Nurse preceptors' experience‐based strategies for supporting learning in the ambulance service—A combined focus group and dyadic interview study

Ambulance service (AS) clinicians, including registered nurses (RN), describe their prehospital work as multifaceted and highly demanding, requiring additional skills to those needed in other nursing contexts (Reay et al., 2018; Rosén et al., 2017), with for example field experience and specific ambulance care training as pivotal for supporting the desired competencies (Andersson et al., 2019; Bennett et al., 2021). Furthermore, the design of educational programmes for students and novice clinicians and the desired competence for work in the AS have been debated in the literature. This is due to a need for adjustments generated by societal changes that affect the professional role, responsibilities and the scope of practice in this field (Jensen, 2020; Plummer, 2017; Wihlborg, 2018). However, the strategies to face these societal changes when organizing, regulating and planning the educational development for AS clinicians differ between countries.

Sweden is one of the few European countries where the university-trained RN is considered to have the most suitable basic competence for meeting contemporary and future patient needs in ambulance care. The Swedish advanced life support (ALS) ambulances are staffed with at least one RN, and the Swedish AS has increased the proportion of RNs during the last two decades, thus now constituting a majority of the ambulance workforce. The RNs have two educational pathways for working in the AS. First, RNs can be employed as university-trained RNs (3-year bachelor's degree) followed by a vocational introduction in the AS for 4–6 weeks. Second, university-trained specialist RNs are qualified for employment after a 1-year education programme. At the end of this additional fourth specialist year (master's level in ambulance care) the students undergo 8–10 weeks of clinical practice. The RNs work as a third colleague together with the ambulance crew during the vocational introduction and the clinical practice. A clinically experienced RN or specialist RN (henceforth referred to as a nurse preceptor) is in these situations responsible for supporting these two groups of RNs in their learning and achievement of independence.

In contrast to the statutory formal competence requirements for employment in the Swedish AS, there is no detailed information outlining the specific training or desired competence of the nurse preceptor and research concerning the nurse preceptor role in the AS is lacking. This is problematical since previous research has identified several barriers for learning in the AS when supervising specialist nursing students and introducing new staff into the workforce (Kennedy et al., 2015; Wallin et al., 2020). However, some research findings indicate that experienced preceptors develop strategies to adjust for the complexities in the AS learning environment (Carver and Lazarsfeld-Jensen, 2018; Wallin et al., 2020). Deficiencies in the competence of nurse preceptors have been reported by Swedish government agencies, and this study thus focuses on clarifying AS nurse preceptors' strategies for supporting learning in a challenging learning environment.

1.1 Background

The educational background of clinicians working in the AS varies internationally. The paramedic system is predominant in most English-speaking countries, with both vocational and university-based educational pathways (Carver and Lazarsfeld-Jensen, 2018; Jensen, 2020). On the other hand, European countries such as Sweden, Finland, the Netherlands and Belgium advocate the university-trained RN for staffing ambulances (Wihlborg, 2018). However, there are also trends towards staffing ambulances with RNs in countries with paramedic systems, for example, in Australia and the UK, (Plummer, 2017; Williams, 2012) and there are ongoing discussions about the length and content of the educational programmes for AS clinicians in the United States (Jensen, 2020). These trends are linked to reports of an expanding and changing scope of practice, roles and responsibilities (Jensen, 2020; Plummer, 2017; Rosén et al., 2017), related to new societal demands and increasing utilization of ALS ambulances and of emergency department attendances during the last decades. The contributory factors for these changes in demands have been proposed as pertaining to an ageing population, changes in the organization of primary health care, a decline in general health, changes in health awareness and public expectations of the AS (Lowthian et al., 2011). The historical role of the AS consisted primarily of a competence, the focus of which was on life-saving skills in a protocol-driven practice (Jensen, 2020; Wihlborg, 2018), This is thus changing and has been described as multifaceted and unclear, comprising a wide range of low acuity prehospital healthcare needs (Rosén et al., 2017). The contemporary role of the AS clinician is thus evolving with increasing responsibilities in terms of advanced assessments and care for an expanding group of patients with non-specific symptoms. This then generates the need to take nursing and medical decisions of a demanding, complex and ethical nature about referrals to alternative healthcare, and decisions whether to convey or not to convey patients (Lederman et al., 2019). The need for supporting the development of non-technical skills such as clinical decision-making, parallel the retention of the traditional life-saving skills, has thus been emphasized as fundamental for upholding patient safety in the AS (Bennett et al., 2021; Wihlborg, 2018). Consequently, there is an ongoing debate in several countries concerning the most desired competence and optimal educational pathway for clinicians working in the AS (Jensen, 2020; Plummer, 2017; Wihlborg, 2018).

Strategies for educating clinicians in the AS could be addressed in different ways based on an educational theory perspective and on strategies for learning. Moreover the methods used to achieve the expected outcome can be affected depending on the perspective (Mukhalalati & Taylor, 2019). However, different educational perspectives and strategies for learning must be reflected in the educational system for healthcare clinicians to support the development of the desired competencies (Jeppesen et al., 2017; Mukhalalati & Taylor, 2019). Clinicians in the AS describe it as a highly dynamic and stressful environment, where having the responsibility for medical assessments and urgent decisions in isolated places are a common occurrence (Reay et al., 2018; Rosén et al., 2017). The need for flexibility and a clinical decision-making competence are emphasized for maintaining patient safety (Andersson et al., 2019). An increasing need for non-technical skills, for example, communication, clinical reasoning, teamwork, situational awareness and leadership, are thus reported as being fundamental parts of the competencies required in the AS (Andersson et al., 2019; Bennett et al., 2021; Perona et al., 2019; Wihlborg, 2018). To support the development of these competencies in the AS, ambulance nurses themselves (Wihlborg, 2018) and paramedic students (Kennedy et al., 2015) have emphasized the importance of workplace experience and clinical practice. This is in line with the extensive international literature on learning for nursing students, indicating that clinical practice is fundamental for the development of a professional identity, clinical competence and clinical reasoning abilities (Jeppesen et al., 2017). However, there are studies indicating that nurse preceptors in healthcare education are ambiguous concerning strategies for supporting learning in hospital contexts (Trede et al., 2016), and lack knowledge about theoretical educational perspectives, thus risking the education quality and the effectiveness of learning (Mukhalalati & Taylor, 2019).

Swedish ALS ambulances are staffed with at least one RN, primarily to enable the administration of drugs. The other team member is a paramedic, RN or a specialist-trained RN. Approximately 65%–90% of the Swedish AS clinicians in 2019 were RNs or specialist-trained RNs. An increasing number of AS regions are demanding specialist training for employment, which is in line with the recommendations of the Swedish National Association for Ambulance Nurses and the Swedish Society of Nursing, but there is at present no national legislation demanding RNs to complete specialist training for employment in the Swedish AS (Wihlborg, 2018). There are no national regulations distinguishing between RNs and specialized RNs in terms of the roles and responsibilities in the AS. Nurse preceptors may or may not be specialized when supporting newly graduated RNs and specialist nursing students' learning during clinical practice in a supernumerary ambulance team. These nurse preceptors are clinically experienced ambulance nurses, selected by the ambulance department and some of them have completed an additional 7.5 credits university-based course in supervision. This course is, however, not mandatory and there are no national guidelines for the content or scope of the preceptor courses, and there is a lack of a national overview of the nurse preceptors' educational role. There is thus a need to address the nurse preceptor role in the Swedish AS as there are no contextualized legal documents regulating teaching and learning, no national Swedish standards for preceptor training, while there are national reports claiming a lack of quality concerning clinical practice. Several research studies report of environmental barriers and challenges for learning in terms of negative workplace attitudes (Lazarsfeld-Jensen et al., 2014), exposure to violence (Boyle & McKenna, 2017), high emotional demands (Williams, 2013) and limited learning opportunities (Kennedy et al., 2015) in the AS context. The literature concerning preceptors in the AS is limited (Carver and Lazarsfeld-Jensen, 2018), but some studies indicate that there is sufficient experienced-based knowledge among preceptors to adjust for challenges that occur when supporting learning in the AS (Carver and Lazarsfeld-Jensen, 2018; Wallin et al., 2020). To support the educational alignment between university studies and clinical practice, to support new preceptors and to enhance the learning environment for future AS nurses, investigating this 'know-how' of the experienced nurse preceptors is of great importance for meeting the contemporary and future needs of patients when cared for by the AS.

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