Executive summary

This education quality intervention was conducted to follow up on education quality concerns identified for paramedic learners in practice placements via a national thematic review of paramedic training undertaken by the former Health Education England (HEE) in 2022 (unpublished). These concerns related to preparation for placements; inconsistent supervision; feeling valued as learners; and unprofessional and inappropriate behaviours by staff.

This review process heard from a total of 277 paramedic learners across eight learner focus groups, seven of which were conducted in person (direct entry) and one using online meetings (apprentices). This represents 58.8% of the second- and third-year direct entry learners (student numbers data source: NHS England student data dashboard Oct 2023), all of whom were invited to participate in the review (first year learners were not invited due to their limited time in placement at the time of the review). The virtual session for apprentice learners was poorly attended, with only two learners giving their feedback on placement experiences.

Each focus group was facilitated by at least three members of the NHS England South East Education Quality Team and/or Clinical Professions Team. All eight focus groups had a lay representative present to observe the process to ensure it was fair and equitable and followed national standard operating procedure for interventions.

The feedback from learners was generally positive regarding their experience on placement at SECAmb, and a majority would recommend SECAmb for their training and intended to seek employment there post qualification. The review team heard about numerous examples of positive experiences in clinical placements, but also examples of inadequate and inconsistent supervision, lack of contact time with practice educators, learners experiencing unprofessional and inappropriate behaviour from paramedic staff within SECAmb. Learners also reported a perceived lack of learning opportunities, and of clinical staff lacking understanding of their scope of practice in non-ambulance placements organised by HEIs.

The key themes that arose across the learner focus groups related to unwarranted variation around various aspects of learners’ experience of placement supervision; the quality and relevance of non-ambulance placements; and feeling valued on placement including witnessing or experiencing unprofessional behaviours, bullying, undermining and harassment. A secondary theme emerged around the impact of systems of rostering within SECAmb on learner experience of placement, supervision and work/ life balance, particularly for mature students and learners with family and other commitments. Learners reported a change from being able to book shifts to having them directly scheduled having a negative impact on their ability to earn money, fulfil caring commitments and tend to aspects of life outside of their paramedic training. The review team also heard from learners describing arriving for shifts only to be informed there was no crew available to go out on the road with, therefore having to return home, and learners having to commute long distances for some placements considerably extending the length of their day and contributing to fatigue.

The review team offer the following recommendations to SECAmb to improve the quality of the learning environment for their learners on placement:

1. SECAmb to undertake evaluation of new rostering system for learners with feedback obtained from learners. We recommend SECAmb undertake biannual reviews of the oversight and coordination of paramedic student placements, informed by student experience and report as part of their governance processes to enable progress to be reviewed.
2. Clarify and document scope of practice for learners at different stages of training to enable quick reference and clarity for practice educators to assist learners’ attainment of learning objectives during both ambulance and interprofessional placements.
3. Students situated in the back of the ambulance on calls should be updated on route by the most appropriate method to enable learners to feel prepared for what they may encounter and to promote psychological safety of learners on placement.
4. SECAmb to promote learners’ awareness of the Sexual Safety Charter and any changes SECAmb have/ will implement as a result of signing the charter.
5. Consider a tripartite partnership approach (SECAmb, Higher Education Institutions and NHSE WT&E) when investigating/responding to concerns raised by learners, to better assure learners regarding impartiality and increase learners’ trust in this process.
6. Recommend that SECAmb commit to implementing Safe Learning Environment Charter (SLEC) in their clinical learning environments.
7. We recommend SECAmb work in partnership with HEIs to ensure regular and anonymous student feedback is sought, obtained and reviewed to inform effective placement experiences for learners.

NHS England WT&E will continue to follow up and monitor the progress to implement these recommendations and identify and develop outcomes in partnership with SECAmb and other stakeholders via the bi-monthly KSS Paramedic Education Partnership Forum. Progress and improvement will also be monitored and shared via this forum.

Review overview

Background to the review

In 2022 the former Health Education England (HEE) undertook a National Thematic Review of Paramedic Training (unpublished).  

The subsequent report highlighted several education quality concerns nationally:

• The negative impact on training (and on psychological wellbeing) of delays in ambulance handovers to emergency departments, along with wider service pressures and staffing issues.
• Inconsistent induction to clinical placements.

Inconsistency in quality of placement supervision and practice educator allocation, compounded by challenged supervision capacity.

Suboptimal utilisation of the potential breadth of placement environments, across all pillars of practice.

Significant cultural issues in some practice environments, with reports of undermining and discriminatory behaviour which cannot be ignored. There were some indications that this behaviour is normalised, accepted, and under-reported.

The thematic review included a range of recommendations around maximising educational opportunities, standardising curriculum requirements, delivering parity of experience for direct entry students and apprentices, addressing cultural issues, establishing more effective communication between HEIs and trusts, strengthening the preceptorship and support offer for newly qualified paramedics, enhancing educator/supervisor support, ensuring mechanisms to raise concerns have effective feedback loops, and improving induction.

NHS England Workforce, Training and Education Southeast Quality Team: Kent, Surrey and Sussex (WT&E KSS Quality) undertook the review reported here to follow up on these education quality concerns and gauge learners’ experience of their clinical placements in South East Coast Ambulance Service (SECAmb) across 2023.

Who we met with

Paramedic pre-registration learners across eight individual focus groups arranged by cohort:

• Second and third year pre-registration undergraduate paramedic learners linked to the following Higher Education Institutions (HEIs): University of Brighton (UoB), Canterbury Christchurch University (CCCU), University of Greenwich (UoG) and University of Surrey (UoS).
• Pre-registration apprentice paramedic learners who are linked with the University of Cumbria (UoC) and employed by SECAmb.

Educators:

• N/A

Education team:

• N/A

Evidence utilised

• NHS England National Thematic Review of Paramedic Training (2023 unpublished).
• Known HEI placement concerns reported to KSS Education Quality team since 2021.
• National Education and Training Survey (NETS) 2023.
• NHS England / SECAmb / HEI education partnership forum meeting notes.

Review panel

• Education Quality Lead for Clinical Placements, Kent, Surrey and Sussex, NHS England South East – Workforce Training & Education, Adrian Dessent, Education Quality Review Lead
• AHP Senior Workforce and Education Specialist – Urgent and Emergency Care (WT&E), NHS England South East, Andy Sharman, Allied Health Professions Representative
• Education Quality Project Officer, NHS England South East – Workforce Training & Education, Sarah Stanbridge, Quality Representative
• Education Quality Project Officer, NHS England South East – Workforce Training & Education, Alex Bamford- Blake, Quality Representative
• Quality Intelligence Manager, South East, NHS England – Workforce, Training and Education Directorate, Amelia Amon, Quality Representative
• Lay Representative, Martin Brand
• Lay Representative, Sallie Nicholas        

Review findings

1. Supervision

The review team heard from learners around significant variation between practice educators (PEd) regarding their attitudes and approach to providing supervision. There were many comments around the influence of individual relationships with PEds and the impact this can have on learners’ overall placement experience. Many practice educators were described as flexible and engaged with learners, they offered the benefit of their practice experience and were proactive in utilising learning opportunities with students.

The majority of PEds were described by learners to be supportive. However, it was fed back that a significant minority of practice educators appeared to not want to supervise students on placement, this was experienced as PEds being disinterested and disengaged around learners. Learners reported the perception that some PEds dislike students and/or did not want to be practice educators but were obligated to do so as part of having an Agenda for Change Band 6 role. 

“There are some great paramedics that teach you, the odd few that spoil it.”

Service pressures were reported to have a detrimental effect on learners’ practice experience. Respondents reported difficulties in booking shifts with their allocated PEds, particularly if their PEd had more than one assigned student, or if the paramedic worked part time. Some learners reported a sense of feeling in competition for practice supervision time with international paramedics and other learners.

“Shortage of Band 6 (paramedics) in SECAmb means that some get assigned part time mentors and some full time, means those with full time have better experience. Part time there is restriction as to what hours they can work with (learners), causes inconsistency.”

Learners also reported experiencing placement issues if their named PEd was unexpectedly absent from work. Learners reported being sent home from shifts when their PEd reported sickness absences and a lack of responsiveness from practice education leads when learners were experiencing issues regarding contact time with a practice supervisor despite SECAmb having processes in place to escalate this type of concern.

“Would take three weeks to reply to email. Another 3 weeks for him (practice education lead) to actually do what you have asked him to do.”

“Last year my mentor was off sick for very long time and then became an OTL (operational team lead), emailed practice (education) lead but didn’t get a new mentor. Emailed multiple times asking for a new mentor but told no.” 

Learners also fed back experiencing variability in the approach of practice educators with regards to signing off practice assessment documentation (PADs), either in terms of finding time during shifts to do this, or interpretation of what level of proficiency students should have achieved to be signed off, or how much of the PAD PEds expected students to complete themselves. Regarding the latter point, students highlighted that there had been a recent change in the processes for PAD sign off, with students no longer being able to edit the document. It was suggested by learners that this variability between educators may relate to their educational route into paramedicine, with some of those trained longer ago being less familiar with the workings of the university direct entry training route. 

Some students highlighted a perceived lack of allocated/protected time for PEds to sign off documentation during work hours, although it was fed back by some learners that PEds have 10 hours protected time per month to attend to this. It was reported that some practice supervisors still did not allocate sufficient time to sign off PAD, and this was reported to generate a degree of stress and anxiety by some learners relating to the successful progression of their training programme.

Learners perceived that some PEds had not received adequate training/familiarisation with regards to the e-portfolio (PAD), noting that each HEI used different documentation, and suggested this may be useful for practice educators. It was also suggested by learners that there was a need for improved communication between the university and SECAmb with regards to this variation between practice educators in terms of expectations for signing off skills and understanding of learners’ scope of practice across the span of their training. There was a suggestion that it would be useful if students were able to attend the key skills sessions at SECAmb with their PEds, it was also suggested that students were unable to give formal feedback to practice educators and that they would have liked to be able to share the positive experiences they had with supervisors.

Some learners fed back their experience that supervisors often demonstrated a wide variation in terms of their interpretation of learner’s scope of practice whilst on placement. Some instances were shared of supervisors being reluctant to let learners undertake tasks and procedures necessary to their training and within their scope of practice, at other times some learners felt pushed to undertake procedures they did not feel confident in or ready for at their stage of training.

“Each paramedic has different opinion of what you can or can’t do, first observational shift, mentor wanted me to cannulate which I didn’t feel comfortable to do and pressured me in front of the patient.”

2. Induction

Learners fed back that the initial formal induction at SECAmb was well delivered and was well received by students, it included meeting with educational leads, familiarisation with equipment, assessments, basic life support and information and materials regarding raising concerns and freedom to speak up (FTSU) guardians. Some learners reported a lag between induction and beginning observational placements and a preference for them to have been closer together while the information was fresh in their mind.

It was reported by learners that formal induction to SECAmb was undertaken in their first year only, first year students received a five day clinical induction with SECAmb, there is a half day refresher organised for year two and year three students, usually on university campus which covers organisational updates, mandatory and statutory training and Freedom to Speak Up information. Students explained there were no formal inductions to ambulance stations and informal inductions in new clinical areas depended on the PEd and thus could vary in consistency. Feedback from learners suggested a desire for first year students to spend time at a make-ready centre to familiarise themselves with equipment. There were also concerns raised around a lack of induction to the new Fiat ambulances (as opposed to Mercedes) which are laid out differently.

“In the back of Fiats the hatch is high up and you can’t see out or know what we are going to, have no geographical awareness. Other times they give a radio or briefing of what’s going on”.

Inconsistency in experiences of induction for interprofessional placements were reported by learners, they recounted difficulties in confirming details regarding interprofessional placements prior to starting and some students reported having these placements cancelled at short notice, resulting in missed learning opportunities. Inductions to interprofessional placements were reported by several learners to often be unsatisfactory and were felt to demonstrate a lack of understanding of paramedic student competencies, learning objectives and scope of practice by staff in these clinical learning environments.

3. Bullying and undermining

Most learners questioned reported a supportive attitude from the majority of SECAmb staff. Positive examples were shared regarding the support provided by some individual PEds, such as actively checking in with students after a difficult job and efforts to ensure students’ safety where there was a perceived risk due to an individual patient’s reputation or previous experience. However, many learners reported experiencing dismissive and/ or derogatory attitudes towards learners from some staff at SECAmb.

It was reported that undermining behaviours within SECAmb could be subtle, and many learners were aware of this. 

“It is out there, you do see it. It wasn’t someone I was with, just heard it, never experienced myself.”

For example, many learners referred to how they were addressed and introduced as an important issue, such as being referred to as “The Student” rather than being addressed or introduced by name.

“…with really good crews you don’t get it, (I worry that) it erodes patient confidence in what you are doing, affecting patient care.”

“It sucks when paramedic is always calling you ‘the student’ instead of using your name. It puts you in a hierarchy. Even though educationally they are higher than us, you want to feel part of a team.”

Several learners referred to experiencing crew members talking disparagingly about other students and colleagues within SECAmb whilst in their presence. Some students explained this made them feel uncomfortable and concerned about what paramedics might be saying about them to others. Some examples were shared with the review team where students had felt bullied or not included by particular individuals on ambulance placements. 

“Have been called the little girl, little one, a dumb blonde. Not all the time, but there are odd people I don’t feel comfortable working with anymore.”

“Some people will come up to you and say ‘How old are you, you look really young’. I’m 18/19. They say ‘Should you be here?’ it’s meant as a joke, but it still makes you question do they respect me?”

More concerningly, the review team heard from learners describing examples of a number of inappropriate and unprofessional behaviours exhibited by a small minority of paramedics towards students. These included unwanted physical contact, initiating contact via social media and making a sexually inappropriate suggestion to a learner on placement. An example where a paramedic had been using sexually inappropriate language to students was reported to have been resolved by SECAmb to the learner’s satisfaction, however the instances of these experiences were reported by learners to have often been dismissed by SECAmb staff as “banter”. These instances were recognised by a majority of learners as taking place within learning environments at SECAmb.

Several other examples, as summarised below, were shared in response to this question, although it was reported that the majority of paramedics did not demonstrate these behaviours, nonetheless the review team strongly feel learners should never be subjected to this kind of experience albeit from a small minority of staff.

• One student reported they had experienced homophobia from some paramedics which had made them feel they had to be mindful of what they were saying to avoid disclosing their sexuality.
• A learner reported comments suggesting a lack of understanding around autism.
• Insensitive comments around eating behaviours.
• An inappropriate response to a genuine question asked by a student in relation to non-binary people.

In relation to experiencing unwarranted behaviour from SECAmb staff, some learners expressed concerns about speaking out due to fear of repercussions for the learner on placement and potential for negatively impacting their training and future employment.  

In addition, several examples of undermining experienced from nursing staff during handovers were shared by learners in relation to this line of enquiry: 

“(I) have experienced nurses getting frustrated with (the) quality of handover where I have been starting off”.

“(I) Had a nurse get very angry that I had brought the patient in before the area was cleaned, I was doing what I had been told (by practice educator), the nurse lashed out.”

“There are nurses that flat out ignore you talking about handover and they just walk off. My old mentor told me keep it short otherwise they won’t listen to you.”

4. Raising concerns

Responses indicated that learners were made aware of the channels to raise concerns and of the freedom to speak up (FTSU) guardian before their first clinical placement, as this was covered at the SECAmb induction and one student shared positive feedback on their experience of raising a concern with SECAmb.

“They gave us all leaflets (at SECAmb induction) to take home with different guidelines (they) included FTSU”

Some comments indicated that there was still scope to improve communication and access to routes to raise concerns, for example one student reported they often did not know who their operational team lead was. A majority of students reported that, depending on nature of the concern, they felt comfortable they could approach their PEd or the university. 

Although SECAmb equipped learners with information regarding processes to raise concerns, many students indicated they would feel reluctant to raise a concern. Many students commented on the perceived negative implications for their education and future career of raising concerns about aspects of the clinical learning environment at SECAmb, particularly if they would have to change PEds or be moved to a different ambulance station. This has the potential to inhibit learners’ flagging poor practice or quality issues whilst on placements at SECAmb.

“If I knew I could provide actual proof would feel a lot more comfortable, but if going off hearsay… if I knew directly it wouldn’t get straight back to me, I would feel a lot more comfortable.”

When concerns were raised, one student shared they had received a positive experience with regards to the way SECAmb managed a concern they had raised, however feedback indicated many students did not feel the concerns they raised were satisfactorily resolved and, in several cases, students reported they had not felt adequately supported. 

5. Sexual Safety Charter (AACE)

Most students, although by no means all, when questioned were not aware of the Sexual Safety Charter or any actions SECAmb may be taking in response to the AACE report. When asked if they were aware of misogyny and sexual safety being an issue in SECAmb, examples were shared relating to behaviours of male patients and it was reported that in most cases paramedics would recognise the behaviours and take steps to call this out or remove the student paramedic from the situation. 

One student reported that around one year ago SECAmb had initiated some training programmes for people to become PEds to signpost people to support around sexual safety in the workplace, however, to their knowledge, this had not yet been implemented. One student commented that they had seen posters on the back of the toilet door at their ambulance station relating to the theme of sexual safety. 

Some students reported to have perceived an increased awareness among SECAmb crew members in terms of appropriate behaviours and efforts to ensure that students felt comfortable in particular situations. 

6. Feeling valued

Generally, students reported a sense of feeling valued at SECAmb, the review team heard feedback regarding how students experienced feeling part of a team and included in decision-making whilst on ambulance placements. Learners also spoke highly of several parts of the organisation.

“I think the safeguarding team in SECAmb are particularly good – at least every interaction I’ve had.”

However, a theme around a wide variation of experiences and treatment across different clinical learning environments and with different colleagues emerged from the discussions.

“Depends on crew- some will ask if you want to sit in front now, swap over, makes it worse if you don’t know who you’re going to get on shift.” 

Responses indicated that students on ambulance placements typically felt well supported, and their safety was proactively prioritised in cases where patient’s behaviour might pose a risk, however one student shared an experience where they had felt unsupported during a hospital placement when they had raised concerns about their safety in response to a patient’s behaviour. 

The degree to which learners felt valued on placement was clearly impacted by the degree of unwarranted variation of experience they encountered.

“With a lot of paramedics, you will sit in front. If there is some opportunity to look at notes, you learn so much more, feel more prepared, a much better experience. A lot of time you work with different people not interested in having students, just sit in the back (of the ambulance).”

Whilst the majority of the learners’ placement experiences were described as supportive of their learning, there were many instances fed back to the review team of unacceptable inconsistency between paramedics/crews in terms of how they interact with and involve students during shift. This was perceived by learners as negatively impacting on their learning opportunities and strayed, at times, into what would be considered unprofessional, bullying or undermining behaviours.

Several learners described being in the back of the ambulance without access to a radio when attending a call, this was described as leaving them feeling isolated, unprepared and uncertain about what may be awaiting the crew on arrival.

“My very first arrest went to, (it took) quite an emotional toll, didn’t know it was an arrest until we got there, no time to prepare, no communication from the front, didn’t have a radio as they asked for it back, made it worse as no time to prepare. After (the call) there was no talk about whether that was ok or if I was ok. No check ins. Entire time I felt like a spare part as I didn’t really know what was going on. Would have been beneficial to be told we were going to an arrest. Afterwards I should have been asked if I was ok as I was not ok.”

While several learners reported being responded to in ways which left them feeling devalued, the review team also heard of positive examples of caretaking of learners, another student (talking about the first arrest they had attended) responded:

“I had great aftercare (from crew).”

7. Interprofessional placements

A general theme emerged during the focus groups around a lack of structured induction to interprofessional placements (placements undertaken outside of SECAmb sites), although this is not the responsibility of SECAMb, it emerged as a key theme in all focus groups for undergraduate learners. It has been included in this report due to the perceived impact on Paramedic learner education, as an issue to highlight for education providers and to acknowledge the learners’ feedback regarding their experience of a challenging aspect of their practice education. This theme will be followed up with HEIs by NHSE via the bi monthly Paramedic Education Partnership Forum.  

Undergraduate learners reported a perceived lack of understanding from other professions of why paramedic students have been placed in particular learning environments and that clinicians outside of paramedicine were often unfamiliar with the paramedic learners’ scope of practice and students’ learning outcomes whilst on their interprofessional placements. Some students shared their experiences of being asked and feeling pressurised to perform tasks outside their scope of practice on interprofessional placements. 

Several examples of negative experiences during hospital placements were shared and a theme emerged around a perceived comparative lack of learning opportunities during hospital placements when compared with ambulance placements and competition with other learner groups for practice experiences. This was suggested by many to relate to a lack of awareness of paramedic student competencies and placement learning outcomes and the relatively short period of time spent in each hospital placement for staff to develop this understanding. Some students reported feeling less valued by staff on interprofessional placements, although other learners reported very positive experience of these placements, and it was felt by many learners that there was a need for more guidance for other clinicians on the role and scope of the modern paramedic.

Many students reported feeling more part of the team during ambulance placements compared with interprofessional placements, albeit with some exceptions, however students did appear to recognise that the relatively short period of time spent at each hospital placement may make it more difficult to build rapport with staff and demonstrate competency to be enabled to practice certain clinical skills. Generally, students described a disparity in the perceived quality of their experiences between interprofessional and ambulance placements, although some variability was noted as some students had described very positive experiences in both settings.

8. Rota design

A parallel theme emerged outside of the review team’s key lines of enquiry around rostering for placements. Learners highlighted changes to the shift booking system for direct entry learners, they reported a lack of consultation with students before implementation and perceived disregard by SECAmb and the universities for the impact on students’ personal circumstances. This emerged as a strong theme in terms of students not feeling valued and impacted on their perceived experience of clinical placements and supervision. 

The review team heard comments around a perceived lack of regard for travel times/distances for students when allocated placements and the impact this had on learners in terms of length of the day and commuting expenses.

The review team also heard learners describe challenges with rostering of shifts. Changes to the shift booking system this year were reported to have resulted in students not being booked shifts with their assigned PEds even when they are both free and delays in getting skills signed off, learners highlighted difficulties booking enough shifts with their PEds in some cases and some learners expressed frustration that booked shifts may sometimes be cancelled at short notice. Several learners reported arriving for shifts but having no available crew to go out with.

“Don’t know who is going to be in, or if they have been assigned to someone else. More unreliable than it needs to be, so we are more stressed.”

Some students had experienced difficulties in booking shifts with their practice educator, for example due to the practice educator having booked annual leave or being booked on shifts with third year students or international paramedics. Students perceived this had been exacerbated by a communication issue whereby some practice educators had not been notified that they had been allocated a student. 

Despite feedback indicating some anxieties around changes to the shift booking system, students recognised the intended benefit of having more shifts with their PEds (examples had been shared of reported difficulties previously in booking enough shifts with their assigned PEds under the prior rostering system), some students expressed they appreciated the opportunity to work with other paramedics and experience different styles and approaches to the role.

Areas for improvement

Recommendations

Recommendations will not be included within any mandatory requirements for the placement provider in terms of action plans or timeframe. They may however be raised at any future reviews or conversations with the placement provider in terms of evaluating whether they have resulted in any beneficial outcome.

NHS England WT&E will continue to follow up and monitor the progress to implement these recommendations and identify and develop outcomes in partnership with SECAmb and other stakeholders via the bi-monthly KSS Paramedic Education Partnership Forum hosted by NHSE. Progress and improvement will also be supported and evaluated alongside other key stakeholders via this forum.

Report approval

Report completed by: Adrian Dessent, Education Quality Lead for Clinical Placements, Kent, Surrey and Sussex, NHS England South East – Workforce Training and Education
Review lead: Adrian Dessent
Date approved by review lead: 21st May 2024

NHS England authorised signature: Dr Paul Sadler, Regional Postgraduate Dean
Date authorised: 26th July 2024

Final report submitted to organisation: 22nd August 2024

Publication reference: PRN01548