by John Donaghy
At the SRHE International Conference in December 2023, I was delighted to have the opportunity to present an insight into my doctoral thesis: ‘An Examination of University Paramedic Students’ Enculturation into the Ambulance Service.’ This was my first time at the SRHE conference, consequently the inevitable nerves were always with me. However, I had no reason to worry, the warm welcome and supportive environment with liked minded people was an excellent opportunity for me to ‘tell my story’. My EdD viva in 2021 followed an ethnography over several years (starting in 2013) which explored university paramedic students’ enculturation (the process of being socialised in a certain culture), into a traditional National Health Service (NHS) Ambulance Service Trust.
The research illustrates the many challenges and dichotomies which faced neophyte paramedics as they went from a university classroom setting into their day-to-day clinical work placements. The challenges they faced were not the result of individuals alone, rather they resulted from an inherent subculture ingrained within the very fabric of the organisational structures of the ambulance service and paramedic profession. This ethnography contributes to the social science literature on health and social care by presenting an introduction to the sociological perspective of student enculturation, from the university classroom into an often-chaotic working environment of the ambulance service.
The research uncovered the way cultural meanings, institutionalised rules, professional identity and working practices determined the working behaviours in the subculture of paramedic practice, as individual situations and experiences were contextualised. Drawing on the work of seminal authors and experts in the field, such as Metz (1981), Mannon (1992) and McCann (2022), this research explores the subculture along with the hidden curriculum which gave rise to it, as it seeks to understand how and why this appeared to hamper and impede the pedagogy experienced by students. This is not the pedagogy taught and encouraged in university, rather a pedagogy which arises out of the intricacies and nuances of the traditional working environment of the paramedic.
There is a complex interplay of subcultural integration between experienced paramedics and students. The work draws on the peculiarity of the language, behaviours, values and working practices of paramedics and students to illustrate the subculture and hidden curriculum which is inherent in their day-to-day working practices. How students transpose what they learn in the university classroom setting to their clinical work placement is examined and unpacked to help illuminate how students contextualise the knowledge formally taught in the university learning environment, to that of the practice setting.
Supported by a plethora of fieldnotes and interviews with students and paramedics, along with my reflective and reflexive accounts collected over a period of eighteen months, my research informs and contributes to the unfolding developments within the paramedic profession. There are working customs and practices not seen by members of the public or portrayed by media representations.
With Professor Diane Waller (OBE) I am co-authoring a book (to be published by Routledge in March 2024) based on my research journey, along with the obstacles, challenges and opportunities presented to me as the principal research investigator. As an experienced paramedic with over 30 years working for a busy inner city NHS ambulance service trust, and 20 years as an academic, teaching student paramedics, I illustrate the various situations that were presented. We delve into the professionalisation of paramedics as we try and make sense of the research findings. One aspect of the doctoral journey shone a light on the insider/outsider dichotomy, which I encountered in the field collecting data.
The ethnography allowed me to engage and witness, first hand, how and why students became so reliant on the subculture and hidden curriculum which O’Reilly (2009), Brewer (2000) and others also highlight, claiming that ethnography can provide forms of in-depth data. It gave me the opportunity to work with participants, to see and be part of their community of practice (Lave & Wenger, 1991), share in their frustrations, anxieties, disappointments and at times sadness which confronted them in their challenging day-to-day work. The intricacies, nuances, colloquialisms, attitudes, and behaviours become exposed, whilst I grappled with the emic position of researcher as I became one of them (Brewer, 2000). I took Burgess’s (1984) advice, that the emic position provides the researcher with full participant observation status, who already belongs to the group being researched. At the same time, I was reminded of Walford (2008), whose opinion highlights the danger of the emic researcher going native – I was keen that my position would not compromise my research findings. Considering the dichotomy between the emic and etic researcher and the potential influence on my study, I illustrate how this dichotomy was managed in the field.
My insider observations helped me to slip between insider (emic) and outsider (etic) roles, to create a persona that encouraged and cajoled participants to disclose and illuminate more confidential and detailed accounts of their day-to-day practices. I was also aware that my research evolved through a reflexive stance related to my personal practice experience throughout the research. Hunt & Sampson (2006) and Van-Maanen (2011) advise using reflexivity to examine the self and voice to help harness and understand the responsibility of the researcher within the research. I combined a meaningful personal, professional and researcher self to the research (Van Maanen, 2007), as I became an integral part of the participants’ community. I worked with them, I copied their language, their slangy terms, their anecdotes and at times their offensive language, to help cement my place within the community. Developments of social research and in particular ethnography, have stimulated discussion on the advantages and disadvantages of ‘insider’ and ‘outsider’ researcher (Allen, 2004).
There were occasions, such as when I was required to treat patients as a paramedic, whereby I removed myself from the research process, then slipped back into the emic role as soon as I had cared for the patient. There were dichotomies within the discourse, as students revealed startling accounts of inappropriate behaviour, or I witnessed criminal damage to the ambulance. These actions often required me to switch between the emic to etic researcher as I continued with the ambulance shift. I questioned myself, at times not really knowing what to do, whether to speak up, or remain silent and ensure my acceptance into their workplace community.
| I was riding out with Rupert, a second year Foundation Degree student. This meant that Rupert was employed by the ambulance service as a student paramedic, who returned to university in blocks to commence his academic studies. This also meant that Rupert was working one-to-one with his crewmate (working partner), an experienced old-timer called Albert. The shift was due to start at 15-00 hours and finish at 23-00 hours at Newmoon ambulance station situated in the outskirts of the city. Albert arrived for the shift ten minutes late, although we had not received any emergency calls, so ambulance control was unaware of the situation. At 15-10 Albert arrived and parked his car on the station. I had not met the paramedic (Albert) before, but Rupert had been working with him for a while now and appeared to get on well with him. It was not long within the shift, after attending our second emergency call, that whilst sitting in the ambulance that I could smell alcohol on Albert’s breath as we were talking. Albert was the driver of the ambulance that day and it soon became apparent that Albert had been drinking alcohol prior to starting the shift and driving the ambulance. I found a moment to speak with Rupert privately about my suspicions and to my surprise Rupert was aware of the situation, stating: “Oh don’t worry John (researcher) he often has a little drink before the shift, he only has a couple of pints at lunchtime, everyone knows him around here, it’s okay it’s just something he does”. Taken from my fieldnotes. * |
| On this occasion I was riding out with Jenny, a foundation degree student. Jenny was driving the ambulance whilst we had a patient in the back of the vehicle taking them to hospital. I sat in the front of the cab so I could talk to Jenny on route to hospital. The patient was in a stable condition, suffering just minor abdominal discomfort. Suddenly, Jenny miscalculated the distance between a passing car and a parked motor vehicle (van) causing us to strike the parked van. I could see from looking through the ambulance wing mirror that we had shattered the van’s right-hand side mirror, which was hanging from the vehicle with shattered glass and debris on the road as we continued passing various vehicles. I looked at Jenny who promptly said: “pretend you didn’t see that John (researcher)” and laughed as we continued en route to hospital. Taken from my fieldnotes. * |
* All names and environments have been anonymised with pseudonyms.
The two accounts above, taken from my fieldnotes, illustrate the dichotomy of my insider/outsider relationship which had formed over time with the participants. O’Reilly (2009:110) claims that it is the “insiders’ explicit goal to gain an insider perspective and to collect insider accounts”. It was therefore important for me to have their trust, assurance and be part of their community if I were to witness and experience their real-life working relationships and behaviours. These were real and challenging dichotomies and ethical tensions which I had to grapple with as I spent time in the field as researcher.
Events such as these were difficult and morally challenging situations which stretched and tested my professional and moral compass.
John Donaghy is a Registered Paramedic and academic, with over thirty years’ experience working in an inner-city NHS Ambulance Service Trust, prior to moving into academia twenty years ago as a Principal Lecturer and Professional Lead for Paramedic Science. He has a professional doctorate in Education (EdD) and is a Fellow of the College of Paramedics. He works extensively with both the UK and Irish Regulator of Pre-hospital Emergency Care and continues to undertake clinical shifts at Wembley National Stadium in London, UK. His research interests lie within the professionalisation of practice which led him to explore the ambulance and paramedic service.
References
Allen, D (2004) ‘Ethnomethodological insights into insider-outsider relationships in nursing ethnographies of healthcare settings’ Nursing Inquiry, 11(1), 14–24
Brewer, J. D (2000) Ethnography – Understanding Social Research. 1st, edn, Open University Press. New York, USA.
Hunt, C. & Sampson, F. (2006) Writing self & reflexivity. 3rd edn, New York: Palgrave.
Mannon, MJ (1992) Emergency Encounters – EMTs and their Work. 1st edn, Boston, MA: Jones and Bartlett, Boston
Metz, LD (1981) Running Hot-Structure and Stress in Ambulance Work 1st edn. Edited by D Metz USA: Abt Books, Cambridge, Massachusetts, USA.
O’Reilly, K. (2009) Key Concepts in Ethnography. 1st edn, London: Sage. Los Angeles, London, New Deli, Singapore, Washington DC.
Walford, G (2008) How to do Educational Ethnography 1st edn, London, UK: The Tufnell Press
