MSc Delivering Quality Health Care (Paramedic Practitioner Programme)
Dissertation NURM112
Abstract
Title
Exploring paramedics views on training to provide wound care in the community.
The study’s aims are to;
Understand paramedics opinions and views towards providing this service and whether paramedics think providing this service is part of their role.
The study’s objectives are to explore;
The barriers and facilitators to paramedics providing wound care.
Paramedics perception of their knowledge of wound assessment and treatment choice.
Paramedics attitudes towards carrying out this role.
Method
A qualitative Grounded Theory approach using focus groups was used. From a review of the literature it appears that there has been little investigation into Paramedic’s developing scope and a theory regarding their perceptions of ability to carry out this role has not been formulated. This lack of earlier investigation suggests that the use of Grounded Theory is appropriate. Ingham-Broomfield (2015) supports this when describing how this method allows for the researcher to use inductive reasoning to attempt to develop a social theory for a phenomenon that has none. Grove (2017) goes on to state that, while data is collected and examined repeatedly, the researcher identifies concepts and relationships between them allowing for a greater understanding to emerge.
Results
Conclusion
Chapter 1
Introduction
- Introduction
The NHS continues to be put under ever increasing pressure and that with finite resources, more efficient and new systems of working need to be implemented. Seeking to address this shortfall in capacity the Urgent and Emergency Care review NHS England (2013) advocates the treatment of patients as close to their home as possible. NHS England (2016) supports this when stating that the number of patients transported to hospital should be reduced by developing the role of the paramedic.
In order to achieve this NHS England (2013) encouraged the development of the paramedic’s scope of practice which is supported by the College of Paramedics Post Registration Career Pathway (2015). Brooks et al (2015) agrees when identifying the requirement for developing paramedics wound care education, to avoid unnecessary wound care referrals. Not being able to treat minor wounds themselves has the effect of delaying care and putting nursing and specialist paramedic services under unnecessary pressure. With the correct training and education non specialist paramedics can address this issue Urgent and Emergency Care review (2013).
1-2 Background
Current Health policy in the UK, set out in the NHS papers Urgent and Emergency Care review (2013) and Five Year Forward View (2014), describe how care should be provided as close to the home as possible. These papers go on to state that Urgent and Emergency care services are to be redesigned to ensure an integrated service between Ambulance, GP, NHS 111 and other urgent care providers with the aim of an improved patient care and efficiency. The NHS Confederation (2008) suggest that due to the myriad of avenues to obtain advice and treatment, individuals are often resorting to the Ambulance Service to provide this advice and care. For these two reasons urgent care, which is defined as care provided to patients urgently when they require, or they feel they require an urgent intervention, be that advice or treatment, has become an increasing aspect of paramedic practice. NHS 111 are also triaging calls to the Ambulance Service that may have otherwise been seen in primary care and that between 2009 and 2016 calls to the Ambulance Service from the public and NHS 111 rose from 7.9 million to 10.7 million, a 30% increase, without a comparable rise in funding, The National Audit Office (2017)
Concerns that Emergency Departments and Ambulance Trusts are under intense pressure to address this rise in demand has driven the requirement to develop the role of Ambulance staff, especially in the areas of clinical history taking, physical examination and treatment skills of paramedics.
In response to this, the role of the paramedic has evolved and extended which has been recognised by the College of Paramedics (2015) who state that the potential contribution that a well-educated and highly trained paramedic workforce can make to healthcare, through its unique field of practice, that intersects healthcare, public health, social care and public safety, has yet to be fully appreciated and understood. Paramedics are very well regarded by the general population and closer engagement of this workforce with pre-hospital urgent care and prevention of hospital admission, should be of benefit to the wider community, College of Paramedics (2013). This is supported by Spence (2017) who describes how paramedics make a valuable contribution to hospital avoidance and appropriate care in the community. Paramedics are now developing into highly trained, professionals, experienced at seeing the same types of patient that a GP sees, and are being supported, both educationally and organisationally to keep patients at home, linking in with the multi-disciplinary health care team, Spence (2017).
The emerging consensus is that paramedics are autonomous professionals at the point of registration and are well placed to effectively deliver a patient focused, out of hospital urgent care service, which was previously the remit of specialist nurses and specialist paramedics, College of Paramedics (2013).
To enable this situation to be realised, a more robust education and training system needs to be in place. The College of Paramedics (2013) state that the current education and training model, in England, is very locally determined, resulting in varied student experiences and different levels of learning outcomes achieved at the point of registration. They are addressing this with the Paramedic Evidence Based Education Project, which is attempting to strategically direct the provision of a more standardised robust education and training curriculum to enable the profession to realise its potential.
The background section is improving but you still seem to be diverting to new/side issues e.g. why paramedics may be leaving the profession. At this stage, it is enough to highlight that there is high turnover rather than going into detail. There should be a clear distinction between entry level and advanced level practice. There should be a clearly stated interest in the impact and acceptance of changing and extending paramedic roles. There should be more information about the wound care role and why you have selected this to study.
Keep to your bullet points for your argument, e.g.
- increasing pressure and demand on emergency services
- policy drive to keep care close to home
- in response to this, the role of the paramedic has evolved and extended
- you are focusing on the regular, entry level paramedic role – summarise some of the changes occurring here (examples of role expansion), e.g. paramedics acknowledged as making a valuable potential contribution in a range of areas of care – this has been acknowledged by recent review of education and banding?
- however there are also changes occurring in the move towards specialist areas of practice and advanced practice roles, including prescribing (this is the bigger picture? why is it important?)
- Why it is important to look at what paramedics think about the evolving role? (you haven’t really made this point clear yet). Is job satisfaction and high turnover part of this answer? If so, link it to your rationale, e.g. given that the role is evolving at a rapid pace and there is evidence for high staff turnover, it is important to examine this topic in more detail.
- Explain wound care, context and why chosen
Chapter 2
Literature Review
2.1 Introduction
The aim of the review is to identify and examine evidence regarding the factors that affect the development of the paramedic role and practical skills development. Research investigating the changing role of the paramedic and whether the profession feels ready to take on extended roles shall be examined.
This review shall provide an insight in the level of investigation and scrutiny the developing paramedic role has been subjected to. Polit and Hungler (1995) discuss the variance in quality of evidence available and advocate the necessity of acquiring evidence from reputable sources and critiquing this information in a robust and equitable manner. Blaxter (1997) supports this view when stating that a robust literature review is essential to put work in context and draw from recognised bodies of knowledge. Although discussing nurses, Ousey (2001) describes how they should be critical when reading research and not assume it has a sound research base. nurse education has developed to meet this challenge with new registration academic levels at Degree level, and more recently paramedic education has changed to facilitate this with the introduction of Degree level pre registration courses. This level necessitates the critical evaluation of evidence facilitating an enquiring nature, allowing both paramedics and nurses to use these skills to accept or reject information affecting their practice.
2.2 Search Strategy
Wichor et al (2018) describes how the creation of search strategies for systematic reviews can be a difficult balance between being too specific and to broad. This results in either no results, too many results or lack of confidence in the robust and accurate nature of the search. They found that there appeared not to be a consistent approach for carrying out a fully replicable search. Therefore, they developed a simple search strategy that shall be used to find papers for the Literature review. Their method uses a step wise approach using single line search phrases and adding these to a thesaurus to ensure completeness (Table 1). This method helps individuals develop systematic reviews to search for evidence to inform their research.
Table 1
| 1 | Determine a clear and focused question |
| 2 | Describe the articles that can answer the question |
| 3 | Decide which key concepts address the different elements of the question |
| 4 | Decide which elements should be used for the best results |
| 5 | Choose an appropriate database and interface to start with |
| 6 | Document the search process in a text document |
| 7 | Identify appropriate index terms in the thesaurus of the first database |
| 8 | Identify synonyms in the thesaurus |
| 9 | Add variations in search terms |
| 10 | Use database-appropriate syntax, with parentheses, Boolean operators, and field codes |
| 11 | Optimize the search |
| 12 | Evaluate the initial results |
| 13 | Check for errors |
| 14 | Translate to other databases |
| 15 | Test and reiterate |
Wichor et al (2018)
Using the frame work described, searches were made using CINAHL and MEDLINE databases and Google scholar. These were used as they are advocated by both the National Institute for Health and Care Excellence (NICE) (2017) and the US National Library of Health (2017) describing them as the premier databases pertaining to life sciences. Reading University (2018) describe Google scholar as an acceptable search engine for accessing a wide rage of literature but state researchers should guard against using it as a sole reference as it is unclear which publishers are included and which excluded.
Key words for the search were Paramedic/s AND/OR Developing AND/OR Extending AND/OR Primary, AND/OR Community, AND/OR Urgent, AND/OR Wound.
2.2.1 Inclusion and Exclusion criteria
A date range of consisted of 2008 to 2018 was used as it covers the period of rapid paramedic practice development driven by increasing demand of an aging population which is reflected in the Urgent and Emergency Care review (2013), and the NHS Confederation (2008) A Vision for Emergency and Urgent Care.
Only English language texts were included due to lack of funding for translation, which is acknowledged as a weakness in the literature review. Full text and research only articles were included, non research articles were excluded from the literature review due to lack of rigor although they are used in the discussion. Following this a hand search was also completed, which is described by Wichor (2018) as an acceptable method for searching the literature.
2.2.2 Search results
As demonstrated by the search results in table 2 there were 906 papers identified with paramedic in the title or text these were further filtered using the keywords in table 2 and duplicates discarded. These were then further filtered assessing their relevance to the aims of the study and 10 papers were found that met the inclusion criteria were included in the review. table 3.
Table 2
CINHAL, MEDLINE, Google Scholar and Hand Search (English Language, full text, Jan 2008 to Sept 2018, filtering duplications)
| Search Term | And | Results | Relevant | Available |
| Paramedic (Tile/Text) | 906 | |||
| Paramedic (Title) | 202 | |||
| Paramedic (Title) | developing (Text) | 16 | 3 | 3 |
| Paramedic (Title) | Extending (Text) | 1 | 0 | |
| Paramedic (Title) | Primary (Text) | 25 | 2 | 2 |
| Paramedic (Title) | Community (Text) | 45 | 5 | 5 |
| Paramedic (Title) | Urgent (Text) | 3 | 0 | |
| Paramedic (Title) | Wound (Text) | 8 | 0 |
Table 3
| Authors | Date | Title | Publication |
| Reeve, C. Pashen, D. Mumme, H De La Rue, S, Cheffins, T. | 2008 | Expanding the role of paramedics in northern Queensland: An evaluation of population health training | BMC Geriatrics. 2018; 18:104.
|
| Roberts, L. Henderson, J. | 2009 | Paramedic perceptions of their role, education, training and working relationships when attending cases of mental illness | British Journal of Midwifery Vol 24 No 6 |
| Bourdon, E | 2914 | A Qualitative Study on Quevec Paramedics’ Role Perception and Attitudes of Cynicism and Disengagement within the Context of Non Urgent Interventions.
Accessed on: 10/11/2018 |
Conference: NAEMSP 2014 Annual Meeting at Tcson.
Available at: www.reseach.net (Requested from author) (Hand Search)
|
| Pauley, T. Dale, A | 2016 | Train together to work together: Reviewing feedback of community-based skills drills training for midwives and paramedics | PLoS One 13 (12)
www.10.137/journal.pone.0208391
|
| Tavares, W. Bowles, R. Donelon, B. | 2016 | Informing a Canadian paramedic profile, roles, and crosscutting themes. | Health Services Research Apr 21 Vol 17 |
| Rees, N. Porter, A. Rapport, F. Hughes, S. John A.
|
2017 | Paramedics’ perceptions of the care they provide to people who self harm: A qualitative study using evolved grounded theory methodology | Public Library of Science Vol 13 (10) |
| Simpson, P. Thomas, R. Bendall, J. Lord, B. Close J. | 2017 | Popping nana back to bed – a qualitative exploration of paramedic decision making when caring for older people who have fallen | Australian Journal of Rural Health Vol 16. |
| Streeps, R. Wilfong,D. Hubble, M. Bercher, D. | 2017 | Emergency Medical Services Professionals’ Attitudes About Community Paramedic Programs. | Journal of Emergency Primary Health Care Vol 7(2) |
| Mi, R. Hollander, M. Jones, C. DuGoff, E. Caprio, T. Cushman, J. Kind, A. Lohmeier, M. Shah, M | 2018 | A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits | BMC emergency Medicine 13:13
|
| McCann TV, Savic M, Ferguson N, Bosley E, Smith K, Roberts L.
|
2018 | Paramedics’ perceptions of their scope of practice in caring for patients with non-medical emergency-related mental health and/or alcohol and other drug problems: A qualitative study. | PLoS ONE 13(12): e0208391. https://doi.org/10.1371/journal. pone.0208391 |
There were no papers that explored paramedics views on developing their wound care role. Therefore, papers looking at paramedic’s perceptions to their developing role in other areas, such as mental health and low acuity presentations, were included. Notable amongst these is the qualitative exploration by Simpson et al (2017) describing the perception of the paramedic’s role when caring for what was described as low acuity calls. Roberts and Henderson’s (2009) mixed method study regarding paramedic’s feelings towards caring for patients with mental illness was included as it looked into similar perceptions of the developing paramedic scope as was Rees et al (2018) Grounded Theory study exploring attitudes towards self harm. This was also the case with Reeve et al (2009) exploring the development of paramedics practice in primary care.
A strength of the search is that it used a replicable structure, however a weakness was that it had to rely on key words being in the title, due to the fact that when key words were included in the text the search was too broad. Hand searching found a number of related papers of which Bourdon’s (2014) qualitative study on Quebec paramedic’s role perception was included which found that there was a degree of cynicism and disinterest regarding low acuity presentations. Although, this paper was in French and for that reason not initially included this was revised once a translation was obtained and it relevance revealed. Sanderson et al (2007) described a number of useful tools for assessing literature, the Critical Appraisals Skills Programme (CASP) CASP UK (2019) being one of them. It is also the tool recommended by the University of Surrey. On this basis it was chosen as the tool for critiquing the evidence selected by the literature search. However, Sanderson (2007) cautions that there must be a robust process in place for these types of tools development. The CASP checklist was used for all the literature selected to provide equity of assessment.
2.2.3 Critical review of research on paramedics developing role within the health care system
Three themes emerged from the literature review which were: Are new expanding roles the paramedic’s responsibility? Are developing roles affecting perceived core roles? Do paramedics feel prepared for new roles?
2.2.4 Are new expanding roles the paramedic’s responsibility?
Roberts and Henderson (2009) mixed method study explored paramedics perceptions of their role regarding mental health attendances. This study consisted of a survey, interrogation of the South Australia Ambulance Service Data base and three focus groups conducted within the same Ambulance service. Their findings, to be reflected by Simpson et al (2017) a decade later, were that paramedic’s perception of their place within health care was different than the reality of their expanding role. Simpson et al (2017) described a qualitative exploration of paramedic decision making when caring for older people who have fallen. Simpson used a constructivist grounded theory methodology. Which Glaser (2012) describes as an appropriate methodology when little is known regarding the subject, and when starting without pre conceived assumptions regarding a hypothesis. Although Strauss (1998) cautioned against becoming constrained and described how the focus of the research may develop and change during the research process. This was the case with this study which started with the aim of exploring paramedic’s decision making with regards elderly falls, but developed into the perceived role of the paramedic, once thematic analysis was applied to the semi structure interviews and further explored in focus groups. Simpson et al (2017) concluded that paramedic decision making regarding elderly falls is affected by their personal, organisational and societies perceived role of a paramedic. And that clarification of their role and decision making, and education and training for low acuity presentations is required to ensure paramedics give this cohort of patient’s evidence based equitable care. The paper acknowledged the limitations, in that the researcher was an experienced paramedic and may have inadvertently become a participant in the study and affected the results. The study was set in an Australian Ambulance service which operates a similar model to the UK, thus adding a level of external validity. Interestingly although carried out in Australia, Roberts and Henderson (2009) earlier study was not referenced in Simpson’s (2017) paper? This may highlight a limitation with Grounded Theory where the focus of a study may change and previous work not referenced as it was not initially seen as relevant. Rees et al (2018) Grounded Theory study exploring paramedic’s perceptions of care provided to patients who self harm also highlighted the perception that a paramedic’s primary role is that of acute life saving interventions rather than caring for those that self harm. This is further supported by McCann et al (2018) who’s mixed method study revealed disagreement between paramedics regarding whether this was routine paramedic work or an extended role.
2.2.5 Are developing roles affecting perceived core roles?
As described above both Rees et al (2018) and McCann et al (2018) studies suggest that mental health care is perceived as taking paramedics away from their core role of acute life saving interventions. Tavares (2016) explores this further when studying the Canadian paramedic profile using a mixed method approach finding that there is a shift in the traditional paramedic role that is putting a tension on traditional roles and expectations of both the workforce, management and society. He concluded that more work needs to be done to address these potential tensions between actual and perceived practice to fully embrace the development of the service. Roberts and Henderson’s (2009) study went on to describe how the implications for paramedic practice in rural areas are that there is the potential for the profession to undertake a greater role in the provision of health care within their communities. It was also suggested that the development of the paramedic role into a more Primary care focused service may improve retention of staff, which is at odds with Simpson et al (2017) and Henderson ‘s (2009) findings that paramedics did not perceive low acuity care to be their remit. However, countering these findings are Streeps (2017) cross sectional survey aimed at gauging the attitude of Emergency Medical Service personnel in the southern US. This study sought paramedic’s opinions on developing a Community Paramedic program, finding that the majority of those questioned were willing to participate in additional study to deliver an extended scope of practice, for the benefit of the population they served. However as this was a quantitative survey using a likert scale, the depth of information regarding attitudes and opinions was limited, which Blaxter (1997) describes as a recognised limitation of quantitative methods. Bourdon’s (2014) study wasn’t found during the initial search as it was not in English. However, following a hand search and correspondence with Emmanuelle Bourdon an English copy of her power point presentation given at the National Association for Emergency Medical Professionals conference (2014) (NAEMSP) was kindly provided. It is acknowledged that this is a less than ideal method of reviewing the literature, however this paper is one of the few available that is directly related to this dissertation’s aims and objectives. Bourdon used a qualitative Grounded Theory approach to investigate paramedic’s perception in relation to the changing role of the paramedic. Using snowball and purposeful sampling and individual interviews, results indicated that paramedics perceived their role to be orientated towards emergency care. Attitudes of cynicism and disengagement were described when caring for low acuity presentations and it was felt that these were not core functions. She goes on to theorise that this conflict between perceived and actual role may affect quality of care and the level of engagement paramedics have with these patients. This assertion supports Simpson et al (2017) and Henderson ‘s (2009) findings regarding role perceptions in mental health and community care.
2.2.6 Do paramedics feel prepared for new roles?
Roberts and Henderson (2009) found that paramedics felt educationally ill prepared for caring for mental health patients and that communication between agencies was limited and not configured to give the best support to paramedics and the patients being cared for. Countering this Reeve et al’s (2008) quantitative study explored the expanding role of the paramedic in rural Australia found that paramedics are an underused resource in remote and rural areas of Australia, and that working with the local healthcare multidisciplinary team would benefit patients, especially in the areas of health promotion and care planning. This study explored expanded roles for paramedics and undertook a survey of paramedics working in different locations. A cohort of paramedics attending the rural and remote Paramedic Practice course were asked to express their opinions on their developing role and their experience of the course, by questionnaire pre and then post course. This study used a qualitative survey method using open ended questions encouraging a more in depth response to explore how the expanding role of the paramedic was perceived by the paramedics them selves. All of the paramedics that attended the course felt that they had benefited and were in a better position to make decisions and act in an autonomous manner.
2.3 Conclusion
A key finding of the literature review revealed that there is a general agreement that the paramedic’s role is developing to support societies needs. However, there appears no consensus regarding the three themes identified. This further identifies the need for further research in this area. Due to the contradictory results found during the literature review the formulation of a theory regarding paramedics opinions on providing wound care cannot be made. This is further support towards using a Grounded Theory approach for this study. Following on from this assertion, is that the review of the literature suggests that the paramedics perception of their role is key in facilitating the change from an emergency focused model to the more wide ranging scope, that many developed nations health care systems and aging populations require. In the reviewed literature there is a consistent assertion that paramedics are ideally positioned to deliver a range of care from chronic to acute in nature. However, the literature suggests that there is still a perception, from themselves, society and employing organisations that their role is providing high acuity acute emergency care rather than primary, chronic and mental health orientated. Which is contrary to numerous government papers and the literature reviewed suggesting that it is in caring for long term chronic illness and looking after patients with low acuity conditions where they are likely to have the greatest effect. However, reviewing the literature has demonstrated the lack of research into whether paramedics feel prepared for this change. The literature that has been reviewed is international in nature, therefore caution should be taken in assuming that the results are directly transferable to UK paramedics.
Taking into account the limitations expressed above, the literature appears to suggest that paramedics, society and employing organisations perception of the role of the paramedic is at odds with the reality. Therefore the aim of this study to explore paramedics opinions regarding developing their role regarding wound care will add to the body of knowledge investigating the paramedics role in the 21st century.
Chapter 3
Research Design, Methodology and Method
3.1 Introduction
The earlier chapters have set out the background to this study in the context of the rapidly developing role of the non specialist paramedic. This was further explored during the literature review that demonstrated that there has been no specific published research assessing paramedics views on providing a wound care service. However, studies regarding other areas of development have been reviewed and have informed this research. As the researcher’s Trust is implementing training to facilitate wound care, and this is the first extended scope of practice area to be developed, it is important to find out paramedic’s views on this subject, to inform an effective change management strategy as advocated by Lewin (1947). This chapter shall therefore set out the study design and method used, discussing their strengths and weaknesses to explore paramedics opinions and views on providing wound care in the community.
Study Aim
To understand paramedic’s opinions and views towards providing a wound care service and whether paramedics think providing this service is part of their role.
Methodology and approach
Gray (2014) describes the importance of understanding the theoretical stance of research and goes on to state that theory guides the methodology used in a piece of research. He also describes how an initial theory may be challenged during the research process and replaced with a new one. As this study is looking into what paramedics feel, rather what can be proved, an interpretivist approach will be used. This approach is appropriate for exploring social sciences especially within this study when a greater depth of understanding is required regarding paramedics opinions and views, this approach does not take the data at face value and strives to find underlying meaning, comparing words with other data such as emotion, body language and expression Kruger (1994).
Mcleod (2018) states, that when studying people, their beliefs and attitudes the traditional scientific, quantitative approach to research is less appropriate as it has a reduced ability to address the human aspects of the study, such as the participants experiences, thoughts and feelings. A qualitative approach, is more able to explore the phenomenon Mcleod (2018). As q
In contrast quantitative research aims to support or reject a theory using numerical data. This data is then turned into useful information by employing statistics that can then be used to suggest relationships between cause and effect. Denscombe (2010) states that quantitative experiments do not usually take place in a natural setting, or allow participants to explain choices and add meaning to their responses, although there are exceptions. This can lead to inferences being drawn from incomplete information. Another disadvantage is that of poor statistical analysis of the data and subsequent interpretation. There is also the issue of bias where the researcher misses’ phenomena as they are focussed on a theory and inadvertently make the data fit the theory. Studies also have to be of a suitable scale to be statistically significant which has resource issues attached to it.
However, a strength of quantitative data, is being able to be be swiftly interpreted with mathematical statistical analysis, which is viewed highly in scientific circles and is viewed as rational and scientifically objective Denscombe (2010). This makes it very useful for testing and validating formed opinions and theories and is highly replicable and un ambiguous in its nature.
To explore paramedics opinions and views towards providing wound care in the community, whether they think providing this service is part of their role and to understand the perceived barriers and facilitators to providing this service, requires an approach that allows for a depth of understanding to be investigated. As the literature review was ambiguous regarding the identified themes, the use of Grounded Theory was selected as it is an appropriate methodology for generating theory from a relatively unexplored area such as this.
When studying people, their beliefs and attitudes the traditional scientific, quantitative approach to research is not appropriate as it fails to address the human aspects of the study. Such as the participants experiences, thoughts and feelings. A qualitative approach is more able to explore the phenomenon. Mcleod (2018) goes on to discuss how qualitative research aims to understand the social reality of individuals, groups and cultures as nearly as possible as its participants feel it or are living it. So groups and individuals are studied in environments as close to their norm as possible.
Denscombe, (2010) describes that although qualitative research can play an important role in suggesting possible relationships, causes and effects, as noted earlier it lacks the level of validity that can be found in a quantitative method. However this does allow for contradictions in the results that are reflective of society.
Grounded Theory 3.2.3
Grounded Theory shall be used and is supported by Engward (2013) who describes Engward (2013) goes on to describe how the process uncovers patterns which are analysed during the research and may lead to direction changes and the discovery of a theory that the researcher may only become aware of during the study. Glasier ((2005) cited in Engward 2013) supports this when describing how Grounded Theory is interested in exploring how people experience phenomena and relate and react to it. This is especially appropriate when investigating the non specialist paramedic population whose role is rapidly developing with little consultation with them, as the service providers. Ke (2010) describes Grounded Theory is a good approach for obtaining and analysing qualitative data. Although a literature review is often carried out the research is not reliant on formulating a theory from the data found in a literature review. In traditional research this theory is formulated and then tested in the real world. The difference with Grounded Theory is that there is not pre conceived theory and that data is gathered from the real world, rather than being bound in theory and then tested once that theory has been formulated. Glaser and Strauss (1967) suggest that the theory develops as the the research progresses. It is therefore an ideal method for exploring paramedics views regarding developing their practice.
As with all approaches, Grounded Theory has its strengths and weaknesses. Positive aspects of this approach are that the study is flexible and can adapt as the findings and themes start to emerge from the data, that the findings can be refined and further developed and the resulting theory can be used to inform future studies. Weaknesses, however are that its is time consuming, develops a large amount of data and it can be difficult to sift the data for relevant information. Understanding when data saturation has taken place and then developing a theory from that information can also be challenging. However being aware of these strengths and weaknesses allows for mitigation in the form or robust processes to be put into place, which are discussed in section 3.2.7.
3.2.4 Sampling and recruitment
Participant sampling is carried out to ensure maximum variation in the sample and continues until there is sampling saturation. This is described by Cooper et al (2009) as when no new themes or data are emerging. Analysis of the data is then carried out after coding and theory developed from the themes that emerge. In qualitative research there tends to be three main types of data that are collected. These are interviews, observation of practice and document review. To explore how paramedics feel regarding their developing role a number of focus groups shall be undertaken allowing for observation and analysis of interaction between participants in the group. It will not be possible to include the whole population of Trust paramedics due to time and resource constraints. As the goal of qualitative research is to develop an understanding of a populations experiences, thoughts and feelings a criteria based sampling technique shall be used. The three main types of sampling for qualitative research are, quota, purposeful and snowballing sampling Bell (2010). This study shall use purposeful sampling, where the sample is chosen as they fulfil certain criteria. In this case that is being a member of the paramedic population and as a member of that population they are a sub set who have just received wound care training. On considering the sample size the Trust had stated that the course numbers should not be greater that 12 participant’s. Therefore, a sample of more than 12 was not an option and multiple focus groups were assessed as being required. Bloor (2001) states that the best groups size is between six to eight participants, noting that below that number can risk limited discussion and above risks that no all participants will have their views heard.
3.2.5 Data collection and analysis
Focus groups shall be used which allow the researcher to gain an insight to non specialist paramedic’s views regarding wound care. Kitzinger, are versatile and can quickly gather data that can be analysed as the research progresses after the first focus group. Data also emerges from participants responding to other participants comments and how the discussion evolves. This has the effect of drawing out data that may not have been identified during an isolated interview and may become a catalyst for change itself. Seal et al (1998) found that where interviews were good for identifying an individual’s views they could not necessarily be placed together to suggest a group view. Where as focus groups are well suited to gathering shared attitudes and beliefs and drawing out previous unshared data, which is relevant to this study’s aims. Disadvantages to be addressed equate to potential breach of confidentiality and conflicts within the group, which have to be managed sensitively but firmly by the facilitator. This suggests that the success of focus groups is very dependent on how skilled the facilitator is in addressing issues as they arise. This is partially mitigated by ensuring the group interview is robust, a pilot is carried out and that ground rules are laid out and understood prior to commencing the group. Another issue is that of recording both the verbal and non verbal data, which is complex and requires skill to interpret. Recording of the groups shall be carried out using two recorders that have been tested in the setting during a pilot to ensure quality of sound as problems with transcription occur with poor sound quality and where individuals are difficult to differentiate between. Non verbal information shall be gathered by the facilitator using field notes taking into account the format suggested by Krueger and Casey (2009). It is acknowledge that this is a difficult process that will focus on the following areas; emotion, strength of feeling, where attitudes change during the discussion and withdrawal from the discussion Bell (2010).
Due to the practicalities of arranging focus groups following wound care study days two focus groups were facilitated. Bloor (2001) describes how analysis of focus group data is subtly different than from other methods due to the interactive nature of the groups and how this may influence responses and discussion. This interaction and how it affects the data must be taken into account when analysing an individual contribution to the focus group. To mitigate this the analysis of data from a focus group data must acknowledge the group dynamics and the situation that the data was gathered in.
Data collection was obtained via recordings and field notes taken during the focus groups, which was then transcribed and analysised before the next focus group. These identified themes were further explored in the subsequent focus group. The data its self, unlike numerical quantitative data, is closely associated with thoughts, feelings, expression and the words that are chosen to describe these. These were analysed by using a three step process consisting of developing codes that are initially open and organise the data, following this is Axial coding that aims to determine links between the categories of identified coded data and then selective coding that aims to frame a story from the interconnecting coded categories. The second step identifies relationships and patterns within the data, such as words and phrases frequently used, comparing this with qualitative data found in the literature review. And step three is the summarising of the data to support a hypothesis, or in the case of Grounded Theory form a hypothesis.
3.2.6 Ethics
Ethical considerations are an important aspect of any research and were addressed in accordance with the Department of Health (2005) framework for research governance, participants who were invited to take part were kept fully informed of the purpose of the study and written informed consent gained. Participants were also made aware that information pertaining to their participation will be kept in accordance with the Data Protection Act (2018) and managed by Surrey University as the sponsor. The only information that will be kept is the information they submit on the consent form, that each participant will be requested to sign which will not be linked to the data in any way.
The study proposal was submitted to both the University of Surrey and South East Coast Ambulance Service Trust Ethics committees, receiving a favourable response Annex ??
When involved in research there are a number of ethical principles that need to be addressed. These are beneficence, do good, non-malfeasance, do no harm, protect confidentiality, give participants the right to withdraw and avoid deception. The RCN (2004) summarises this by stating that research ethics are concerned with confidentiality, informed consent, data protection and addressing potential benefits and harms. Central to addressing these issues is the importance of informed consent, this aims to ensure that participants are aware of the aims and objectives of the project, the methods that will be used and any risks or benefits inherent in the research. Informed consent for this study was obtained by ensuring potential participants were given a copy of the participant information sheet, Annex ?? and given the opportunity to discuss the project with the researcher or supervisor, should they wish. Another aspect of informed consent is to ensure that participants are volunteers and that there has been no coercion or deception to manipulate them to take part, which is also explained in the participant information sheet Annex ??. Gray (2014) supports this stating that it is of great importance to ensure that participants are fully informed when agreeing to take part in research. As noted earlier this was addressed using a participant information sheet which detailed the purpose and nature of the study, risks and benefits, the projects funding, how data will be handled and stored and described how confidentiality will be ensured. It also detailed the route for candidates to take should they have concerns or further questions and described how the focus group will be conducted and that it is voluntary following a wound care study day. The researcher ensured that he carried out the research in an area away from where he worked and did not know any of the participants with the aim of avoiding coercion bias.
3.2.7 Rigour and Validity
According to Burns (1993), the validity of a study provides a ‘measure’ of the truth or accuracy of a claim. This reflects the confidence that can be placed on the results of a study. Beck (1993) describes how Grounded Theory can be criticised for a perceived lack of validity and rigour. Beck (1993) went on to identify credibility, auditability and fittingness as the main concepts of qualitative rigour. However Cooney (2009) states that to demonstrate these in a Grounded Theory study is not as straight forward a question as it seems. Cooney (2009) identifies different stages regarding the answering of this question, which are consistent with Glaser and Strause’s (1967) two main criteria for assessing emerging theories. These are that the theory fits the situation and that it helps people involved in the situation make sense of it. However, Elliott (2005) argued that this level of rigour is inadequate and suggest that it is more important to consider that appropriate research methods were used and carried out correctly and consistently. Cooney (2009) literature review found three broad concepts of proving rigour in Grounded Theory. These were; methodological rigour, concerned with ensuring the methods were used correctly and consistently; interpretative rigour emphasizing the trustworthiness or the data interpretation and combined focus which as it suggests is a combination of both concepts. Davis (2002) and Cooney (2009) both advocate how a combined focus method allows the greatest demonstration of rigour within Grounded Theory. This is the concept that was used for this study, ensuring that both the method and theory generation were peer reviewed to expose, any methodology or interpretative inconsistencies’.
Chapter 4
Presentation of Findings
4.1 Introduction
4.2 Discussion
4.3 Conclusions
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Appendix 1
Research Summery for FHMS Ethics approval
MSc Delivering Quality Health Care (Paramedic Practitioner Programme)
Dissertation research proposal NURM112
Question
Are front line Paramedics ready to undertake wound care in the community?
The study’s aims are to;
Understand paramedics opinions and views towards providing this service.
Understand whether paramedics think providing this service is part of their role.
The study’s objectives are to explore;
The barriers and facilitators to paramedics providing wound care.
Paramedics perception of their knowledge of wound assessment and treatment choice.
Paramedics attitudes towards carrying out this role.
Background
Current Health policy in the UK, set out in the NHS papers Urgent and Emergency Care review (2013) and Five Year Forward View (2014), describe how care should be provided as close to the home as possible. To facilitate this paramedics are increasingly developing their role. This study aims to explore the attitudes and experiences of a group of paramedics after attending a wound care study day.
Method
A qualitative Grounded Theory approach using a focus group shall be used. From a review of the literature it appears that there has been little investigation into paramedic’s developing scope and a theory regarding their perceptions of ability to carry out this role has not been formulated. This lack of earlier investigation suggests that the use of Grounded Theory is appropriate. Ingham-Broomfield (2015) supports this when describing how this method allows for the researcher to use inductive reasoning to attempt to develop a social theory for a phenomenon that has none. Grove (2017) goes on to state that, while data is collected and examined repeatedly, the researcher identifies concepts and relationships between them allowing for a greater understanding to emerge.
Trust Paramedic Practitioners have been given the task of facilitating wound care study days. The Trust Learning and development team have been asked and have agreed to contact Paramedic Practitioners facilitating the training to ask if paramedics attending the study would consent to attending a focus group after the session, but still within the programmed working day. This shall be the opportunity to explore whether paramedics feel ready to carry out wound care and if they see it as their role. The Paramedic Practitioner who has facilitated the training will not be present at the focus group, as this could affect participants responses. I shall not observe the training day so as not to form any pre conceived ideas regarding the participants and shall only join to guide the focus group.
I shall facilitate the focus group ensuring that they are in areas within the Trust where I am not known. Identifying data of name and profession shall be collected, due to the requirement to obtain written consent, this data will be stored by Surrey University, as the sponsor, in accordance with the data protection act.
Results shall be promulgated via the Trust Learning and Development, who will not know who the participants are, with the aim that hey will be able to use the results to tailor further wound care development.
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Ingham-Broomfield, R. (2015). A nurses’ guide to qualitative research. Australian Journal of Advanced Nursing, 32(3), 34-40.
Monitor (2014) NHS paper Five Year Forward View. Monitor, London
Available at: www.gov.uk
Accessed on: 13/12/2018
NHS England (2013) Urgent and Emergency Care review
Available at: www.england.nhs.uk
Accessed on: 03/01/2019
Velmurugan, R (2017) Nursing issues in leading and managing change. International Journal of Nursing Education. Oct-Dec 2017; 9(4): 148-151
Appendix 2
FHMS Ethics Approval
