standing (Gadamer, 1995). This approach meets the criterion of studying students’learning processes with openness and flexibility, based on the students’ ownexperiences.

Setting and sample

The study was carried out at the School of Health Sciences, a University in WesternSweden, as part of the year 2008 programme in Specialist Nursing, PrehospitalCare, for educating specialist ambulance nurses. The focus was on the final course,Prehospital Emergency Care, with clinical studies and clinical practice amounting to15 credits, plus one of two theoretical examinations.

The first author is supervising in Master’s Degree Projects and the second authoris teaching in Caring Science theory. Both authors are also registered nurses butneither of them has been working in the EMS. The pre-understanding was due tofurther research that points out that there could be difficulties in the integration ofthe caring science approach in emergency oriented settings.

Figure 1. The overall research question to explore students’ learning process in prehospitalemergency care when the didactic model presented in the form of three didactic ideas isapplied.


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Examination in Prehospital Emergency Care, clinical studies and clinicalpractice

The examination was rated as 0.5 credits, i.e. corresponding to three days’ theoreti-cal studies. The overall task was formulated as follows:

Describe how you experienced your learning during clinical studies and clinical prac-tice, using the didactic model for Prehospital Emergency Care!

(a) Give examples of situations when you learned to interweave caring scienceknowledge and medical knowledge in your approach (Didactic idea 1)!

How did this contribute to your possibility to meet the patient’s and next-of-kin’scare needs?

(b) Give examples of situations when learning was hampered on account of yourbeing unprepared and not having had time to reflect on the situation(Didactic idea 2)!

How did this prevent you from meeting the patient’s and next-of-kin’s care needs?

(c) Give examples of situations when learning was hampered on account of rap-idly changing circumstances during the caring assignment (Didactic idea 3)!

How did your need for control contribute to your possibility to meet the patient’sand next-of-kin’s care needs?

Participants

In connection to the examination the students were informed in writing by the firstauthor about this study, and asked if they wanted to participate with their individualwritten answers and reflections. No extra questions or tasks were set, and the princi-ples of anonymity, integrity and confidentiality were ensured by the same writtendocument. The students who did not want to participate were asked to send in awritten refusal to the first author. No written refusal was sent in. All communicationbetween the students and the first author was managed through the web-basedplatform Ping Pong.

Table 2. Socio-demography of the students (N=37).

Sex

Male 22Female 15

AgeAverage age = 34 years old

24–34 years old 2435–45 1046–55 3


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The students were 38 RNs. One student did not pass the examination in timefor the study. The study is therefore based on 37 participants between 24–55 yearsold, 22 men and 15 women, some with prehospital emergency care experience andsome without such experience (Table 2).

Data collection

Approximately ten weeks were allowed between the day the students received theirexamination papers and the day that they had to hand in their papers. The twocourse teachers, neither of them one of the authors of this paper, assessed the indi-vidual examinations. After completing their assessments and informing the studentsof the results, the students were offered the opportunity of refusing to participate inthe study, which nobody did. The papers were then handed over to the first author.

Data analysis

Written data from all 37 examinations was analysed by the phenomenological RLRapproach (Dahlberg et al., 2008). Such data analyses are characterised by a tripartitestructure and described as a movement between whole–parts–whole. They entailunderstanding the data as a whole, then dividing it into parts before returning to anew whole. In order to be able to do this the researcher has to move betweendifferent abstract levels during the process of analysis. The analysis can thus beseen as a process of understanding with a movement between different abstractlevels, instead of an analysis in separate stages.

By an ongoing dialogue throughout the data analyses both researchers main-tained a dialectical process with a sensitive and reflective stance and tried to be asopen as possible in order to understand something that was completely new, whichmeans that tradition as well as pre-understanding became challenged. The decisionsof the meaning changed a lot through the process of analysis. The first author madethe first drafts and the second author read and gave suggestions of changes. Duringmeetings we then discussed ‘faithfulness’ to the data as well as depth ofunderstanding in relationship to the phenomenon (Dahlberg et al., 2008).

Data from the examinations was read several times by both researchers so thatall data were considered as ‘a whole’. Subsequently, the search for meanings began.We moved back and forth between the parts and the whole in order to uncoversimilarities and discrepancies in the data and we were able to identify clusters ofmeaning. These clusters could be seen as themes describing how caring assessmentis learnt.

Each of the five themes has its own characteristics with a distinctive meaning inrelation to the others. Thus, each theme can be seen as ‘isolated’ in order to presentprominent learning features. However, at the same time the learning process is acomplex phenomenon and the meanings from the five themes overlap.

The learning process of caring assessment manifests itself in different ways andour findings consist of the following themes of meaning: 1. The learning process ischallenged by care inadequacies; 2. The learning process goes through participationin caring; 3. The learning process is in close relationship with the patient; 4. Thelearning process is influenced of the unpredictable caring encounter; 5. The learningprocess relies on support from the supervisor. We have included quotations from theexaminations in order to illustrate the meaning with individual students’ reflections.


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When we use the term ‘students’ we are referring to RN undergoing educationto become a specialist ambulance nurses, and when we use the term ‘ambulancepersonnel’ we are referring to either an RN, a specialist ambulance nurse or aparamedic, and finally the term ‘care team’ refers collectively to all ambulancepersonnel. The supervisor is always a specialist-trained nurse.

Findings

1. The learning process is challenged by care inadequacies

The character of medical emergency and the often complex care situations in prehos-pital emergency care are experienced as challenges to the learning process, especiallyin care situations where it is not possible to make contact with the patient, e.g. becausethe patient’s condition is life-threatening. Learning caring assessment can in such situ-ations be associated with inadequacy. One student writes in the following way aboutan unsuccessful care situation when a serious ill patient had been rushed to hospital:

Afterwards I felt guilt because our concentration was almost exclusively on themedical level. I learned that more routine will allow me to give more attention to theperson behind all the symptoms and to prevent the caring from being given lowpriority. // This situation felt “non-caring”, because the caring was minimal and theambulance was used merely as a means of transport for the sick person.

Another situation, in which the ambulance nurse was under pressure on account oflack of time, is described as that the patient had been completely ignored. The med-ical decisions had the upper hand and the student writes about her/his inadequacyin the following way:

Afterwards I feel that I have just “transported” a body and not a person. I was so busywith her symptoms that I did not look after her at all well. The feeling that she wasgravely ill and that we must get her to hospital took the upper hand. My learning inthis situation was limited by the medical decisions to be made and the pressure oftime there was on account of her critical condition.

The learning challenge is also described as containing feelings of inadequacy in rela-tion to treatment, when the ambulance nurse cannot help patients in need of caredespite doing everything that the treatment guidelines permit, e.g. in connection withpain control. One student writes in the following way about his shortcomings in thecare of a patient with chest pains and how he experienced learning caring assessment:

This man did not get any relief from the pain control he was given in the ambulance,which meant that I felt that we could not help him properly. I did everything correctlyaccording to the treatment instructions there were but felt even so that it was notoptimal. I was unable to meet the patient’s needs since I could not relieve his painsatisfactorily, that was what I learned.

2. The learning process goes through participation in caring

When students are allowed to be present and to participate in caring experiencemakes the learning process easier. One such situation concerned a patient with dia-betes. The student writes in the following way about how good she felt when hersupervisor made her part of the caring:


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“See if you can find an intravenous line”, said my supervisor and that made me getgoing. It was good to have a task to do so that I could learn something. In the mean-time, my supervisor did a p-glucose test and it was very low. As soon as I hadinserted the line, we started a glucose infusion. The patient [a woman] regained con-sciousness quickly and after a short while she was sitting up on the edge of her bed.Then I felt that I had been useful, that I had actually made a difference to the patient’scondition.

Other caring situations in which the student is treated with trust and is allowed tocarry out various caring tasks independently also facilitate learning when it comesto caring assessment in the encounter with a patient. One student writes in thefollowing way about how it feels to be shown trust both by the patient and thesupervisor, even if the caring is uncomplicated:

Made good contact with the patient from the first moment, felt that she trusted me.That made me more confident and I dared to do more. Being allowed to give care inthe back of the ambulance made me think about what tests I should do, etc. And thefairly long transport time meant that I had time to prepare my report at the casualtydepartment. // The patient was very satisfied and thanked me for helping her. Feltgood even though it was a simple case.

3. The learning process is in close relationship with the patient

Students in prehospital emergency care can be experienced as an extra resourcewhen it comes to caring. Naturally, the students do not have any defined dutieswhich means that they can focus on whatever offers them possibilities for learningnew things, like e.g. creating caring relationships with patients. Being an extra nurseon the care team can be taken advantage of as an opportunity for creating close con-tact with the patient, e.g. after an unsuccessful resuscitation the extra nurse can lookafter a husband who has just lost his wife. A male student describes in the followingway how his learning was stimulated by having time to give support to this man:

“I must go over to him”, I thought, “I’m extra here anyway”. That was the way Ithought. Kind of to make use of the situation. // At the hospital, I accompanied thisman to the relatives’ room and helped him to search for his son’s phone number. Feltthat I was able to do that as an “extra person”, I wasn’t really needed anywhere else.It was a luxury just to be able to be close to a person in crisis, it taught me just howterribly alone he was.

Caring situations involving closeness to a patient can also be experienced in thecompany of a supervisor. The student will then be instructed to stay with the patientto carry out supportive conversations. One student writes about one such caringsituation in the following way:

We sat and talked to his wife and relatives for a long time, trying to give them somesupport and helping them to get in touch with the psychiatric emergency people totalk and get support.

Caring situations in which caring science knowledge and medical knowledge aresimultaneously combined and integrated are also experienced as opportunities forlearning, e.g. as when the assignment concerns a female patient with a suspectedheart infarction. The student writes about this as follows:


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This assignment taught me a lot and demonstrates the interaction between caring sci-ence knowledge and medical knowledge. We gave quite extensive medication inaccordance with our treatment guidelines and for that we had to have good medicalknowledge in order to know what to give and why. At the same time it was importantto behave professionally, since the patient suffered anxiety and agitation, which couldbe relieved by our showing her that we were there to help her.

4. The learning process is influenced by the unpredictable caring encounter

The preparations for every new assignment include decisions as to which equipmentmust be taken along to the caring encounter, in order to prevent the lack of impor-tant equipment, e.g. equipment for cardiopulmonary resuscitation in a situation withcardiac arrest. The unpredictable caring encounter can lead to impractical behaviorsince students may be extra careful and include far too much extra equipment. Onestudent writes about her/his learning process in the following way:

My lack of experience makes me tend to want to take along more equipment than experi-enced people would. My load is much heavier than the others’ [ambulance personnel’s]!

In other caring situations, students may plan and prepare themselves for the wrongassignment, i.e. the information from the dispatch centre may turn out to be mis-leading. In that case expectations of carrying out a specific care measure will not berealised. Unpredictable caring encounters can lead to the student’s becomingincapable of doing anything during the caring encounter. Here one student describesa kind of passivity in relation to the unpredictable caring encounter:

I was not at all prepared for what was there when we arrived. My behavior in thatsituation was inadequate. I was not at all prepared for what I saw. We arrived too late.

Learning from the unpredictable thus means being confronted with unprepared car-ing situations. However, the unprepared can be experienced as a positive challengethat may actually stimulate learning. One of the students writes about this in thecase of an emergency caring situation demanding quick action:

Although I was clearly unprepared for what happened, I was not hampered in mylearning. My learning was reinforced instead since I had to act quickly without beingprepared.

The significance of reflection for being able to cope with the unpredictable is appar-ent in connection with another emergency caring situation. On this occasion too theencounter with praxis was quite different from what the information from thedispatch centre had prepared the ambulance personnel for. The information was:“Young man unconscious in connection with domestic brawl” but the student andsupervisor were confronted by a man with no vital signs at all. The woman studentreflects below over her role as a student and the feelings she experienced in relationto the totally different experiences of the ambulance personnel:

They [the ambulance personnel] soon understood that I was uncomfortable in thatsituation and they gave me plenty of time to think. For me in my role as a student,this situation was a totally different experience from that of the ambulance personnel.They did not experience the assignment as being as hard as I did. Through reflecting


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on my own and together with my supervisor, I have now understood the importanceof always being open when faced with an assignment.

5. The learning process relies on support from the supervisor

Support and guidance by the supervisor are essential to the student’s learning andthey are described as decisive for both the student and the patient, especially in caringsituations where the patient’s condition is difficult to assess. One such caring situationconcerned a dying woman in a nursing home. There was a prior decision that CPRwould not be carried out. The ambulance personnel were only there to establish thatthe patient was dead. However, when they arrived, the patient was still breathing andhad a pulse. The student describes how two supervisors wanted to make two differentdecisions. The learning situation was thus confused as is clear below:

I thought that it was a very difficult situation for everyone concerned. We were onlysupposed to establish that the patient [a woman] was dead, but now the situation wasdifferent! We could drive her to the emergency department and risk the possibility ofrelatives not being able to share a good farewell with her, or we could let her remainin her bed in the home. It was an ethical dilemma for us. My supervisors were ofdifferent opinions on the matter and that made things even more confused. It felt asthough we would have to start CPR if the patient’s heart stopped while we were there.That did not feel right. I had a lot of unanswered questions.

In this caring situation no supervision was given, the student’s questions remainedunanswered and the patient’s situation remained uncertain. In other words, thepatient’s situation and the student’s learning are parallel processes. A student writesbelow about a different caring situation, in which the student and the supervisorwere on a collision course in relation to each other concerning the care of a patientwith chest pains:

It was chaotic. I was the first to make contact and was just about to start examiningthe patient when suddenly the supervisor (S) gave the order from the other side of theroom that the patient was to sit up! // The patient’s frail body resisted a little, sheclearly had pains in her left side. It looked as though she was going to faint when shesat herself on the edge of the bed. Can’t even remember what S did next, I handedover the patient to the other two [the caring team] and started to get out the equipmentfor the electrocardiogram (ECG). “I must do an ECG before they decide on somethingeven crazier”, I thought. // In that situation I did not trust anyone any longer, I was soshocked over the decision to make her sit on the edge of the bed right in the middleof her chest pains.

The student learns by watching the caring in situations where the supervisor andother ambulance personnel seem to be busy, and for the moment the student isexcluded from the caring and the professional solidarity. This kind of supervision,when the student backs off and becomes an observer of the caring promotes areflective relationship to caring. One student describes an occasion during herpractical training when she was not qualified enough to be one of the professionals,and instead learned to meet the needs of the patient in a different way:

They had been working together for quite a while and their roles were clear. Theymade quick decisions and I felt slightly invisible in the group. Since I was not givenany “orders” about what to do, I just watched. I saw that the patient [a man] was sit-


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ting alone on the sofa. It was clear that the care-givers in the room sometimes talkedover his head. At that point it felt absolutely right just to be a fellow human being. //I didn’t do anything medical and my job was on the human level. You could say Iwas like a relative – nothing else.

In another caring situation the supervisor was described as being focused on provid-ing support for an inexperienced ambulance nurse, a new colleague on the team.This kind of supervision may hamper the student’s learning, because the studentdoes not want to compete for the attention of the supervisor. A student writes aboutthis as “I was only given lower priority. I backed off and just watched”.

Discussion

Our results show that the contextual model has been fruitful during clinical praxisin prehospital emergency care so that learning has been highlighted in a nuancedway in relation to the students’ experiences. The results also show that caring sci-ence and medical knowledge have manifestly been merged in the learning process.This result is especially obvious when the students describe emergency situations.An attitude of reflective awareness is adopted under those circumstances, showingthat the different types of knowledge content are equally valuable and that they areapplied simultaneously. An awareness of the difference between these two types ofknowledge is also apparent, i.e. caring science knowledge is paramount in the car-ing relation with the patient and medical knowledge is especially dominant whenapplying treatment measures. However, a caring relationship is required at the sametime in order to explain the aim and effects of the treatment to the patient and thenext-of-kin. The focus is thus simultaneously upon both types of knowledge, asnoted earlier by Elmqvist, Fridlund, and Ekebergh (2008), Holmberg and Fagerberg(2010), and can also be compared with Leachasseur, Lazure, and Guilbert (2011)who wrote about knowledge mobilisation. In addition, Janing (1996) noted thatmedical conditions often present as ill-defined problems, which practitioners bestare prepared for by problem solving and reflective-thinking skills. According toEkebergh (2009), the findings in this study can be understood as a form of didacticswhere theory and practice and different kinds of knowledge, i.e. knowledge incaring and medicine, are merged though reflection.

In accordance with Sullivan and Chumbley (2010), the result can be understoodas a new approach to patient care and makes it clear that didactics must be basedon the concept of the patient’s perspective. This is demonstrated for example by thestudents’ descriptions of their active participation in caring and influencing thepatients’ medical conditions. At the same time our results underline the importantfact that the patient and his/her experiences and condition are the foundation forlearning in prehospital emergency care.

According to our findings, we suggest in accordance to Berg and Kisthinios(2007) that the supervisor should not emphasise one perspective at the cost of theother, but should instead demonstrate by means of skilful didactics that both areequally valuable. The didactics of prehospital emergency care offer the opportunityfor mutual learning in which the supervisor’s attitude, by counteracting thepolarisation of different kinds of knowledge, communicates instead that the patient’sperspective constitutes both the structure and the content. The main point is that therelationship to the supervisor simultaneously reflects the learning environment aswell as the caring environment.


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However, one challenge that has been demonstrated in the learning process con-cerns caring situations that are particularly dominated by medical emergency, whenthe student’s learning does not meet an approach with the interweaving of knowl-edge types and adaptation to the patients’ perspective, i.e. caring science is missingin such care situations. This challenge exposes the students to difficulties in thelearning process involving how to relate to strongly emotional experiences includingguilt and inadequacy. These findings underline just how important it is for supervi-sion to meet the students in their own lifeworlds and with their specific needs forsupport and supervision. In other words, supervision must be adapted to the factthat the students’ previous experiences of caring with severely ill patients can vary.We should note that not all students (RN) have been employed within the EMSbefore their specialist education.

Based on the didactic model and the findings in this study, learning environmentscan be created within the caring praxis of prehospital emergency care so that themerging of caring science and medical science is focused upon, problematised andcommunicated to the students. This merging makes a critical analysis of theory andpraxis possible. For students to learn reflectively together with experienced supervi-sors in direct contact with various ambulance assignments is a way to create suchlearning environments. This form of didactics prepares students to meet human suffer-ing in different types of caring situation. Caring in prehospital emergency care is thusa type of caring that must be learnt in the company of supervisors and patients. Thesupervisor’s role appears thus to be decisive for learning, a conclusion that is inagreement with earlier research (Ekebergh, 2009; Johansson, Kaila, Ahler-Elmqvist,Leksell, Isoaho, & Saarikoski, 2010). These findings make it clear that therelationship between student and supervisor is the central factor influencing learning.

Based on these findings and in order to counteract the exclusion of studentsfrom learning situations, we suggest that students should be invited into the caringcontext with the patient and also into the professional fellowship of the prehospitalemergency care team. Learning is stimulated by the students’ active physical partici-pation in caring measures that affect the wellbeing and medical condition of thepatient. On the other hand, it is also clear that without the support of the supervisor,the student becomes invisible and her/his learning is downgraded priority-wise. Inthat situation, the student abandons caring, at the same time abandoning the caringrelationship with the patient. Both the student and the patient are put in an exposedposition. The student loses confidence in the supervisor and it is probable that thepatient loses confidence in the student as a care-giver. It would appear thatsupervision should be aimed at making students into active participators in actualcaring situations, in other words that the patient and his/her experiences constitutethe foundation for learning.

However, in this context one particular challenge to the learning process hasbeen shown. The findings also show that even the supervisor may constitute anobstacle to learning, when the student with her/his own professional responsibilityas a registered nurse and the supervising nurse do not share the same approach tocaring. This particular finding is in accordance with Berg and Kisthinios (2007)who report that only three-quarters of supervisors stated a use of theoretical nursingperspective. Further, our findings show that the student abandons her/his own con-victions in that kind of situation, to adopt instead the approach of the supervisor,even though this may be less appropriate to the patient’s lifeworld. Consequently, ashaky relationship with the supervisor can complicate and perhaps even prevent a


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caring relationship with the patient. The learning process in caring relationshipsinvolves handling powerful feelings characterised by competence and strength butalso with ingredients of incompetence and ineptitude.

We suggest that this challenge should receive more attention in the EMS, seenin the light of our findings and the fact that specialist ambulance nurses’ caringwork is naturally enough independent and relatively solitary. Specialist ambulancenurses’ particular responsibility concerning caring assessment has special implica-tions in prehospital emergency care. It is thus of central importance in prehospitalemergency care for learning to be a process of preparation for autonomous caringwith great responsibility for assessing the patients’ needs. It is therefore of thegreatest possible significance to choose supervisors who can not only supervise butwho also have a caring approach, grounded in caring science.

Furthermore, the findings show that this didactic model can be seen as criticalthinking in education (Pithers and Soden, 2000), and supports a learning processwhose ultimate goal is that the student will be able to be prepared for the unpredict-able, by which is meant an openness to the uniqueness of the patient and her/hisneed for prehospital emergency care (Wireklint Sundström and Dahlberg, 2011).Thus the preconditions of prehospital emergency care with their character of unpre-dictability in the caring encounter make demands of openness in the encounter withevery new patient. A didactic balancing act can enable a student to develop acapacity for rapid, action-based behaviour, i.e. to be able to provide medical helpwith a caring science approach when the patient is suffering from a life-threateningcondition. This didactic model means that preconditions can also be created for aperson of ability to encounter the patient with thoughtfulness on an existential level.It is thus clear that the unpredictability of the caring situation creates awarenessabout the need for openness when confronting the patient’s care needs.

However, one specific challenge to the learning process was demonstratedregarding openness in prehospital emergency care. It became evident that the emer-gency medical atmosphere and fixed routines for making rapid decisions canobstruct the possibilities of maintaining an open approach. Based on these findingswe suggest that students need training in how to maintain an open approach toinformation from the dispatch centre and, if possible to, creating conditions underwhich they can listen to the patients’ stories – before any decisions about caring aremade. This has been shown to be a significant part of the didactic model. Supervi-sion in situations involving closeness to patients is based on the experiences of thepatients, and this creates possibilities for encounters between the students’ andpatients’ lifeworlds. The supervisor is thus seen to be a significant factor in creatingbalance in the dialogue so that it will become a meaningful encounter for bothstudent and patient. The student who is learning must be trained to have a caringapproach that will affirm the patient’s participation, and simultaneously reject anyapproach that is merely routine and unreflective during caring assessment.

Earlier research discusses the effects of reflection on the learning process in rela-tion to the student’s lifeworld (Gustafsson et al., 2007; Ekebergh, 2009), in relationto the context (Jones, 2008; Campeau, 2008), and in relation to self-reported medi-cation errors (Vilke et al., 2007). This study, which tests a didactic model based onthe prehospital context, demonstrates that the students had developed a reflectiveattitude as described by Ekebergh (2007). Consequently it becomes apparent thatthe student’s lifeworld is decisive for the learning processes that occur in intimateconjunction with it. And finally, this result is a unique addition to further research


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on the development of knowledge in caring science and the nursing profession asspecialist ambulance nurses.

Conclusions

The results of our research emphasise the significance of a didactic model, pre-sented in the form of three didactic ideas, building on the specific preconditionsprevailing in the learning context. The model generates knowledge that underlinesthe importance of the encounter with the patient in a care-giving context in theprehospital environment, making it possible for the student to be able to developunderstanding and to learn caring assessment in prehospital emergency care. Thus itis in the encounter with the patient that one’s knowledge and skills develop!

Recommendation for future research

To make further advances in the knowledge about the learning process inprehospital emergency care, more research is needed in the future. One of the mostimportant questions to continue with is: “How can the caring science perspective inacute and emergency-dominated care be developed even more markedly andstrongly?” This research question is of extra importance since simulated clinicalscenarios and simulation learning are undergoing intensive development as a newdidactic model, a development partly at the cost of clinical practice.

Implications for learning practice

In order to harmonise with the findings achieved in this study the student mustreceive support:

• in order to acquire an open approach to information from the dispatch centre,and in order never to take anything for granted before the caring encounterwith the patient

• for an inclusive approach allowing caring science knowledge and medicalknowledge to be applied in a natural way at the same time and in all caringsituations

• for applying an explicitly patient-orientated/lifeworld-orientated perspectiveeven in medically advanced emergency situations.

And further, as a decisive factor in the student’s learning process, attention mustbe paid to:

• the co-operation with the EMS, their chiefs and their specialist ambulancenurses;

• the supervisor’s approach and support in caring situations and• education for supervisors.

AcknowledgementsThe authors gratefully acknowledge the agreement given by the students and the two courseteachers to this study and their co-operation in gathering in the examination papers.


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Note1. In this paper “didactic” is used with the meaning of “learning support” as implies a con-

frontation between the student’s lifeworld, the caring science and the patient’s lived world.

Notes on contributorsBirgitta Wireklint Sundström, RN, PhD, is an assistant professor in caring science at Schoolof Health Sciences, University of Borås. The author’s research interests are learning incaring science within in the context of pre-hospital emergency care. The author has currentlydeveloped “Competence Description for Registred Nurse with Postgraduate Diploma inSpcialist Nursing – Prehospital Emergency Care (2012)”, by order of the SwedishAssociation for Ambulance Nurses – SAAN, Stockholm, Sweden.

Margaretha Ekebergh, RN, PhD, is a professor in caring science at University of Borås,School of Health Sciences and a visiting professor at Linnaeus university, School of Healthand Caring Science. She is the head of the Centre of Health, Learning and Reflection inHeath Care. Within this centre, her research focus is on the intertwining process of caringtheory and caring praxis with the learner’s lifeworld. An overall theme is, Creatinginnovative environments that bridging the theory – practice gap: the interaction betweencaring and learning.

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How caring assessment is learnt – reflective writing on the examination of Specialist Ambulance...

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